+Model MEDMAL-3611; No. of Pages 8
ARTICLE IN PRESS Disponible en ligne sur
ScienceDirect www.sciencedirect.com Médecine et maladies infectieuses xxx (2015) xxx–xxx
Original article
Rapid HIV test in family practice夽 Tests rapides d’orientation diagnostique pour le VIH (TROD) en médecine générale C. Poirier a,∗,b , S. Aymeric b,c,d , L. Grammatico-Guillon b,c,d , J.P. Lebeau b,d,e , L. Bernard a,b , P. Le Bret f , G. Le Moal g , G. Gras a a
Service de médecine interne et maladies infectieuses, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France b Université Fran¸ cois-Rabelais, 60, rue du Plat-D’Étain, 37020 Tours cedex 1, France c Service d’information médicale d’épidémiologie et d’économie de la santé, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France d Équipe émergente éducation éthique santé, 60, rue du Plat-D’Étain, 37020 Tours cedex 1, France e Département universitaire de médecine générale, 60, rue du Plat-D’Étain, 37020 Tours cedex 1, France f Réseau ville hôpital VIH 37, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France g COREVIH centre Poitou-Charentes, service de maladies infectieuses et tropicales, CHRU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers cedex, France Received 19 January 2015; accepted 24 March 2015
Abstract Background. – The 2010-2014 HIV/AIDS French program recommends using HIV rapid diagnostic tests in family practice. Our aim was to assess the acceptability and feasibility of the RDT in family practice in France. Methods. – The first part of this study was to determine the opinions of family practitioners (FPs) concerning the news guidelines for screening and the possible use of rapid HIV tests in their practice. The second part was a feasibility study of the actual use of rapid HIV tests given to FPs during six months. The third part was a qualitative analysis of experience feedback to determine the impediments to using rapid HIV tests. Results. – Seventy-seven percent of the 352 FPs interviewed were favorable to rapid HIV tests use. The three main impediments were: misinterpretation of test result, complexity of quality control, and lack of training: 23 of the 112 FPs having volunteered to evaluate the rapid HIV tests followed the required training session. Sixty-nine tests were handed out, and three rapid HIV tests were used; the qualitative study involved 12 FPs. The participants all agreed on the difficult use of rapid HIV tests in daily practice. The main reasons were: too few opportunities or requests for use, complex handling, difficulties in proposing the test, fear of having to announce seropositivity, significantly longer consultation. Conclusion. – Although FPs are generally favorable to rapid HIV tests use in daily practice, the feasibility and contribution of rapid HIV tests are limited in family practice. © 2015 Elsevier Masson SAS. All rights reserved. Keywords: Family practice; HIV screening; Rapid HIV tests
Résumé Introduction. – Le plan VIH/sida 2010/2014 préconise d’évaluer l’utilisation des tests rapides d’orientation diagnostique (TROD) en médecine générale. L’objectif était de déterminer l’acceptabilité et la faisabilité des TROD en médecine générale, ainsi que les freins limitant leur utilisation. Méthode. – Le premier volet de cette étude était descriptif de l’opinion des médecins généralistes en région centre vis-à-vis des recommandations de dépistage et de l’utilisation des TROD en médecine générale. Le deuxième volet était une étude de soins primaires interventionnelle avec mise à disposition de TROD auprès des médecins généralistes durant 6 mois. Le troisième volet était une étude qualitative de retour d’expérience, visant à définir les freins à l’utilisation des TROD en médecine générale.
夽
This article was presented in the following congresses: 14th Congress of the French Society for the Prevention of AIDS (French acronym SFLS) in Poitiers, from October 24 to 25, 2013 and RICAI 2014 – 34th Interdisciplinary Meeting on Anti-infectious Chemotherapy, from November 27 to 28, 2014 in Paris. ∗ Corresponding author. E-mail addresses: poirier [email protected] (C. Poirier), [email protected] (S. Aymeric). http://dx.doi.org/10.1016/j.medmal.2015.03.010 0399-077X/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8 2
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
Résultats. – Parmi les 352 médecins généralistes interrogés, 77 % étaient favorables aux TROD. Trois principaux freins étaient évoqués : potentielles erreurs d’interprétation, contrôle qualité fastidieux, manque de formation : sur les 112 médecins généralistes de l’étude évaluant les TROD en soins primaires, 23 ont suivi la formation, 69 TROD ont été distribués, trois TROD ont été réalisés ; l’analyse qualitative concernait 12 médecins généralistes. Les TROD ne semblaient pas adaptés à la médecine générale. Les principales raisons évoquées étaient : peu d’occasions et peu de demandes, manipulation du test complexe, difficultés à proposer le test, crainte d’avoir à annoncer une séropositivité sans préparation préalable, rallongement majeur de la durée de consultation. Conclusion. – Si l’acceptabilité des TROD par les médecins généralistes paraît bonne, la faisabilité et l’intérêt des TROD sont limités en médecine générale. © 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : Dépistage du VIH ; Médecine générale ; TROD
1. Introduction In France, 150,000 people are infected with the Human Immunodeficiency Virus (HIV), and 6100 new patients are infected every year [1]. Nineteen percent of HIV-positive patients are not diagnosed [2]. The delay before management is a major risk factor for mortality. An average four years was recorded in 2011, between HIV infection and the diagnosis [3] that was made for 29% of patients at an advanced stage (AIDS or CD4 < 200/mm3 ). Five million HIV tests are performed every year in France, 77 serologic tests per 1000 inhabitants, placing the country second in Europe for screening. Seventy-five percent of the tests are performed in private laboratories [4]. The 2010/2014 national HIV/STI (sexually transmitted infections) plan is based on a new proactive strategy of HIV screening [5], with a reinforced screening of at-risk populations, and an accessible screening for the global population (screening proposed at least once in a lifetime for all the population 15 to 70 years of age, when consulting with primary care health professionals, even without any risk exposure). Family practitioners (FPs) were identified as the key physician and involved. The rapid HIV test, a new tool, was made available to them and paramedics, to complete screening procedures. This test, with immediate results, could help decrease the 30,000 people who ignore their status, and could facilitate access to screening. The November 9, 2010 decree sets the circumstances and determines the target populations for rapid HIV tests use in family practice [6]. Rapid HIV tests are, for the moment, neither available free of charge for FPs or refunded. Only few authors have assessed the acceptability and feasibility of these tests in primary care. Our objective was to investigate the acceptability and feasibility of rapid HIV tests in family medicine, and to determine the impediment to their use.
2. Materials and methods We conducted a prospective multicenter, observational, and interventional study of primary care, between May 2012 and July 2013. The method was both quantitative and qualitative.
The first part was a descriptive study of the FPs opinion concerning the new recommendations for screening and use of rapid HIV tests in family practice. The second part was a 6-month interventional study of primary care with provision of rapid HIV tests for FPs. The last part was dedicated to collecting experience data for a qualitative analysis of impediments and potential limitations of rapid HIV tests use in family practice.
2.1. First part: opinion of family practitioners on HIV testing and rapid HIV tests use in daily practice: a descriptive study The FPs were randomly selected from the computer files of the Regional Union of Healthcare Professionals (URPS) of the region Centre. Physicians with an exclusive practice mode (MEP) and SOS physicians were excluded. The selected FPs were sent a multiple-choice questionnaire on their practice concerning prevention and HIV testing. Comparisons were made with Fisher’s exact test. The data was processed with Microsoft Excel® .
2.2. Second part: assessing the feasibility of rapid HIV tests use in family medicine: an interventional study The FPS who had received the questionnaire were asked to participate in the feasibility study. Each then received three rapid HIV tests and a quality assurance workbook. The primary endpoint was the number of proposals for a rapid HIV test, followed or not by its use. The indications for rapid HIV tests use were those recommended by the High Authority for Health (French acronym HAS): populations considered at “risk” and “emergency” situations [5]. The inclusion criteria were: criteria for offering rapid HIV test met, adult patient 18 years of age or more, and written consent. The exclusion criteria were: known HIV seropositivity, or patient under guardianship. The test used was a qualitative single-use INSTI HIV1/HIV 2® in vitro diagnostic test, allowing the detection of anti-HIV 1 and 2 antibodies in capillary blood. The sensitivity and specificity of this immediate visual reading test were > 99.5% [7].
