A multifaceted educational intervention for doctors and practice nurses working in general practice in London led to a tripling in the number of HIV tests provided, researchers report in an open-access article in the May issue of Sexually Transmitted Infections.
Guidelines recommend an expansion of HIV testing in general practice (primary care), but implementation has been patchy. While testing is generally acceptable to patients, behaviour change is required of GPs and practice nurses. Some staff lack the confidence, skills and resources required to offer and provide more testing.
In general, there is limited evidence to show that patient outcomes are affected by printed educational materials and meetings for clinicians. However there is some evidence that multifaceted interventions can effect change.
Developed by staff in Birmingham, the Sexual Health in Practice (SHIP) programme includes role play, interactive sessions and didactic teaching. Much of it is delivered by local GPs and practice nurses who act as local champions, can explain how barriers can be addressed and describe the local services that are available.
SHIP deals with all aspects of sexual health, including sexually transmitted infections and contraception. It recognises that to provide HIV tests, staff need clinical knowledge, communication skills, risk-assessment skills and sexual history taking skills, as well as confidence and motivation. The programme pays attention to stigma.
In line with national guidelines, the training encourages appropriate HIV testing in a number of scenarios – on patient request; when risk factors are identified during discussion; when symptoms could be associated with HIV infection; and as part of screening (e.g. in a high-prevalence area, to all women seeking contraception).
In 2010-2011, the SHIP programme was implemented in Haringey in north London – the area with the twelfth highest prevalence of HIV in the country. A total of 52 GPs and 28 practice nurses attended the sessions on HIV testing. In all, three-quarters of all local practices had at least one member of staff trained. Practices that did not send staff tended to have fewer patients and offer fewer HIV tests before the training began.
The programme was delivered during two or three afternoon sessions. To encourage attendance, locum (replacement staff) costs were covered, and free supplies of condoms and pregnancy test kits were arranged. However, there were no financial incentives for GPs to provide HIV testing.
In order to evaluate the impact of the training on clinical behaviour and patient outcomes, local HIV testing laboratories provided data on HIV tests requested in primary care. Data from two years before the training began were compared with those from six months after all training had been completed. One limitation of the study is that it does not show whether testing rates will be sustained in the longer term.
Before training, participating practices conducted 2.29 HIV tests for each 1000 patients per year. This rose to 6.66 tests per 1000 patients per year, an almost tripling of the test rate.
At the same time, in general practices which did not participate, the testing rate did not change significantly (1.54 and 1.90 tests for each 1000 patients per year).
Whereas the number of HIV tests had been steadily but very slowly increasing before the intervention (an extra 0.1 tests each month), there were increases of an extra 3.5 tests per month during the six-month follow-up period.
As more tests were done, more people were diagnosed with HIV. The proportion of tests that resulted in a positive diagnosis was maintained (around 1.5%), suggesting that tests were being offered to appropriate individuals. The increase in testing was concentrated in parts of the local area with higher HIV prevalence.
The authors say that this evaluation, coming from a real life, primary care setting demonstrate that commissioning of the Sexual Health in Practice programme for general practices is likely to support the implementation of increased HIV testing and diagnosis in primary care.
Pillay TD et al. Unlocking the potential: longitudinal audit finds multifaceted education for general practice increases HIV testing and diagnosis. Sexually Transmitted Infections 89: 191-196, 2013. (Full text freely available).