Primary care practice still fails to diagnose HIV patients from high-risk groups or with symptomatic acute infection

Fiona Burns from the Royal Free and UCL Medical School presented results from a survey of almost 290 recently diagnosed African patients, attending 14 London HIV clinics, between April 2004 and February 2006.

The purpose of the self-completed surveys, which were linked to medical records, was to identify whether opportunities for an earlier diagnosis in African patients could be established.

236 questionnaires were completed (82% response rate). 66% of respondents were women and 34% were men. These patients were from high risk group, with over 70% coming from countries with an HIV prevalence of over 15%, almost 80% were aged between 25 and 44, and with just of half having advanced HIV (CD4 <200 cells/mm³ or an AIDS-defining illness) at the time of diagnosis.

These individuals were also accessing NHS care with a high level of GP services: 85% had been registered with a GP for a medium time of 3 years, and 75% saw their GP within the 2 years prior to diagnosis, most commonly for flu or chest infection. In the year prior to diagnosis 70% saw their GP for a medium of two visits (range 118).

It is a concern that HIV testing was raised by a GP with only 16% of participants in the survey, despite a demography that should have alerted doctors to consider HIV, irrespective of health.

The authors concluded that work with primary care services is required to understand and overcome the barriers to discussing HIV infection for this, and all, populations.

A second study, presented by Darshan Sudarshi from Brighton, looked at how frequently primary HIV infection (PHI) had been identified in patients presenting with symptoms of acute seroconversion prior to their HIV diagnosis, both in primary care and GUM settings.

Of the 119 individuals who were diagnosed with PHI between 2003 and 2005, clinical notes were available for 102 patients (99 male, 88 MSM). Symptoms (recorded prospectively) and previous presentation to other healthcare providers were obtained from GUM clinic notes and laboratory records (a single laboratory performs all HIV tests in Brighton).

Just over half of the 71 patients, where previous symptoms had been recorded, had not presented to a healthcare provider while symptomatic.

Of the 38 patients who did seek care, 22 were diagnosed with PHI at first presentation (14 in GUM, eight non-GUM settings).

The 15 patients where PHI was missed at first presentation were all non-GUM settings.

In their conclusions the researchers raised the public health risk associated with undiagnosed HIV during PHI, and the related risk of further onward transmission.

It is important that this study recorded that only half of individuals sought any medical care, but also that almost 60% of symptomatic presentations in primary care setting (15/23) were missed by those doctors.

Comment

Earlier diagnosis generally translates to reduction in HIV-related morbidity and mortality and better response rate to treatment. Levels of awareness in this sample of patients accessing London GPs, where HIV awareness should be amongst the highest, is worrying, especially given the financial pressure on HIV clinics to restrict medical care and treatment that is only directly related to HIV, and for HIV-positive patients to access primary care services more routinely.

Almost 60% of symptomatic primary HIV patients in primary care setting in Brighton and East Sussex (15/23) were missed on first presentation for medical care, however, eight cases were diagnosed. Brighton Hospital runs a GP training course that includes how to spot seroconversion that has anecdotally pickled up additional cases.