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I was pleased that the authors suggested that missed opportunities for early diagnosis could be reduced by tackling the problem from both the patient and the provider side. They note:
"From a patient perspective, the likelihood of future diagnosis could be improved by encouraging at-risk groups (for example, MSM) to access health care when they experience symptoms of seroconversion or followi...
"From a patient perspective, the likelihood of future diagnosis could be improved by encouraging at-risk groups (for example, MSM) to access health care when they experience symptoms of seroconversion or following high risk exposure."
Would it be too much to urge members of groups at high risk for infectious disease to mention to their service provider that they are a member of that group? And would it be too much for doctors who suspect risky behaviours to ask? I understand the importance of patient confidentiality but primary HIV infection is dangerous for behavioural as well as virological reasons, and uninfected people have rights, too. Those rights are best protected by reducing all possible barriers to diagnosing early HIV infection, and providing active prevention services for those diagnosed.
We agree with the authors of this paper (1) that improved awareness of Primary HIV Infection is of great importance in all areas of medical practice. Nevertheless we feel that there are some observations we wish to make.
In a relatively small study such as this recall bias is likely to influence the findings. Although this point is discussed this bias means that the interpretation of results re...
In a relatively small study such as this recall bias is likely to influence the findings. Although this point is discussed this bias means that the interpretation of results requires further consideration. It is easy, with the benefit of hindsight, to point the finger at primary care
but, crucially in the study, the opportunity to examine the clinical notes for these patients was apparently not possible.
There is much emphasis in the paper on "missed diagnosis" but the results show that half the study group (52%) were correctly diagnosed with primary HIV infection at first presentation and of this figure general practitioners were successful in 4 patients – making up about a fifth of
cases. These figures, while not optimal, show that a degree of awareness of HIV infection in the community is present, but could be better (as it could in other sectors). That 79% of the missed diagnosis occurred in general practice is surely no surprise – 80% of all care happens here
anyway (2). Obviously a good history, an awareness of HIV risk and an ability to discern flu-like symptoms as possible indicators of acute HIV infection are the requirements any doctor should possess in order to make such diagnoses. Perhaps this is why MEDFASH (Ruth Lowbury, personal
communication) is producing a booklet for hospital doctors which emulates the existing one for general practitioners (3).
Importantly we are not saying that everything is rosy in this particular garden – how could we when at least one study illustrates that in an area of North London over the period from 2003-6 the majority of general practices did not test at all for HIV infection (4). There is still much to do in the field of general practice and sexual health, including HIV infection – but focusing on an area fraught with difficulty (only 1:2 patients sought advice or care at the time of their illness in the study above ) will inevitably result in negative outcomes.
Finally, and certainly implied by Sudarshi’s paper, it is essential that we include an awareness of primary HIV infection in the undergraduate medical curricula of all universities and ensure that all doctors who graduate in future are capable of taking an HIV risk history.
1. D Sudarshi, D Pao, G Murphy et al. Missed opportunities for diagnosing primary HIV infection. Missed opportunities for diagnosing primary HIV infection Sex Transm Infect 2008; 84: 14-16
2. Keeping it personal: clinical case for change. Report by Dr David Colin-Thomé. Department of Health, London UK 2006
3. Madge, S, Matthews P, Singh S, Theobald N. HIV in Primary Care. MEDFASH Publications, 2004
4. K Sadler, L Sutcliffe C Mercer et al. Variations in Chlamydia and HIV testing in general practices in London, UK: opportunities for increasing access to sexual health care?
(Poster presentation as part of the CaPSTI study – funded by the Medical search Council). International
society for sexually transmitted research 2007.