Effective pre-test discussion? A case note review

1. Effectivepre-test discussion? A case note review Mel Ottewill & Dr Zoe Warwick SSHA Conference 2008

2. Context • HIV +ve patients still dying - non-adherence - late presentation • Current national targets to reduce late presentation Within GU clinics by end 2007 -100% offer of HIV test - 60% uptake - 50% reduction in number of HIV infected people who remain unaware of their infection after their visit • Changes in testing policy towards opt-out - CDC - WHO - BASHH/BHIVA/BIS review

3. BHIVA Audit 2006: Scenario leading to death Top bars: reclassified during audit Bottom bars: as initially reported Mortality audit BHIVA audit and Standards Sub-Committee 2006; accessible at www.bhiva.org

4. Late Diagnosis (MSM)

5. Local context • Patient stay & morbidity & mortality

6. Late Presenters in Brightonlast 100 admissions 37% 23% Bed days on Inpatient Unit Number of admissions

7. Local context • Patient stay & morbidity & mortality • National targets • 100% offered • 71.8% tested at first visit • 78.2% either tested or had tested within the last year

8. Effect of knowing HIV status on sexual behaviour • Meta-analysis of 11 study analyses • 6 HIV+ “aware” versus HIV+ “unaware” • 5 pre- and post- HIV seroconversion • rates of unprotected anal or vaginal intercourse • UPI 53% (CI 45-60%) lower in those aware versus unaware of HIV+ status • If only considering where partner HIV-, 68% (59-76%) Marks, JAIDS, 2005

9. HIV Testing in GUM % accepting an HIV test % of HIV+ remaining undiagnosed after GUM visit

10. Are we effectively targeting our HIV testing? Anonymous sero-prevalence study (2004) of MSM - HIV prevalence within MSM=13.7% - 33% undiagnosed. • Breakdown by GU attendance: - 78% of HIV +ve men in the community had attended a GU clinic in the last year -23.8% of GU attendees were HIV +ve -of whom 28.2% were undiagnosed - 5.4% of non-GU attendees were HIV +ve -of whom 54.5% were undiagnosed Dodds et al STI 2007

11. 2005 audit of CNC HIV testing • HIV test was offered to 76% of patients and was performed in 48% • Men having sex with men accounted for 14% of the total visitors to CNC • The rate of testing in MSM and low risk group were 53% and 15% respectively.

12. One year later……. Clinic targeting of high risk groups for HIV testing (Jan-Jun 2006) - 79.1% of gay men have an HIV test on first visit - 77.7% of non-whites had a test on the first visit But belonging to a high risk group doesn’t necessarily mean you’re high risk

13. Objectives • To establish: • if risk assessment was adequate • If the response was appropriate according to the level of risk • To identify common themes in reasons given for declining a test • To suggest changes in practice to improve uptake of testing

14. Methodology • Search database for MSM, Black African & IVDUs attending as a new episode between Jan-June 2006 who did not have an HIV test • Included patients diagnosed HIV +ve in 2006 who had previously visited the CNC and left without an HIV test • Agree level of risk (high, not-high) • Review notes against a data collection tool • Statistical analysis – Chi-squared

15. Results • 259 new episode attendances at CNC belonging to high risk gps who did not test for HIV at that visit • We reviewed 100 MSM case notes, all endemic and all IVDU • Risk category • 9 endemic; 98 MSM (2 coded incorrectly); 0 IVDU • Age range 20-67; median 38

16. Results • 12/107 had an HIV test within previous 3 mths - 7 high risk • 5/107 had a HIV + partner since last test • None had had UPAI ie none high risk

17. Risks in those never tested before (n=21)

18. Risk in non-testers • 43/107 (40%) assessed as being high risk according to sexual behaviour (all MSM)

19. STIs in non-testers • Of the 107 • All STIs were in MSM • 7 had an STI since last test (but not at this visit) • 5 low risk • 13 had STI at that visit (but not since last HIV test) • 9 low risk • 12 had STI at this visit and since last test • 7 low risk

20. STIs in high risk patients

21. PTD in high risk non-testers • Of those assessed as high risk (43) • 4 saw a HA • All had a risk assessment, extensive pre-test discussion & reason for declining test documented • 2/3 subsequently tested negative; 1/3 no subsequent test; 1 subsequently tested positive • 39 did not see HA • 31/39 had no documentation of extensive PTD 4/28 subsequently tested negative, 3 tested positive • 8/39 had documentation of extensive PTD 4/8 subsequently tested negative

22. Documented reasons for declining • Perceived low risk (1 x high; 15 x low) • Not psychologically ready (5 x high; 7 x low) • Both of above (1 x high; 1 x low) • Tested within last 3 months (3 x high; 7 x low) • Wants fast test (2 x high; 0 x low) • Other (5 x high) • 17/39 High risk patients with reason for declining test documented

23. Reasons for declining HIV test(where documented n=47)

24. Patients subsequently testing HIV Positive

27. Should the presence of an STI define a MSM as high risk? • 7 non-testers subsequently tested HIV + • 4 were defined as high risk according to behaviour • 2 were defined as “not high” but did have an STI at that visit or since last test • 6/7 (86%) would have been targeted for EPTD

28. Of the 52 “not high risk” according to behaviour • 17 subsequently tested –ve • 4 subsequently tested positive • 31 had no subsequent test

29. Defining risk according to behaviour only Of the 34 in whom we have a HIV test result • 13 individuals of would have been given EPTD. • 3 of these tested +ve (23%), 10 –ve (77%) • 21 individuals would not have been targeted for EPTD • 4 of these tested +ve (19%), 17 tested –ve (81%)

30. Defining risk according to behaviour and presence of STI • Of the 34 in whom we have a test result • 24 would have been given EPTD • 6 of these tested +ve (25%), 18 –ve (75%) • 10 individuals would not have been targeted for EPTD • 1 of these tested +ve (10%), 9 –ve (90%)

31. HIV positivity rate according to risk definition (%)

32. Messages • Individualised EPTD positively determines future testing. • Anyone defined as high risk according to reported sexual behaviour and those with STI at this visit or since last test should be targeted for EPTD.

33. Implications for Practice • Accurate risk assessment and documentation • Target EPTD to all high risk individuals • HA involvement • ?Offer HA discussion • ?Make routine in care pathway • Spend time performing individualised PTD • think HIV test at EVERY visit • Address common barriers to testing

35. Undiagnosed HIV in MSM“A tale of 3 cities” 69% accessed GUM in past 12 months Dodds et al, STIs 2007 (e-pub;1/5/07)