Article Text
Statistics from Altmetric.com
Studies from HIV specialist clinics suggest that undiagnosed HIV-positive patients often present in general practice, where opportunities for diagnosis are missed.1–3 So, what can we learn from analysing general practice records of known HIV-positive patients?
We performed a service evaluation in December 2011 of all known HIV-positive patients aged ≥15 registered at four general practices in Tower Hamlets, London (UK), with a combined 25 533 patients aged 15–59. Patients were identified using modified code searches (see online supplementary appendix 1) on the EMIS computer system (Egton Medical Information Systems, UK) as described elsewhere.4 Practice staff used a standardised template to analyse face-to-face general practitioner (GP) consultations in the 3 years prediagnosis.
One hundred and twelve HIV-positive patients were identified, giving a known practice prevalence of 4.38/1000 aged 15–59. Of these, 40 patients were diagnosed between 1995 and 2011 while registered at a study practice, meaning we could analyse their prediagnosis notes. Median age was 46 years (IQR 38–49), 32 (80%) were male and 22 (55%) were recorded as high-risk5 before diagnosis (32% MSM, 23% from high prevalence countries, 45% no risk recorded).
GPs diagnosed 10/40 (25%) and offered or considered HIV testing in another eight (20%) who were subsequently diagnosed elsewhere (either the patient refused testing, or the GP recorded considering HIV but it was unclear from the notes whether testing was offered). The remaining 22 (55%) patients were diagnosed elsewhere with the GP never recording consideration of HIV testing. Two out of eight (25%) women were diagnosed through antenatal screening. Twenty-five patients (63%) presented to GPs with indicator conditions (ICs) for HIV testing,5 with median 6 months (IQR 3–15) and four GP appointments (IQR 2–7) from first IC presentation to diagnosis. Fourteen ICs were recorded: bacterial pneumonia (n=9); oral candidiasis (n=5); unexplained blood dyscrasia (n=5); possible primary HIV infection (n=5); STI (n=4); severe seborrhoeic dermatitis (n=3); lymphadenopathy of unknown cause, severe psoriasis and unexplained weight loss (n=2 each); Kaposi's sarcoma, Pneumocystis pneumonia, pyrexia of unknown origin, dementia and oral hairy leucoplakia (n=1 each). In 12/22 (55%) high-risk patients and 15/25 (60%) with ICs the GP diagnosed HIV or offered/considered testing.
The lower prevalence of known HIV in the study practices (4.38 compared to estimated local prevalence of 5.96/1000)6 is likely to represent a combination of lack of registration with, or disclosure to, GPs, as well as underdiagnosis. We found that GPs diagnosed HIV or offered/considered testing in 45% of patients, which although comparing favourably to previous studies,1–3 can be improved. This will require GP specific training that provides knowledge of local HIV prevalence, recognition of ICs commonly seen in general practice and confidence to successfully offer testing.7
Acknowledgments
The authors would like to thank Heather Anderson, Dr James Cole, Dr Rebecca Gidley, Dr Sharjeel Hasan and Professor Chris Griffiths for their contributions.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online appendix
Footnotes
-
Contributors JD, NG, VA and WL designed the study. JD, AC and WL collected data. JD, VA and WL analysed the data. All authors contributed to the preparation of the manuscript.
-
Competing interests None.
-
Ethics approval This was a service evaluation using case notes review, so ethics approval was not required.
-
Provenance and peer review Not commissioned; internally peer reviewed.
-
▸ Additional supplementary files are published online only. To view these files please visit the journal online (http://dx.doi.org/10.1136/sextrans-2012-050712).