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
3
2.3. Third part: qualitative analysis of rapid HIV tests use in family medicine: feedback Participants were recruited through a reasoned sampling. Collective and semi-structured individual interviews were offered to FPs to share experience and determine the impediments associated with the use of rapid HIV tests. The interviews were conducted from June to July 2013 until data saturation. Two focus groups and six telephone interviews were conducted. The verbatim analysis was conducted by grounded theory method according to the constant comparative method of qualitative analysis [8]. The encoding and qualitative analysis were performed with the QSR NVivo-software. 3. Results 3.1. First part: opinion of family practitioners on HIV testing and rapid HIV tests use in daily practice The questionnaire was sent to 1000 FPs, and was completed by 352 physicians. Table 1 summarizes the characteristics of responding FPs. Few physicians were well aware of the issue prior to HIV testing since only 3.7% participated in a drug Table 1 Characteristics of family practitioners having participated in the survey on the acceptability of HIV screening and the use of rapid HIV tests in family practice (FP). Caractéristiques des médecins généralistes ayant participé à l’enquête sur l’acceptabilité du dépistage du VIH et l’utilisation des TROD en médecine générale. Characteristics
n = 352 (%)
Gender
Male FP: 235 (66.8) Female FP: 117 (33.2) < 40 years of age: 48 (13.6) 40–49: 72 (20.4) 50–59: 143 (40.6) > 60 years of age: 89 (25.3) 10–20: 64 (18.2) 21–30: 179 (50.8) > 30: 108 (30.7) Not documented: 1 (0.3) < 2000: 83 (23.6) 2000–20,000: 162 (46) > 20,000: 105 (28.8) Not documented: 2 (0.6) Individual: 149 (42.3) Group: 198 (56.2) Not documented: 5 (1.4) Convention type 1: 352 (100) Convention type 2: 0 (0) Acupuncture: 14 (3.9) Homeopathy: 29 (8.2) Mesotherapy: 25 (7.1) Others: 30 (8.5) Not documented: 282 (80.1) Cancer and palliative care network: 20 (5.7) Drug addiction/Hepatitis/HIV network: 13 (3.7) Diabetes network: 58 (16.5) Gerontology network: 9 (2.6) Others (perinatality MS, MAP, etc.): 19 (5.4)
Age (in years)
Number of daily consultations
Area of practice (inhabitants)
Type of practice
Type of SS convention Specific FP sub-practice
Participation in a healthcare network
Fig. 1. Prescription of HIV tests by family practitioners according to the settings, in the survey for the acceptability of HIV screening and rapid HIV tests use, n = 352. Pratique de prescription des sérologies VIH par les médecins généralistes en fonction de la situation, dans l’enquête d’acceptabilité du dépistage VIH et des TROD, n = 352.
addiction hepatitis-HIV network. Thirty percent (n = 104) of the physicians surveyed did not manage any HIV positive patient. Sixty-three percent (n = 221) of physicians managing HIV positive patients had only one to four HIV patients and 50.3% (n = 177) did not renew the antiretroviral treatment for their patient. Around 98.6% of the surveyed physicians were favorable to screening and prevention globally, and 96% considered that prevention in the field of sexual activity concerned the family practitioner. Concerning their activity in terms of HIV screening, 52% (n = 183) of the surveyed physicians said they had carried out between two and five HIV tests in the previous month. Fig. 1 describes the practice of family practitioners for targeted HIV screening in four common cases: STI, patient from a country of high endemicity, change of sexual activity and partners, sexually active young patient. The surveyed physicians reported prescribing HIV screening readily in these cases. Around 71.3% of the surveyed physicians were favorable to the global screening of the population from 15 to 70 years of age, without any risk factor, and 77% of them were favorable (20.2% “very favorable”, 56.8% “favorable”) to the use of rapid HIV tests in family practice, in case of risk exposure. Seventy-three percent (n = 257) of the surveyed physicians considered that there were impediments to the use of rapid HIV tests in daily practice. The four main impediments were potential test interpretation errors (54.8%), quality control (51.1%), a lack of training, and being time-consuming for the consultation (50%) (Fig. 2).
3.2. Second part: assessing the feasibility of rapid HIV tests use in family medicine Twenty-three FPs participated in the evaluation of rapid HIV tests in family practice. Only three rapid HIV tests, out of the 69 distributed, were used during the survey (Fig. 3). Two for an accidental exposure to viral risk in retirement homes (source patient and nurse), and one for a drug-addict having made the
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8 4
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
Region Centre: 3,062 family physicians 113 dermatologists 95 gynecologists
1,143 randomized physicians, including 1,000 family physicians, 95 dermatologists and 48 gynecologists Fig. 2. Impediments mentioned for the use of rapid HIV tests by family practitioners, in the survey for the acceptability of HIV screening and rapid HIV tests use in family practice, n = 352. Freins évoqués à l’utilisation des TROD par les médecins généralistes dans l’enquête sur l’acceptabilité du dépistage du VIH et de l’utilisation des TROD en médecine générale, n = 352.
352 responding family physicians
request. The three tests corresponded to an indication validated by the HAS recommendations. The three tests were negative. 3.3. Third part: qualitative analysis of rapid HIV tests use in family medicine: feedback
112 family physicians having volunteered to parcipate in the study having received rapid HIV
tests The characteristics of the 12 participating physicians in the qualitative survey and the criteria chosen for the maximum variation are presented in Table 2. 3.3.1. Criteria determining the prescription of HIV testing and the use of rapid HIV tests The main criteria used for the proposal of an HIV test were: suspicion of an opportunistic infection, probable STI, use of injected drugs. The physician’s choice was not always based on defined criteria. For some, the proposal was systematic, without any targeting, for others, the proposal was a response to “a seemingly risk case”. Several physicians mentioned the difficulty to discuss and screen for HIV in patients more than 50 years of age. The criteria leading to proposing a rapid HIV test were: the risk of losing patient to follow-up, the patient’s great reluctance to undergo a traditional blood test, and emergency cases. The reported advantages of rapid HIV tests were: the FP’s autonomy and independence, the possible use of rapid HIV tests “outside of the office,” and the low-cost of rapid HIV tests for the patient. Treatment advances were strong arguments to encourage screening. 3.3.2. Impediments for rapid HIV tests use 3.3.2.1. Prevention and screening: difficult activities in family practice. Some mentioned the difficulty to participate in the prevention and screening activities as an FP. Others explained that they performed screening by necessity or obligation, and some felt that they were not qualified for this activity. Some felt that the family physician was not the best partner for prevention
= 11.2% of consulted physicians and 31.8% of physicians having answered the quesonnaire
23 family physicians having received rapid HIV tests, 69 RDTS provided
3 rapid HIV tests performed, (4.4%)
Fig. 3. Recruitment of family practitioners for the study assessing the acceptability and feasibility of HIV screening and use of rapid HIV tests in family practice. Recrutement de l’étude visant à évaluer l’acceptabilité et la faisabilité du dépistage du VIH et de l’utilisation des TROD en médecine générale.
and screening. Many felt that the current organization of primary care was not adapted to these activities. Either screening and prevention did not appear to be a usual reason to consult, or these activities required a specific consultation, difficult to implement. The non-salary organization of family practice did not seem adapted to these time-consuming tasks: workload
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
Table 2 Characteristics of family practitioners having participated in the qualitative study assessing the feasibility of HIV screening by rapid HIV tests in family practice. Caractéristiques des médecins généralistes ayant participé à l’étude qualitative évaluant la faisabilité du dépistage VIH par TROD en médecine générale. Criteria of maximal variation
n = 12 (%)
Gender
Male FP: 9 (75) Female FP: 3 (25) < 40 years of age: 1 (8.3) 40–49: 1 (8.3) 50–59: 5 (41.6) > 60 years of age: 5 (41.6) < 2000: 4 (33.3) 2000–20,000: 3 (25) > 20,000: 5 (41.6) Individual: 8 (66.6) Group: 4 (33.3) Convention type 1: 12 (100) Convention type 2: 0 (0) Yes: 3 (25) No: 9 (75)
Age (in years)
Area of practice (inhabitants)
Type of practice Type of SS convention Participation in a healthcare network (type Drug addiction/Hepatitis/HIV network) Has already announce seropositivity HIV positive patients Opinion on screening and global prevention Opinion on global screening of population 15 to 70 years of age, without risk factors Opinion on use of rapid HIV tests for population at risk, in family medicine Use of rapid HIV tests during the study
Yes: 6 (50) No: 6 (50) Yes: 6 (50) No: 6 (50) Favorable: 10 (83.2) Unfavorable: 2 (16.6) Favorable: 11 (91.6) Unfavorable: 1 (8.3) Favorable: 10 (83.3) Unfavorable: 2 (16.6) Yes: 2 (16.6) No: 10 (83.3)
making it impossible to increase consultation time in a pay per act system, managing multiple concurrent requests during the same consultation, need to involve the patient in the management being time-consuming. 3.3.2.2. The specificities of HIV infection. The low prevalence of HIV and the fact that the “usual patients” of family medicine were not considered as a population at risk increased the impression of an infrequent pathology for patients and their physicians. HIV was a little known pathology for FPs, initially requiring hospital treatment. FPs said that they were less concerned by this disease, gradually excluded from their usual area of expertise. Another impediment was the severity of HIV infection in the opinion of physicians and the global population: “the psychological impact of announcing HIV-positivity is huge and often considered as a death sentence for the patient”. The influence of social, cultural, and religious considerations could prevent the physician and patient from speaking about HIV and performing the test. HIV-positive patients were still strongly stigmatized, by the society and caregivers because HIV is related to sexuality, a concept of sin, and guilt. Some FPs mentioned embarrassment. Proposing an HIV test was not an ordinary prescription. Some FPs explained that proposing to test could alter the physician/patient trust relationship.
