Quality improvement report: Investigating barriers in HIV testing oncology patients to optimize HIV testing practice.

Background
In 2010, we observed missed opportunities for earlier human immunodeficiency virus (HIV) diagnosis among people newly diagnosed with HIV attending our service. We reached out to clinical services with low HIV testing rates.Local Problem
In the oncology service, <5% of all patients seen were tested for HIV between 2010 and 2012. With the rationale of excluding HIV-related immunosuppression prior to prescribing immunosuppressive treatment, we aimed to identify barriers to HIV testing (Plan).Methods
In 2013, we conducted the Investigating Barriers in HIV-Testing Oncology Patients (IBITOP I) study among people newly diagnosed with non-AIDS-defining cancers (non-ADCs) (Do). We observed that 18% of patients were offered HIV testing, 16% of physicians gave reasons for not offering testing and 91% of patients accepted testing offered (Study). The Swiss HIV testing recommendations were updated in November 2013, listing aggressive immunosuppressant treatment as a testing indication. In 2015, we organized interactive training sessions on HIV testing with oncology staff (Act) and conducted a follow-up study, IBITOP II, to examine residual barriers to testing. The primary endpoints of IBITOP II were (1) physician HIV testing offer rates, (2) physician reasons for not offering testing and (3) patient acceptance of testing offered.Interventions
Training sessions were designed following engagement with senior oncology colleagues and covered the 2013 national testing recommendations, the rationale for excluding HIV prior to prescribing immunosuppressive treatment, the excellent prognosis of HIV on antiretroviral therapy and the practical aspects of offering HIV testing.Results
Of 423 patients of unknown HIV status with newly diagnosed non-ADCs, 257 (60.8%) were offered HIV testing. The most frequent physician reasons for not offering testing were forgetting (19.9%), patients tested recently (19.3%) and lack of time (11.5%). Patient acceptance of testing offered was 83.2%. No HIV test was positive. Since the IBITOP II study, cancer treatment options have shifted from chemotherapy to targeted therapies or immunotherapies. Consequently, HIV is now included in baseline oncology workups, circumventing the testing barriers of forgetting and lack of time and increasing HIV testing rates to almost 100%.Conclusion
HIV testing rates at our oncology service have improved following two IBITOP studies, updated national testing recommendations and the broader oncology workup required by new therapies. By including HIV testing in the baseline workup, residual barriers to HIV testing have been circumnavigated. Modelling improvement in testing practice has stemmed from engagement with oncology colleagues, despite the fact that HIV testing is mentioned in a minority of specialist oncology guidelines.