Who cares for syphilis? A cross-sectional study on diagnosis and treatment of syphilis by GPs in Amsterdam, the Netherlands.

BACKGROUND: Syphilis is a re-emerging infection. Sexually transmitted infection (STI) clinics and GPs are important providers of STI care in the Netherlands. The role of GPs in syphilis care is assumed to be small, since most men who have sex with men (MSM) visit STI clinics for STI care. AIM: To explore the role of GPs in the diagnosis and treatment of syphilis. DESIGN & SETTING: Data on syphilis diagnostics by GPs in Amsterdam between 2011 and 2017 were retrieved from laboratories, covering 90% of the GPs. The study also used the academic GPs' network database to explore the management of syphilis by GPs between 2013 and 2018. METHOD: Syphilis tests requested by GPs were analysed and compared with annual reports of the STI clinic. Patients with an International Classification of Primary Care-1 (ICPC-1) syphilis code were identified in the GP database. Cases diagnosed by the GP were evaluated whether they were treated by the GP or referred to secondary care. RESULTS: In the laboratory database, GPs had diagnosed syphilis 522 times, compared with 2515 times by the STI clinics. Based on the 90% coverage of GPs, the contribution of all Amsterdam's GPs was 19% of the total number of diagnoses. Consequently, the annual incidence of syphilis diagnosed by the GP was 10.2 per 100 000 inhabitants. Of the 43 cases identified in the GP database, six (14.0%) were referred and 33 (76.7%) were treated by a GP. CONCLUSION: Although for an individual GP, syphilis is rare to diagnose, GPs in Amsterdam do contribute to the rate of syphilis diagnosis and appear to treat the majority of cases that they have diagnosed.

General practitioners' barriers and facilitators towards new provider-initiated HIV testing strategies: a qualitative study.

European guidelines recommend offering an HIV test to individuals who display HIV indicator conditions (ICs). UK guidelines recommend performing a 'routine offer of HIV testing' in primary care where HIV prevalence exceeds 2 in 1000. Implementation of new provider-initiated HIV testing strategies in general practice is limited, while the numbers of undiagnosed and late for care HIV patients remain high. We have explored Dutch general practitioners' barriers to and facilitators of both strategies. We combined semi-structured in-depth interviews with focus groups. Nine general practitioners - key informants of sexually transmitted infection/HIV prevention and control - were selected for the interviews. Additionally, we organised focus groups with a broad sample of general practitioners (n = 81). Framework analysis was used to analyse the data. Various barriers were found, related to (1) the content of the guidelines (testing the right group and competing priorities in general practice), (2) their organisational implementation (lack of time, unclear when to repeat the HIV test and overlong list of ICs) and (3) the patient population (creating fear among patients, stigmatising them and fear regarding financial costs). Multiple general practitioners stated that performing a sexual risk assessment of patients is important before applying either strategy. Also, they recommended implementing the IC-guided approach only in high-prevalence areas and combining HIV tests with other laboratory blood tests. General practitioners tend to cling to old patterns of risk-based testing. Promoting awareness of HIV testing and educating general practitioners about the benefits of new provider-initiated HIV testing strategies is important for the actual uptake of HIV testing.

HIV indicator condition-guided testing to reduce the number of undiagnosed patients and prevent late presentation in a high-prevalence area: a case-control study in primary care.

OBJECTIVES: Recent guidelines advocate accelerated provider-initiated HIV testing by general practitioners (GPs). We aimed to identify the number of patient consultations in six general practices in the South-East of Amsterdam, and the incidence of HIV indicator conditions reported in their medical files prior to diagnosis. METHODS: A cross-sectional search in an electronic general practice database. We used a case-control design to identify those conditions most associated with an HIV-positive status. RESULTS: We included 102 HIV cases diagnosed from 2002 to 2012, and matched them with 299 controls. In the year prior to HIV diagnosis, 61.8% of cases visited their GP at least once, compared with 38.8% of controls. In the 5 years prior to HIV diagnosis, 58.8% of HIV cases had exhibited an HIV indicator condition, compared with 7.4% of controls. The most common HIV-related conditions were syphilis and gonorrhoea. The most common HIV-related symptoms were weight loss, lymphadenopathy and peripheral neuropathy. During this period, average HIV prevalence among people aged 15-59 years increased from 0.4% to 0.9%. CONCLUSIONS: This study revealed many opportunities for HIV indicator condition-guided testing in primary care. As yet, however, HIV indicator conditions are not exploited as triggers for early HIV testing.

The influence of two different invitation letters on Chlamydia testing participation: randomized controlled trial.

BACKGROUND: In The Netherlands, screening for chlamydia (the most prevalent sexually transmitted infection worldwide) is a relatively simple and free procedure. Via an invitation letter sent by the public health services (PHS), people are asked to visit a website to request a test kit. They can then do a chlamydia test at home, send it anonymously to a laboratory, and, within two weeks, they can review their test results online and be treated by their general practitioner or the PHS. Unfortunately, the participation rates are low and the process is believed to be not (cost-) effective. OBJECTIVE: The objective of this study was to assess whether the low participation rate of screening for chlamydia at home, via an invitation letter asking to visit a website and request a test kit, could be improved by optimizing the invitation letter through systematically applied behavior change theories and evidence. METHODS: The original letter and a revised letter were randomly sent out to 13,551 citizens, 16 to 29 years old, in a Dutch municipality. Using behavior change theories, the revised letter sought to increase motivation to conduct chlamydia screening tests. The revised letter was tailored to beliefs that were found in earlier studies: risk perception, advantages and disadvantages (attitude), moral norm, social influence, and response- and self-efficacy. Revisions to the new letter also sought to avoid possible unwanted resistance caused when people feel pressured, and included prompts to trigger the desired behavior. RESULTS: No significant differences in test package requests were found between the two letters. There were also no differences between the original and revised letters in the rates of returned tests (11.80%, 581/4922 vs. 11.07%, 549/4961) or positive test results (4.8%, 23/484 vs. 4.1%, 19/460). It is evident that the new letter did not improve participation compared to the original letter. CONCLUSIONS: It is clear that the approach of inviting the target population through a letter does not lead to higher participation rates for chlamydia screening. Other approaches have to be developed and pilot tested.

Sexually transmitted infection health-care seeking behaviour in the Netherlands: general practitioner attends to the majority of sexually transmitted infection consultations.

Health-care seeking behaviour for sexually transmitted infection (STI)-related symptoms is not well known in the Netherlands. Within the framework of a large representative study, the second National Survey of General Practice (NIVEL 2001), 9687 persons aged 18 years and older were interviewed about their STI and STI-related health-care seeking behaviour. In total, 1.2% of the interviewees reported STI-related symptoms in the past year (18-24 years: 5%). A (lifetime) history of STI was reported by 2.7% (18-44 years: 4%). In all, 63% of interviewees visited their general practitioner (GP) for these complaints; 20% went to an STI-clinic and/or municipal public health services and 8% to a different care-provider. A total of 9% did not undertake any action. The majority of persons with STI-related symptoms in the Netherlands visit the GP. Reported history of STI-related symptoms was twice lower in the Netherlands compared with the UK National Sexual Health Survey. Appropriate attention for sexual health in primary care is needed.