5
3.3.2.3. Constraints related to rapid HIV tests use. Another mentioned impediment was the low demand for HIV screening and ignorance of rapid HIV tests by the global population. There is a lack of media relay needed to develop rapid HIV tests, and patients less frequently ask about their HIV status. Furthermore, the proximity to a laboratory would limit the contribution of rapid HIV tests because patients readily agree to undergo blood tests in a laboratory. Some technical constraints have also been reported. Learning how to handle the test was difficult because rapid HIV tests were not used daily. Compared to other rapid tests, they appeared less simple to perform. Time management was a significant limitation. Proposing the test, pre- and post-counselling, and the potential announcement of seropositivity significantly increased the consultation time. Performing the test, ensuring quality control and traceability of results, required a lot of time at the expense of time dedicated to listening to the patient. Finally, the immediacy of the response was a major impediment. The physician had no time to prepare himself and the patient for the announcement of seropositivity, whereas giving results in a second stage made it possible to prepare the announcement and to dampen the consequences. The immediacy of the result could be seen as too intrusive. The patient could feel that he was tested without time to reflect on and consider the consequences. Some physicians preferred not to suggest the test to avoid this predicament. The last constraint mentioned was the lesser rapid HIV test performance compared to conventional blood tests (serologic window extended to 3 months, second serological control test necessary if the first was positive, inability to screen for other STIs concomitantly).
4. Discussion Overall, our study demonstrated that rapid HIV tests were poorly adapted to HIV testing in family practice. Around 76.9% of family practitioners were favorable to rapid HIV tests office use. However, only three rapid HIV tests were used. The authors of two other studies, conducted with French FPS, reported an even lower implementation rate at 1.5% [9,10]. The authors of a study conducted in 27 emergency services offering rapid HIV test systematically to all consultants, reported a higher completion rate of 17.3%. [11] The rapid HIV test could be more suitable for hospital use. Two major barriers to screening, besides the rapid HIV test issue, were identified: the difficulty of achieving screening in family medicine, as well as the complex representations of the HIV pathology among family practitioners and patients. The specific characteristics of family practice (managing multiple concurrent requests in a single consultation, the need to involve the patient in the management with or without his consent while ensuring a long-term relationship, and the multiplicity of potential prevention and screening actions useful for the patient) were impediments preventing family practitioners from participating in screening campaigns.
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8 6
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
Nevertheless, prevention and screening are part of FPs’ missions [12,13]. The FP’s activities are carried out in an often-limited time and lengthening consultation time is a major impediment to using the test [9,10]. Around 91.4% of surveyed FPs would like to have more time to better fulfil their public health missions [14,15,16,17]. This limitation is closely related to the pay per act of FPs, and complicated by a decrease in the number FPs. Changing the payment mode could improve the feasibility of screening activities. Compensation by salary could be associated to longer consultations allowing the family physician to better adapt his care management [18,19,20]. Another possibility would be to specifically pay the physician for screening [21]. Introducing lump sum to pay for this extra activity could also improve adherence of FPs. The introduction of financial incentives to reward “performance” and “quality” as in the CAPI program (Contract improvement of individual practices) in France, and the “Quality and Outcomes Framework” program in England are already being tested. Nevertheless, the authors of several Cochrane reviews concluded that there was not enough evidence to determine whether these programs could lead to improving the quality of care [22,23]. Some primary care centers in GreatBritain have validated the transfer of jurisdiction and proposed consultations with a family physician and a nurse. The screening rate could be twice higher when it was performed by nurses trained in screening and counselling [24]. The implementation of a true interprofessional collaboration would present many assets [25]. Other means can be suggested: facilitate access to HIV epidemiological knowledge and increase training for rapid HIV tests use by providing of practical material [14]; adapting cancer screening software aid, based on risk factors, to HIV issue; the promotion of screening could be included in the existing activity “consultations for prevention at different stages of life” so that strategies adapted to family practice would be consistent with national plans; further upstream, training on public health issues and use of future screening and prevention tools should be integrated into the future FPs’ curriculum. Despite all the breakthroughs, HIV is still a disease associated with many ambiguous representations, with fear of detection and denial of risk. Stigma, lack of training, feeling it is a peculiar disease, was detected in the study as impediments to an effective screening. The perception of personal risk of HIV infection is low in the global population [26]. However, several authors have demonstrated that a lower perception of personal risk was a risk factor for late detection [27,28], as being over 40 years of age, being a foreigner, and a heterosexual mode of transmission [29]. Another author found that “senior citizens”, heterosexual men, and married individuals without children and without reported multiple sexual partners, were the most frequent risks for late treatment [30]. Yet it is these populations, with low obvious risk factors, that interviewed physicians had a hard time to bring to screening. Physicians frequently underestimate the risk behaviour of their patients [31]. The authors of a recent French study reported a very high rate missed opportunities for screening [32]. It would be useful to provide physicians with epidemiological, medical, and economic arguments on
the contribution of screening once in a lifetime, in the global population (improved survival rate, cost-effective action plan [33]). The results of an INPES study [34] showed that one of the most difficult topics was sexuality. Religious and cultural considerations limit the exchange between physician and patient when speaking about sexuality and therefore about HIV. The authors of a French study indicated that a strong religious practice was a limitation for proposal and acceptance of screening tests [35]. The fear of HIV seropositivity is also a major limitation to screening both for the physician and the patient. Several authors have reported that fear of positivity and its potential impact on the quality of life were the 2 main impediments for the patient, to achieve HIV testing [36,37,38,39]. Some physicians and patients agree not to have to announce or to hear about HIV-positivity. The potential announcement of HIV positivity is also a major limitation to the proposal of HIV testing for FPs [23,40]. The difficulty to assess whether the patient is mentally apt to hearing the diagnosis and the fear of triggering anxiety are stress factors mentioned by FPs [16,40]. Finally, the difficulty to adequately perform the test was also mentioned in other studies [9,10]. Our study had limitations. The first part of the study was intended to obtain the FPs opinion about rapid HIV tests, using a questionnaire, before providing them with tests. Closed questions can be adapted to the observation of simple indicators but they are more difficult to use when it for subjective or complex issues. This limitation was partially compensated by adding open questions. Another limitation was that the answers collected with the questionnaire were not spontaneous, but instigated, and that the data was declarative. Physicians could have been inclined to provide the estimated “correct” answer. The physicians included in the last part were a cohort of volunteer practitioners, not representative of the FP population. The selection bias related to the completed questionnaires on a voluntary basis was limited by randomization (only 3.7% of physicians participating in a network, compared to 8.8% according to the 2009 Healthcare Barometer). The sociodemographic data of randomized FPs and their patients’ profile were comparable to those of French FPs [34]. The 23 physicians included in the qualitative survey were favorable to rapid HIV tests use but only three rapid HIV tests were performed. Despite this bias, our investigation proved that rapid HIV tests were not adapted to family medicine practice, even in a population of physicians favorable to their use. Our quantitative survey did not allow anticipating future behaviours. The usual biases of qualitative analysis are undeniable. Nevertheless, matching quantitative and qualitative results, and comparing opinions before and after providing tests added value to the answers provided. This double reading allowed comparing opinions and experienced facts. The rapid HIV test does not appear to be adapted to HIV testing in family practice. There are many impediments to their use in office practice but rapid HIV tests may be useful “outside of the office” as self-tests. The social considerations of HIV, including cultural and ethical ones, influence behaviours quite specifically. They require innovative solutions. Improving the screening conditions will probably require, as suggested by the HAS, making rapid HIV tests use more common and available.
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Contributions of authors C. Poirier, L. Guillon, JP. Lebeau, L. Bernard, and G. Gras helped draft the study protocol. C. Poirier, L. Guillon, JP. Lebeau, L. Bernard, G. Gras, P. Le Bret, and G. Lemoal participated in the study. C. Poirier, S. Aymeric, L. Guillon, JP. Lebeau, L. Bernard, and G. Gras helped write the article. Acknowledgements The Region Centre Union of Healthcare Professionals– Private Practitioners (French acronym URPS-ML) that provided material and technical support for the random selection of physicians and sending questionnaires. Valerie Chaigne, Muriel Ribadeau, and Gaelle Fajole of the Centre/Poitou-Charente COREVIH. Etienne Huard, MD, for the Val de Loire HIV Association. This project was supported by the Centre/Poitou-Charente COREVIH and the Val de Loire HIV Association, with a total budget estimated at 8000 euros. References [1] Cazein F, Pinget R, Lot F, Pillonel J, Le Strat Y, Sommen C, et al. Découvertes de séropositivité VIH et SIDA – France, 2003–2011. Bull Épidémiol Hebd 2013;(28-29):333. [2] Supervie V, Costagliola D. The spectrum of engagement in HIV care in France: strengths and gaps. In: 20th Conference on retroviruses and opportunistic infections. Atlanta (USA); 2013. [3] Ndawinz JDA, Costagliola D, Supervie V. New method for estimating HIV incidence and time from infection to diagnosis using HIV surveillance data: results for France. AIDS Lond Engl 2011;25(15):1905–13. [4] Morlat P. Prise en charge médicale des personnes vivant avec le VIH Recommandations groupe d’experts; 2013 [978-2-11-009563-3]. [5] Ministère du Travail, de l’Emploi et de la Santé. Plan national de lutte contre le VIH-SIDA et les IST 2010-2014; 2010. [6] Arrêté du 9 novembre 2010 fixant les conditions de réalisation des tests rapides d’orientation diagnostique de l’infection à virus de l’immunodéficience humaine (VIH 1 et 2). [7] Pavie J, Rachline A, Loze B, Niedbalski L, Delaugerre C, Laforgerie E, et al. Sensitivity of five rapid HIV tests on oral fluid or finger-stick whole blood: a real-time comparison in a healthcare setting. PLoS One 2010;5(7):e11581. [8] Glaser BG. The constant comparative method of qualitative analysis. Soc Probl 1965;12(4):436–45. [9] Gauthier R, Livrozet JM, Prevoteau du Clary F, Taulera O, Bouée S, Aubert JP, et al. Feasibility and acceptability of rapid HIV test screening (DEPIVIH) by French family physicians. Med Mal Infect 2012. [10] Aubert WAJSBROTA. Barriers to implement rapid HIV Testing (RHT) in French General Practitioners’ Offices. In: 13th European AIDS Conference (EACS). Serbia: Belgrade; 2011. [11] Cremieux AC, d’Almeida Wilson K, Kierzek G, de Truchis P, Le Vu S, Pateron D, et al. Acceptabilité et faisabilité du dépistage systématique du VIH dans 27 services d’urgences d’Île-de-France (ANRS 95008 et Sidaction), mai 2009–août 2010. Numéro thématique. L’infection à VIH-sida en France en 2009 : dépistage, nouveaux diagnostics et incidence; 2010.
7
[12] Loi no 2002-303 du 4 mars 2002 relative aux droits des malades et à la qualité du système de santé. 2002. [13] OMS. « Cadre pour le développement professionnel et administratif de la médecine générale – médecine de famille – en Europe ». Société franc¸aise de médecine générale société savante; sept 1999. [14] Korthuis PT, Berkenblit GV, Sullivan LE, Cofrancesco Jr J, Cook RL, Bass M, et al. General internists’ beliefs, behaviors, and perceived barriers to routine HIV screening in primary care. AIDS Educ Prev Off Publ Int Soc AIDS Educ 2011;23(3 Suppl.):70. [15] Kellock DJ, Rogstad KE. Attitudes to HIV testing in general practice. Int J STD AIDS 1998;9(5):263–7. [16] Burke RC, Sepkowitz KA, Bernstein KT, Karpati AM, Myers JE, Tsoi BW, et al. Why don’t physicians test for HIV? A review of the US literature. AIDS Lond Engl 2007;21(12):1617–24. [17] Turban F [Thèse d’exercice] Education thérapeutique du patient en médecine générale : représentations, pratiques et attentes des praticiens de la somme. France: Université de Picardie; 2008. [18] Gosden T, Pedersen L, Torgerson D. How should we pay doctors? A systematic review of salary payments and their effect on doctor behaviour. Quaterly J Med 1999;92(1):47–55. [19] Gosden T, Sibbald B, Williams J, Petchey R, Leese B. Paying doctors by salary: a controlled study of general practitioner behaviour in England. Health Policy 2003;64(3):415–23. [20] Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, et al. Impact of payment method on behaviour of primary care physicians: a systematic review. J Health Serv Res Policy 2001;6(1):44–55. [21] Ruelle Y. The role of European general practitioners in cervical cancer screening and its effects on the success of this screening. Istanbul: Wonca Europe; 2008. [22] Scott A, Sivey P, Ait Ouakrim D, Willenberg L, Naccarella L, Furler J, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev 2011;(9):CD008451. [23] Giuffrida A, Gosden T, Forland F, Kristiansen IS, Sergison M, Leese B, et al. Target payments in primary care: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2000;(3):CD000531. [24] Anaya HD, Hoang T, Golden JF, Goetz MB, Gifford A, Bowman C, et al. Improving HIV screening and receipt of results by nurse-initiated streamlined counseling and rapid testing. J Gen Intern Med 2008;23(6):800–7. [25] Barrett J, Curran V, Glynn L, Godwin M. Synthèse de la Fondation canadienne de la recherche sur les services de santé : collaboration interprofessionnelle et services de santé de première ligne de qualité. Canadian Health Services Research Foundation; 2007. [26] Saboni L. Vingt years d’évolution des connaissances, attitudes, croyances et comportements face au VIH/sida en France métropolitaine. ANRS-ORSInpes-IReSP-DGS, Observatoire régional de santé d’Île-de-France, Paris, France. [27] Lanoy E, Mary-Krause M, Tattevin P, Perbost I, Poizot-Martin I, Dupont C, et al. Frequency, determinants and consequences of delayed access to care for HIV infection in France. Antivir Ther 2007;12(1):89. [28] Couturier E, Schwoebel V, Michon C, Hubert JB, Delmas MC, Morlat P, et al. Determinants of delayed diagnosis of HIV infection in France. AIDS 1998;12:795–800. [29] InVS (Institut de Veille Sanitaire). « Lutte contre le VIH/sida et les infections sexuellement transmissibles en France: 10 years de surveillance, 1996-2005 »; 2007. [30] Delpierre C, Dray-Spira R, Cuzin L, Marchou B, Massip P, Lang T, et al. Correlates of late HIV diagnosis: implications for testing policy. Int J STD AIDS 2007;18(5):312–7. [31] Boekeloo BO, Marx ES, Kral AH, Coughlin SC, Bowman M, Rabin DL. Frequency and thoroughness of STD/HIV risk assessment by physicians in a high-risk metropolitan area. Am J Public Health 1991;81(12):1645– 8. [32] Champenois K, Cousien A, Cuzin L, Le Vu S, Deuffic-Burban S, Lanoy E, et al. Missed opportunities for HIV testing in newly-HIV-diagnosed patients, a cross sectional study. BMC Infect Dis 2013;13(1):200. [33] Yazdanpanah Y, Sloan CE, Charlois-Ou C, Le Vu S, Semaille C, Costagliola D, et al. Routine HIV screening in France: clinical impact and costeffectiveness. PLoS One 2010;5(10):e13132.
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8 8
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
[34] Lert F, Lydié N, Richard JB. Baromètre santé médecins généralistes. Les médecins généralistes face au dépistage du VIH : nouveaux enjeux, nouvelles pratiques ? Institut national de prévention et d’éducation pour la santé; 2009. [35] Fernandez-Gerlinger MP, Bernard E, Saint-Lary O. What do patients think about HIV mass screening in France? A qualitative study. BMC Public Health 2013;13(1):526. [36] Mikolajczak J, Hospers HJ, Kok G. Reasons for not taking an HIV-test among untested men who have sex with men: an Internet study. AIDS Behav 2006;10(4):431–5. [37] Forsyth SF, Agogo EA, Lau L, Jungmann E, Man S, Edwards SG, et al. Would offering rapid point-of-care testing or non-invasive methods
improve uptake of HIV testing among high-risk genitourinary medicine clinic attendees? A patient perspective. Int J STD AIDS 2008;19(8):550–2. [38] De Wit JBF, Adam PCG. To test or not to test: psychosocial barriers to HIV testing in high-income countries. HIV Med 2008;9(Suppl. 2):20–2. [39] Flowers P, Duncan B, Knussen C. Re-appraising HIV testing: an exploration of the psychosocial costs and benefits associated with learning one’s HIV status in a purposive sample of Scottish gay men. Br J Health Psychol 2003;8(2):179–94. [40] Deblonde J, De Koker P, Hamers FF, Fontaine J, Luchters S, Temmerman M. Barriers to HIV testing in Europe: a systematic review. Eur J Public Health 2010;20(4):422–32.
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
ARTICLE IN PRESS Disponible en ligne sur
ScienceDirect www.sciencedirect.com Médecine et maladies infectieuses xxx (2015) xxx–xxx
Original article
Rapid HIV test in family practice夽 Tests rapides d’orientation diagnostique pour le VIH (TROD) en médecine générale C. Poirier a,∗,b , S. Aymeric b,c,d , L. Grammatico-Guillon b,c,d , J.P. Lebeau b,d,e , L. Bernard a,b , P. Le Bret f , G. Le Moal g , G. Gras a a
Service de médecine interne et maladies infectieuses, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France b Université Fran¸ cois-Rabelais, 60, rue du Plat-D’Étain, 37020 Tours cedex 1, France c Service d’information médicale d’épidémiologie et d’économie de la santé, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France d Équipe émergente éducation éthique santé, 60, rue du Plat-D’Étain, 37020 Tours cedex 1, France e Département universitaire de médecine générale, 60, rue du Plat-D’Étain, 37020 Tours cedex 1, France f Réseau ville hôpital VIH 37, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France g COREVIH centre Poitou-Charentes, service de maladies infectieuses et tropicales, CHRU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers cedex, France Received 19 January 2015; accepted 24 March 2015
Abstract Background. – The 2010-2014 HIV/AIDS French program recommends using HIV rapid diagnostic tests in family practice. Our aim was to assess the acceptability and feasibility of the RDT in family practice in France. Methods. – The first part of this study was to determine the opinions of family practitioners (FPs) concerning the news guidelines for screening and the possible use of rapid HIV tests in their practice. The second part was a feasibility study of the actual use of rapid HIV tests given to FPs during six months. The third part was a qualitative analysis of experience feedback to determine the impediments to using rapid HIV tests. Results. – Seventy-seven percent of the 352 FPs interviewed were favorable to rapid HIV tests use. The three main impediments were: misinterpretation of test result, complexity of quality control, and lack of training: 23 of the 112 FPs having volunteered to evaluate the rapid HIV tests followed the required training session. Sixty-nine tests were handed out, and three rapid HIV tests were used; the qualitative study involved 12 FPs. The participants all agreed on the difficult use of rapid HIV tests in daily practice. The main reasons were: too few opportunities or requests for use, complex handling, difficulties in proposing the test, fear of having to announce seropositivity, significantly longer consultation. Conclusion. – Although FPs are generally favorable to rapid HIV tests use in daily practice, the feasibility and contribution of rapid HIV tests are limited in family practice. © 2015 Elsevier Masson SAS. All rights reserved. Keywords: Family practice; HIV screening; Rapid HIV tests
Résumé Introduction. – Le plan VIH/sida 2010/2014 préconise d’évaluer l’utilisation des tests rapides d’orientation diagnostique (TROD) en médecine générale. L’objectif était de déterminer l’acceptabilité et la faisabilité des TROD en médecine générale, ainsi que les freins limitant leur utilisation. Méthode. – Le premier volet de cette étude était descriptif de l’opinion des médecins généralistes en région centre vis-à-vis des recommandations de dépistage et de l’utilisation des TROD en médecine générale. Le deuxième volet était une étude de soins primaires interventionnelle avec mise à disposition de TROD auprès des médecins généralistes durant 6 mois. Le troisième volet était une étude qualitative de retour d’expérience, visant à définir les freins à l’utilisation des TROD en médecine générale.
夽
This article was presented in the following congresses: 14th Congress of the French Society for the Prevention of AIDS (French acronym SFLS) in Poitiers, from October 24 to 25, 2013 and RICAI 2014 – 34th Interdisciplinary Meeting on Anti-infectious Chemotherapy, from November 27 to 28, 2014 in Paris. ∗ Corresponding author. E-mail addresses: poirier [email protected] (C. Poirier), [email protected] (S. Aymeric). http://dx.doi.org/10.1016/j.medmal.2015.03.010 0399-077X/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8 2
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
Résultats. – Parmi les 352 médecins généralistes interrogés, 77 % étaient favorables aux TROD. Trois principaux freins étaient évoqués : potentielles erreurs d’interprétation, contrôle qualité fastidieux, manque de formation : sur les 112 médecins généralistes de l’étude évaluant les TROD en soins primaires, 23 ont suivi la formation, 69 TROD ont été distribués, trois TROD ont été réalisés ; l’analyse qualitative concernait 12 médecins généralistes. Les TROD ne semblaient pas adaptés à la médecine générale. Les principales raisons évoquées étaient : peu d’occasions et peu de demandes, manipulation du test complexe, difficultés à proposer le test, crainte d’avoir à annoncer une séropositivité sans préparation préalable, rallongement majeur de la durée de consultation. Conclusion. – Si l’acceptabilité des TROD par les médecins généralistes paraît bonne, la faisabilité et l’intérêt des TROD sont limités en médecine générale. © 2015 Elsevier Masson SAS. Tous droits réservés. Mots clés : Dépistage du VIH ; Médecine générale ; TROD
1. Introduction In France, 150,000 people are infected with the Human Immunodeficiency Virus (HIV), and 6100 new patients are infected every year [1]. Nineteen percent of HIV-positive patients are not diagnosed [2]. The delay before management is a major risk factor for mortality. An average four years was recorded in 2011, between HIV infection and the diagnosis [3] that was made for 29% of patients at an advanced stage (AIDS or CD4 < 200/mm3 ). Five million HIV tests are performed every year in France, 77 serologic tests per 1000 inhabitants, placing the country second in Europe for screening. Seventy-five percent of the tests are performed in private laboratories [4]. The 2010/2014 national HIV/STI (sexually transmitted infections) plan is based on a new proactive strategy of HIV screening [5], with a reinforced screening of at-risk populations, and an accessible screening for the global population (screening proposed at least once in a lifetime for all the population 15 to 70 years of age, when consulting with primary care health professionals, even without any risk exposure). Family practitioners (FPs) were identified as the key physician and involved. The rapid HIV test, a new tool, was made available to them and paramedics, to complete screening procedures. This test, with immediate results, could help decrease the 30,000 people who ignore their status, and could facilitate access to screening. The November 9, 2010 decree sets the circumstances and determines the target populations for rapid HIV tests use in family practice [6]. Rapid HIV tests are, for the moment, neither available free of charge for FPs or refunded. Only few authors have assessed the acceptability and feasibility of these tests in primary care. Our objective was to investigate the acceptability and feasibility of rapid HIV tests in family medicine, and to determine the impediment to their use.
2. Materials and methods We conducted a prospective multicenter, observational, and interventional study of primary care, between May 2012 and July 2013. The method was both quantitative and qualitative.
The first part was a descriptive study of the FPs opinion concerning the new recommendations for screening and use of rapid HIV tests in family practice. The second part was a 6-month interventional study of primary care with provision of rapid HIV tests for FPs. The last part was dedicated to collecting experience data for a qualitative analysis of impediments and potential limitations of rapid HIV tests use in family practice.
2.1. First part: opinion of family practitioners on HIV testing and rapid HIV tests use in daily practice: a descriptive study The FPs were randomly selected from the computer files of the Regional Union of Healthcare Professionals (URPS) of the region Centre. Physicians with an exclusive practice mode (MEP) and SOS physicians were excluded. The selected FPs were sent a multiple-choice questionnaire on their practice concerning prevention and HIV testing. Comparisons were made with Fisher’s exact test. The data was processed with Microsoft Excel® .
2.2. Second part: assessing the feasibility of rapid HIV tests use in family medicine: an interventional study The FPS who had received the questionnaire were asked to participate in the feasibility study. Each then received three rapid HIV tests and a quality assurance workbook. The primary endpoint was the number of proposals for a rapid HIV test, followed or not by its use. The indications for rapid HIV tests use were those recommended by the High Authority for Health (French acronym HAS): populations considered at “risk” and “emergency” situations [5]. The inclusion criteria were: criteria for offering rapid HIV test met, adult patient 18 years of age or more, and written consent. The exclusion criteria were: known HIV seropositivity, or patient under guardianship. The test used was a qualitative single-use INSTI HIV1/HIV 2® in vitro diagnostic test, allowing the detection of anti-HIV 1 and 2 antibodies in capillary blood. The sensitivity and specificity of this immediate visual reading test were > 99.5% [7].
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
3
2.3. Third part: qualitative analysis of rapid HIV tests use in family medicine: feedback Participants were recruited through a reasoned sampling. Collective and semi-structured individual interviews were offered to FPs to share experience and determine the impediments associated with the use of rapid HIV tests. The interviews were conducted from June to July 2013 until data saturation. Two focus groups and six telephone interviews were conducted. The verbatim analysis was conducted by grounded theory method according to the constant comparative method of qualitative analysis [8]. The encoding and qualitative analysis were performed with the QSR NVivo-software. 3. Results 3.1. First part: opinion of family practitioners on HIV testing and rapid HIV tests use in daily practice The questionnaire was sent to 1000 FPs, and was completed by 352 physicians. Table 1 summarizes the characteristics of responding FPs. Few physicians were well aware of the issue prior to HIV testing since only 3.7% participated in a drug Table 1 Characteristics of family practitioners having participated in the survey on the acceptability of HIV screening and the use of rapid HIV tests in family practice (FP). Caractéristiques des médecins généralistes ayant participé à l’enquête sur l’acceptabilité du dépistage du VIH et l’utilisation des TROD en médecine générale. Characteristics
n = 352 (%)
Gender
Male FP: 235 (66.8) Female FP: 117 (33.2) < 40 years of age: 48 (13.6) 40–49: 72 (20.4) 50–59: 143 (40.6) > 60 years of age: 89 (25.3) 10–20: 64 (18.2) 21–30: 179 (50.8) > 30: 108 (30.7) Not documented: 1 (0.3) < 2000: 83 (23.6) 2000–20,000: 162 (46) > 20,000: 105 (28.8) Not documented: 2 (0.6) Individual: 149 (42.3) Group: 198 (56.2) Not documented: 5 (1.4) Convention type 1: 352 (100) Convention type 2: 0 (0) Acupuncture: 14 (3.9) Homeopathy: 29 (8.2) Mesotherapy: 25 (7.1) Others: 30 (8.5) Not documented: 282 (80.1) Cancer and palliative care network: 20 (5.7) Drug addiction/Hepatitis/HIV network: 13 (3.7) Diabetes network: 58 (16.5) Gerontology network: 9 (2.6) Others (perinatality MS, MAP, etc.): 19 (5.4)
Age (in years)
Number of daily consultations
Area of practice (inhabitants)
Type of practice
Type of SS convention Specific FP sub-practice
Participation in a healthcare network
Fig. 1. Prescription of HIV tests by family practitioners according to the settings, in the survey for the acceptability of HIV screening and rapid HIV tests use, n = 352. Pratique de prescription des sérologies VIH par les médecins généralistes en fonction de la situation, dans l’enquête d’acceptabilité du dépistage VIH et des TROD, n = 352.
addiction hepatitis-HIV network. Thirty percent (n = 104) of the physicians surveyed did not manage any HIV positive patient. Sixty-three percent (n = 221) of physicians managing HIV positive patients had only one to four HIV patients and 50.3% (n = 177) did not renew the antiretroviral treatment for their patient. Around 98.6% of the surveyed physicians were favorable to screening and prevention globally, and 96% considered that prevention in the field of sexual activity concerned the family practitioner. Concerning their activity in terms of HIV screening, 52% (n = 183) of the surveyed physicians said they had carried out between two and five HIV tests in the previous month. Fig. 1 describes the practice of family practitioners for targeted HIV screening in four common cases: STI, patient from a country of high endemicity, change of sexual activity and partners, sexually active young patient. The surveyed physicians reported prescribing HIV screening readily in these cases. Around 71.3% of the surveyed physicians were favorable to the global screening of the population from 15 to 70 years of age, without any risk factor, and 77% of them were favorable (20.2% “very favorable”, 56.8% “favorable”) to the use of rapid HIV tests in family practice, in case of risk exposure. Seventy-three percent (n = 257) of the surveyed physicians considered that there were impediments to the use of rapid HIV tests in daily practice. The four main impediments were potential test interpretation errors (54.8%), quality control (51.1%), a lack of training, and being time-consuming for the consultation (50%) (Fig. 2).
3.2. Second part: assessing the feasibility of rapid HIV tests use in family medicine Twenty-three FPs participated in the evaluation of rapid HIV tests in family practice. Only three rapid HIV tests, out of the 69 distributed, were used during the survey (Fig. 3). Two for an accidental exposure to viral risk in retirement homes (source patient and nurse), and one for a drug-addict having made the
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8 4
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
Region Centre: 3,062 family physicians 113 dermatologists 95 gynecologists
1,143 randomized physicians, including 1,000 family physicians, 95 dermatologists and 48 gynecologists Fig. 2. Impediments mentioned for the use of rapid HIV tests by family practitioners, in the survey for the acceptability of HIV screening and rapid HIV tests use in family practice, n = 352. Freins évoqués à l’utilisation des TROD par les médecins généralistes dans l’enquête sur l’acceptabilité du dépistage du VIH et de l’utilisation des TROD en médecine générale, n = 352.
352 responding family physicians
request. The three tests corresponded to an indication validated by the HAS recommendations. The three tests were negative. 3.3. Third part: qualitative analysis of rapid HIV tests use in family medicine: feedback
112 family physicians having volunteered to parcipate in the study having received rapid HIV
tests The characteristics of the 12 participating physicians in the qualitative survey and the criteria chosen for the maximum variation are presented in Table 2. 3.3.1. Criteria determining the prescription of HIV testing and the use of rapid HIV tests The main criteria used for the proposal of an HIV test were: suspicion of an opportunistic infection, probable STI, use of injected drugs. The physician’s choice was not always based on defined criteria. For some, the proposal was systematic, without any targeting, for others, the proposal was a response to “a seemingly risk case”. Several physicians mentioned the difficulty to discuss and screen for HIV in patients more than 50 years of age. The criteria leading to proposing a rapid HIV test were: the risk of losing patient to follow-up, the patient’s great reluctance to undergo a traditional blood test, and emergency cases. The reported advantages of rapid HIV tests were: the FP’s autonomy and independence, the possible use of rapid HIV tests “outside of the office,” and the low-cost of rapid HIV tests for the patient. Treatment advances were strong arguments to encourage screening. 3.3.2. Impediments for rapid HIV tests use 3.3.2.1. Prevention and screening: difficult activities in family practice. Some mentioned the difficulty to participate in the prevention and screening activities as an FP. Others explained that they performed screening by necessity or obligation, and some felt that they were not qualified for this activity. Some felt that the family physician was not the best partner for prevention
= 11.2% of consulted physicians and 31.8% of physicians having answered the quesonnaire
23 family physicians having received rapid HIV tests, 69 RDTS provided
3 rapid HIV tests performed, (4.4%)
Fig. 3. Recruitment of family practitioners for the study assessing the acceptability and feasibility of HIV screening and use of rapid HIV tests in family practice. Recrutement de l’étude visant à évaluer l’acceptabilité et la faisabilité du dépistage du VIH et de l’utilisation des TROD en médecine générale.
and screening. Many felt that the current organization of primary care was not adapted to these activities. Either screening and prevention did not appear to be a usual reason to consult, or these activities required a specific consultation, difficult to implement. The non-salary organization of family practice did not seem adapted to these time-consuming tasks: workload
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
Table 2 Characteristics of family practitioners having participated in the qualitative study assessing the feasibility of HIV screening by rapid HIV tests in family practice. Caractéristiques des médecins généralistes ayant participé à l’étude qualitative évaluant la faisabilité du dépistage VIH par TROD en médecine générale. Criteria of maximal variation
n = 12 (%)
Gender
Male FP: 9 (75) Female FP: 3 (25) < 40 years of age: 1 (8.3) 40–49: 1 (8.3) 50–59: 5 (41.6) > 60 years of age: 5 (41.6) < 2000: 4 (33.3) 2000–20,000: 3 (25) > 20,000: 5 (41.6) Individual: 8 (66.6) Group: 4 (33.3) Convention type 1: 12 (100) Convention type 2: 0 (0) Yes: 3 (25) No: 9 (75)
Age (in years)
Area of practice (inhabitants)
Type of practice Type of SS convention Participation in a healthcare network (type Drug addiction/Hepatitis/HIV network) Has already announce seropositivity HIV positive patients Opinion on screening and global prevention Opinion on global screening of population 15 to 70 years of age, without risk factors Opinion on use of rapid HIV tests for population at risk, in family medicine Use of rapid HIV tests during the study
Yes: 6 (50) No: 6 (50) Yes: 6 (50) No: 6 (50) Favorable: 10 (83.2) Unfavorable: 2 (16.6) Favorable: 11 (91.6) Unfavorable: 1 (8.3) Favorable: 10 (83.3) Unfavorable: 2 (16.6) Yes: 2 (16.6) No: 10 (83.3)
making it impossible to increase consultation time in a pay per act system, managing multiple concurrent requests during the same consultation, need to involve the patient in the management being time-consuming. 3.3.2.2. The specificities of HIV infection. The low prevalence of HIV and the fact that the “usual patients” of family medicine were not considered as a population at risk increased the impression of an infrequent pathology for patients and their physicians. HIV was a little known pathology for FPs, initially requiring hospital treatment. FPs said that they were less concerned by this disease, gradually excluded from their usual area of expertise. Another impediment was the severity of HIV infection in the opinion of physicians and the global population: “the psychological impact of announcing HIV-positivity is huge and often considered as a death sentence for the patient”. The influence of social, cultural, and religious considerations could prevent the physician and patient from speaking about HIV and performing the test. HIV-positive patients were still strongly stigmatized, by the society and caregivers because HIV is related to sexuality, a concept of sin, and guilt. Some FPs mentioned embarrassment. Proposing an HIV test was not an ordinary prescription. Some FPs explained that proposing to test could alter the physician/patient trust relationship.
5
3.3.2.3. Constraints related to rapid HIV tests use. Another mentioned impediment was the low demand for HIV screening and ignorance of rapid HIV tests by the global population. There is a lack of media relay needed to develop rapid HIV tests, and patients less frequently ask about their HIV status. Furthermore, the proximity to a laboratory would limit the contribution of rapid HIV tests because patients readily agree to undergo blood tests in a laboratory. Some technical constraints have also been reported. Learning how to handle the test was difficult because rapid HIV tests were not used daily. Compared to other rapid tests, they appeared less simple to perform. Time management was a significant limitation. Proposing the test, pre- and post-counselling, and the potential announcement of seropositivity significantly increased the consultation time. Performing the test, ensuring quality control and traceability of results, required a lot of time at the expense of time dedicated to listening to the patient. Finally, the immediacy of the response was a major impediment. The physician had no time to prepare himself and the patient for the announcement of seropositivity, whereas giving results in a second stage made it possible to prepare the announcement and to dampen the consequences. The immediacy of the result could be seen as too intrusive. The patient could feel that he was tested without time to reflect on and consider the consequences. Some physicians preferred not to suggest the test to avoid this predicament. The last constraint mentioned was the lesser rapid HIV test performance compared to conventional blood tests (serologic window extended to 3 months, second serological control test necessary if the first was positive, inability to screen for other STIs concomitantly).
4. Discussion Overall, our study demonstrated that rapid HIV tests were poorly adapted to HIV testing in family practice. Around 76.9% of family practitioners were favorable to rapid HIV tests office use. However, only three rapid HIV tests were used. The authors of two other studies, conducted with French FPS, reported an even lower implementation rate at 1.5% [9,10]. The authors of a study conducted in 27 emergency services offering rapid HIV test systematically to all consultants, reported a higher completion rate of 17.3%. [11] The rapid HIV test could be more suitable for hospital use. Two major barriers to screening, besides the rapid HIV test issue, were identified: the difficulty of achieving screening in family medicine, as well as the complex representations of the HIV pathology among family practitioners and patients. The specific characteristics of family practice (managing multiple concurrent requests in a single consultation, the need to involve the patient in the management with or without his consent while ensuring a long-term relationship, and the multiplicity of potential prevention and screening actions useful for the patient) were impediments preventing family practitioners from participating in screening campaigns.
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8 6
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
Nevertheless, prevention and screening are part of FPs’ missions [12,13]. The FP’s activities are carried out in an often-limited time and lengthening consultation time is a major impediment to using the test [9,10]. Around 91.4% of surveyed FPs would like to have more time to better fulfil their public health missions [14,15,16,17]. This limitation is closely related to the pay per act of FPs, and complicated by a decrease in the number FPs. Changing the payment mode could improve the feasibility of screening activities. Compensation by salary could be associated to longer consultations allowing the family physician to better adapt his care management [18,19,20]. Another possibility would be to specifically pay the physician for screening [21]. Introducing lump sum to pay for this extra activity could also improve adherence of FPs. The introduction of financial incentives to reward “performance” and “quality” as in the CAPI program (Contract improvement of individual practices) in France, and the “Quality and Outcomes Framework” program in England are already being tested. Nevertheless, the authors of several Cochrane reviews concluded that there was not enough evidence to determine whether these programs could lead to improving the quality of care [22,23]. Some primary care centers in GreatBritain have validated the transfer of jurisdiction and proposed consultations with a family physician and a nurse. The screening rate could be twice higher when it was performed by nurses trained in screening and counselling [24]. The implementation of a true interprofessional collaboration would present many assets [25]. Other means can be suggested: facilitate access to HIV epidemiological knowledge and increase training for rapid HIV tests use by providing of practical material [14]; adapting cancer screening software aid, based on risk factors, to HIV issue; the promotion of screening could be included in the existing activity “consultations for prevention at different stages of life” so that strategies adapted to family practice would be consistent with national plans; further upstream, training on public health issues and use of future screening and prevention tools should be integrated into the future FPs’ curriculum. Despite all the breakthroughs, HIV is still a disease associated with many ambiguous representations, with fear of detection and denial of risk. Stigma, lack of training, feeling it is a peculiar disease, was detected in the study as impediments to an effective screening. The perception of personal risk of HIV infection is low in the global population [26]. However, several authors have demonstrated that a lower perception of personal risk was a risk factor for late detection [27,28], as being over 40 years of age, being a foreigner, and a heterosexual mode of transmission [29]. Another author found that “senior citizens”, heterosexual men, and married individuals without children and without reported multiple sexual partners, were the most frequent risks for late treatment [30]. Yet it is these populations, with low obvious risk factors, that interviewed physicians had a hard time to bring to screening. Physicians frequently underestimate the risk behaviour of their patients [31]. The authors of a recent French study reported a very high rate missed opportunities for screening [32]. It would be useful to provide physicians with epidemiological, medical, and economic arguments on
the contribution of screening once in a lifetime, in the global population (improved survival rate, cost-effective action plan [33]). The results of an INPES study [34] showed that one of the most difficult topics was sexuality. Religious and cultural considerations limit the exchange between physician and patient when speaking about sexuality and therefore about HIV. The authors of a French study indicated that a strong religious practice was a limitation for proposal and acceptance of screening tests [35]. The fear of HIV seropositivity is also a major limitation to screening both for the physician and the patient. Several authors have reported that fear of positivity and its potential impact on the quality of life were the 2 main impediments for the patient, to achieve HIV testing [36,37,38,39]. Some physicians and patients agree not to have to announce or to hear about HIV-positivity. The potential announcement of HIV positivity is also a major limitation to the proposal of HIV testing for FPs [23,40]. The difficulty to assess whether the patient is mentally apt to hearing the diagnosis and the fear of triggering anxiety are stress factors mentioned by FPs [16,40]. Finally, the difficulty to adequately perform the test was also mentioned in other studies [9,10]. Our study had limitations. The first part of the study was intended to obtain the FPs opinion about rapid HIV tests, using a questionnaire, before providing them with tests. Closed questions can be adapted to the observation of simple indicators but they are more difficult to use when it for subjective or complex issues. This limitation was partially compensated by adding open questions. Another limitation was that the answers collected with the questionnaire were not spontaneous, but instigated, and that the data was declarative. Physicians could have been inclined to provide the estimated “correct” answer. The physicians included in the last part were a cohort of volunteer practitioners, not representative of the FP population. The selection bias related to the completed questionnaires on a voluntary basis was limited by randomization (only 3.7% of physicians participating in a network, compared to 8.8% according to the 2009 Healthcare Barometer). The sociodemographic data of randomized FPs and their patients’ profile were comparable to those of French FPs [34]. The 23 physicians included in the qualitative survey were favorable to rapid HIV tests use but only three rapid HIV tests were performed. Despite this bias, our investigation proved that rapid HIV tests were not adapted to family medicine practice, even in a population of physicians favorable to their use. Our quantitative survey did not allow anticipating future behaviours. The usual biases of qualitative analysis are undeniable. Nevertheless, matching quantitative and qualitative results, and comparing opinions before and after providing tests added value to the answers provided. This double reading allowed comparing opinions and experienced facts. The rapid HIV test does not appear to be adapted to HIV testing in family practice. There are many impediments to their use in office practice but rapid HIV tests may be useful “outside of the office” as self-tests. The social considerations of HIV, including cultural and ethical ones, influence behaviours quite specifically. They require innovative solutions. Improving the screening conditions will probably require, as suggested by the HAS, making rapid HIV tests use more common and available.
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Contributions of authors C. Poirier, L. Guillon, JP. Lebeau, L. Bernard, and G. Gras helped draft the study protocol. C. Poirier, L. Guillon, JP. Lebeau, L. Bernard, G. Gras, P. Le Bret, and G. Lemoal participated in the study. C. Poirier, S. Aymeric, L. Guillon, JP. Lebeau, L. Bernard, and G. Gras helped write the article. Acknowledgements The Region Centre Union of Healthcare Professionals– Private Practitioners (French acronym URPS-ML) that provided material and technical support for the random selection of physicians and sending questionnaires. Valerie Chaigne, Muriel Ribadeau, and Gaelle Fajole of the Centre/Poitou-Charente COREVIH. Etienne Huard, MD, for the Val de Loire HIV Association. This project was supported by the Centre/Poitou-Charente COREVIH and the Val de Loire HIV Association, with a total budget estimated at 8000 euros. References [1] Cazein F, Pinget R, Lot F, Pillonel J, Le Strat Y, Sommen C, et al. Découvertes de séropositivité VIH et SIDA – France, 2003–2011. Bull Épidémiol Hebd 2013;(28-29):333. [2] Supervie V, Costagliola D. The spectrum of engagement in HIV care in France: strengths and gaps. In: 20th Conference on retroviruses and opportunistic infections. Atlanta (USA); 2013. [3] Ndawinz JDA, Costagliola D, Supervie V. New method for estimating HIV incidence and time from infection to diagnosis using HIV surveillance data: results for France. AIDS Lond Engl 2011;25(15):1905–13. [4] Morlat P. Prise en charge médicale des personnes vivant avec le VIH Recommandations groupe d’experts; 2013 [978-2-11-009563-3]. [5] Ministère du Travail, de l’Emploi et de la Santé. Plan national de lutte contre le VIH-SIDA et les IST 2010-2014; 2010. [6] Arrêté du 9 novembre 2010 fixant les conditions de réalisation des tests rapides d’orientation diagnostique de l’infection à virus de l’immunodéficience humaine (VIH 1 et 2). [7] Pavie J, Rachline A, Loze B, Niedbalski L, Delaugerre C, Laforgerie E, et al. Sensitivity of five rapid HIV tests on oral fluid or finger-stick whole blood: a real-time comparison in a healthcare setting. PLoS One 2010;5(7):e11581. [8] Glaser BG. The constant comparative method of qualitative analysis. Soc Probl 1965;12(4):436–45. [9] Gauthier R, Livrozet JM, Prevoteau du Clary F, Taulera O, Bouée S, Aubert JP, et al. Feasibility and acceptability of rapid HIV test screening (DEPIVIH) by French family physicians. Med Mal Infect 2012. [10] Aubert WAJSBROTA. Barriers to implement rapid HIV Testing (RHT) in French General Practitioners’ Offices. In: 13th European AIDS Conference (EACS). Serbia: Belgrade; 2011. [11] Cremieux AC, d’Almeida Wilson K, Kierzek G, de Truchis P, Le Vu S, Pateron D, et al. Acceptabilité et faisabilité du dépistage systématique du VIH dans 27 services d’urgences d’Île-de-France (ANRS 95008 et Sidaction), mai 2009–août 2010. Numéro thématique. L’infection à VIH-sida en France en 2009 : dépistage, nouveaux diagnostics et incidence; 2010.
7
[12] Loi no 2002-303 du 4 mars 2002 relative aux droits des malades et à la qualité du système de santé. 2002. [13] OMS. « Cadre pour le développement professionnel et administratif de la médecine générale – médecine de famille – en Europe ». Société franc¸aise de médecine générale société savante; sept 1999. [14] Korthuis PT, Berkenblit GV, Sullivan LE, Cofrancesco Jr J, Cook RL, Bass M, et al. General internists’ beliefs, behaviors, and perceived barriers to routine HIV screening in primary care. AIDS Educ Prev Off Publ Int Soc AIDS Educ 2011;23(3 Suppl.):70. [15] Kellock DJ, Rogstad KE. Attitudes to HIV testing in general practice. Int J STD AIDS 1998;9(5):263–7. [16] Burke RC, Sepkowitz KA, Bernstein KT, Karpati AM, Myers JE, Tsoi BW, et al. Why don’t physicians test for HIV? A review of the US literature. AIDS Lond Engl 2007;21(12):1617–24. [17] Turban F [Thèse d’exercice] Education thérapeutique du patient en médecine générale : représentations, pratiques et attentes des praticiens de la somme. France: Université de Picardie; 2008. [18] Gosden T, Pedersen L, Torgerson D. How should we pay doctors? A systematic review of salary payments and their effect on doctor behaviour. Quaterly J Med 1999;92(1):47–55. [19] Gosden T, Sibbald B, Williams J, Petchey R, Leese B. Paying doctors by salary: a controlled study of general practitioner behaviour in England. Health Policy 2003;64(3):415–23. [20] Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, et al. Impact of payment method on behaviour of primary care physicians: a systematic review. J Health Serv Res Policy 2001;6(1):44–55. [21] Ruelle Y. The role of European general practitioners in cervical cancer screening and its effects on the success of this screening. Istanbul: Wonca Europe; 2008. [22] Scott A, Sivey P, Ait Ouakrim D, Willenberg L, Naccarella L, Furler J, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev 2011;(9):CD008451. [23] Giuffrida A, Gosden T, Forland F, Kristiansen IS, Sergison M, Leese B, et al. Target payments in primary care: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2000;(3):CD000531. [24] Anaya HD, Hoang T, Golden JF, Goetz MB, Gifford A, Bowman C, et al. Improving HIV screening and receipt of results by nurse-initiated streamlined counseling and rapid testing. J Gen Intern Med 2008;23(6):800–7. [25] Barrett J, Curran V, Glynn L, Godwin M. Synthèse de la Fondation canadienne de la recherche sur les services de santé : collaboration interprofessionnelle et services de santé de première ligne de qualité. Canadian Health Services Research Foundation; 2007. [26] Saboni L. Vingt years d’évolution des connaissances, attitudes, croyances et comportements face au VIH/sida en France métropolitaine. ANRS-ORSInpes-IReSP-DGS, Observatoire régional de santé d’Île-de-France, Paris, France. [27] Lanoy E, Mary-Krause M, Tattevin P, Perbost I, Poizot-Martin I, Dupont C, et al. Frequency, determinants and consequences of delayed access to care for HIV infection in France. Antivir Ther 2007;12(1):89. [28] Couturier E, Schwoebel V, Michon C, Hubert JB, Delmas MC, Morlat P, et al. Determinants of delayed diagnosis of HIV infection in France. AIDS 1998;12:795–800. [29] InVS (Institut de Veille Sanitaire). « Lutte contre le VIH/sida et les infections sexuellement transmissibles en France: 10 years de surveillance, 1996-2005 »; 2007. [30] Delpierre C, Dray-Spira R, Cuzin L, Marchou B, Massip P, Lang T, et al. Correlates of late HIV diagnosis: implications for testing policy. Int J STD AIDS 2007;18(5):312–7. [31] Boekeloo BO, Marx ES, Kral AH, Coughlin SC, Bowman M, Rabin DL. Frequency and thoroughness of STD/HIV risk assessment by physicians in a high-risk metropolitan area. Am J Public Health 1991;81(12):1645– 8. [32] Champenois K, Cousien A, Cuzin L, Le Vu S, Deuffic-Burban S, Lanoy E, et al. Missed opportunities for HIV testing in newly-HIV-diagnosed patients, a cross sectional study. BMC Infect Dis 2013;13(1):200. [33] Yazdanpanah Y, Sloan CE, Charlois-Ou C, Le Vu S, Semaille C, Costagliola D, et al. Routine HIV screening in France: clinical impact and costeffectiveness. PLoS One 2010;5(10):e13132.
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
+Model MEDMAL-3611; No. of Pages 8 8
ARTICLE IN PRESS C. Poirier et al. / Médecine et maladies infectieuses xxx (2015) xxx–xxx
[34] Lert F, Lydié N, Richard JB. Baromètre santé médecins généralistes. Les médecins généralistes face au dépistage du VIH : nouveaux enjeux, nouvelles pratiques ? Institut national de prévention et d’éducation pour la santé; 2009. [35] Fernandez-Gerlinger MP, Bernard E, Saint-Lary O. What do patients think about HIV mass screening in France? A qualitative study. BMC Public Health 2013;13(1):526. [36] Mikolajczak J, Hospers HJ, Kok G. Reasons for not taking an HIV-test among untested men who have sex with men: an Internet study. AIDS Behav 2006;10(4):431–5. [37] Forsyth SF, Agogo EA, Lau L, Jungmann E, Man S, Edwards SG, et al. Would offering rapid point-of-care testing or non-invasive methods
improve uptake of HIV testing among high-risk genitourinary medicine clinic attendees? A patient perspective. Int J STD AIDS 2008;19(8):550–2. [38] De Wit JBF, Adam PCG. To test or not to test: psychosocial barriers to HIV testing in high-income countries. HIV Med 2008;9(Suppl. 2):20–2. [39] Flowers P, Duncan B, Knussen C. Re-appraising HIV testing: an exploration of the psychosocial costs and benefits associated with learning one’s HIV status in a purposive sample of Scottish gay men. Br J Health Psychol 2003;8(2):179–94. [40] Deblonde J, De Koker P, Hamers FF, Fontaine J, Luchters S, Temmerman M. Barriers to HIV testing in Europe: a systematic review. Eur J Public Health 2010;20(4):422–32.
Please cite this article in press as: Poirier C, et al. Rapid HIV test in family practice. Med Mal Infect (2015), http://dx.doi.org/10.1016/j.medmal.2015.03.010
