Sexual Health in Practice Training to increase HIV testing in primary care

SHIP (Sexual Health in Practice) is a quality improvement educational intervention for sexual health care in the general practice context that has a positive impact on staff confidence in, and attitudes to, sexual history taking (Mullineux et al, 2008) and clinical care and outcomes (Pillay et al, 2018: Pillay et al, 2012).

SHIP uses a range of half-day teaching sessions, delivered by GP and practice nurse peer educators, as its foundation. The training is designed to impact broadly across sexual health care, although impact on general practice HIV testing rates and diagnosis has been demonstrated. There are a range of intended outcomes related to SHIP training. Some of these outcomes include, that clinicians (GPs and practice nurses in primary care) should:

• Have increase confidence and skills of clinicians to raise the topic of sexual health in primary care
• Be able to carry out rapid risk assessment for sexual and reproductive health and Blood borne viruses
• Offer appropriate STI testing, contraception advice and health promotion advice regarding risk reduction (e.g. condoms, hepatitis vaccination) following this individual rapid risk assessment
• Reduce number of high vaginal swabs taken, and use self-taken vulvovaginal swabs for diagnosis of chlamydia and gonorrhoea
• Increase HIV and viral hepatitis tests offered in general practice
• Increase HIV and viral hepatitis diagnoses in general practice, including reducing the proportion of patient with HIV who are diagnosed late.

When SHIP training was developed in the early 1990s, the service model was entirely focussed on Genitourinary Medicine (GUM) clinics as open-access providers of STI diagnosis and care. One the problems associated with this was the exceptionalisation of sexual health within the general practice setting. Despite people at risk attending general practice frequently (much more than was recognised) quality of STI diagnosis and care in this context was demonstrably poor.

Asymptomatic HIV infection remained unseen and unaddressed. Symptomatic infection was also under-recognised in the UK general practice setting. General practice clinicians did not consider STIs as a differential often enough at a time when symptomatic patients were becoming more likely to present to them (rather than to a GUM clinic) with their varied, non genital, symptoms.

There are numerous barriers for HIV testing in primary care. SHIP training explicitly elicits and addresses the barriers to HIV testing expressed by participants. Elicited from participants over years of training in Birmingham and London, these barriers are summarised in diagram 1, available here.   We have measured HIV testing rates in the London borough of Haringey.

Haringey is the fourth most deprived London borough and has a population of over 250,000. The diagnosed HIV prevalence in 2014 was 7 per 1000 aged 15-59. Our first published paper (Pillay et al, 2012) demonstrates significant increases in HIV testing following SHIP training and the annual number of new HIV diagnoses more than doubled.

Our follow-up publication (Pillay et al, 2018) using an extended data set shows that SHIP training produces a significant, sustained increase in HIV testing in primary care for each GP trained in this high prevalence area of the UK. This increase in testing was:

• a six-fold increase in GP testing rates during the period of observation
• a 16% increase in practice HIV testing rates per GP trained (testing rate ratio 1.16, 95% CI 1.05-1.28, p value 0.004)
• sustained over the 6 year observation period.
• driven by practices in high prevalence areas (>2 per 1000)

Compared with general population screening, HIV tests used in routine clinical care in general practice in Haringey have a high probability of detecting a positive person (1.42% average positivity). Positivity rates are substantially higher than found in London screening pilots, suggesting that SHIP training nurtures complex clinical skills; risk assessment may identify negative individuals who would benefit from PrEP.

SHIP training precedes the NICE HIV testing guidelines NG60, but is entirely consistent with them. We are making this submission in response to the draft NICE quality standards (Quality standard for HIV testing: encouraging uptake) as a relevant case study. Statements 2, 3, 5 and 6 in the draft quality standard are all explicitly taught on SHIP training.

SHIP is an educational intervention, closely tailored to the general practice setting, delivering peer-developed and peer-led face-to-face training for GPs and practice nurses to improve quality of sexual and reproductive health care.

SHIP delivers a range of half-day teaching sessions taught by GP and practice nurse peer educators, using a variety of teaching methods. A central focus of SHIP is communication tailored to the setting, including use of rapid risk assessment for sexual and reproductive health (SRH) and blood borne viruses. SHIP training explicitly elicits and addresses the barriers to HIV testing, including those expressed by participants. The intervention is grounded in educational theory including tailoring to individual role and addressing barriers to change. When possible, performance feedback is given to attendees of their individual practice HIV testing rates.

Overall implementation went very smoothly and we had excellent support from the commissioners. Peer trainers were recruited by speaking to enthusiastic attendees who approached current trainers. At one point, a specialist sexual health team asked to deliver the training. However they began to profoundly change and abbreviate the training and they did not use GP peer educators. Therefore this was stopped by the commissioner who instead paid the charity MedFASH to deliver SHIP training in its fully developed form.

SHIP training consists of 2 afternoons for GPs, currently these two sessions total around £3000 including teaching delivery by peer educators, teaching resources and take away resources (but excluding room and catering costs, as these are usually covered by commissioners). Some of the sessions were not fully attended; if implemented in future it would be good to have the backing of commissioners to help ensure maximal attendance.

SHIP is an educational intervention, closely tailored to the general practice setting, delivering peer-developed and peer-led face-to-face training for GPs and practice nurses to improve quality of sexual and reproductive health care.

SHIP delivers a range of half-day teaching sessions taught by GP and practice nurse peer educators, using a variety of teaching methods. A central focus of SHIP is communication tailored to the setting, including use of rapid risk assessment for sexual and reproductive health (SRH) and blood borne viruses. SHIP training explicitly elicits and addresses the barriers to HIV testing, including those expressed by participants. The intervention is grounded in educational theory including tailoring to individual role and addressing barriers to change. When possible, performance feedback is given to attendees of their individual practice HIV testing rates.

Overall implementation went very smoothly and we had excellent support from the commissioners. Peer trainers were recruited by speaking to enthusiastic attendees who approached current trainers. At one point, a specialist sexual health team asked to deliver the training. However they began to profoundly change and abbreviate the training and they did not use GP peer educators. Therefore this was stopped by the commissioner who instead paid the charity MedFASH to deliver SHIP training in its fully developed form.

SHIP training consists of 2 afternoons for GPs, currently these two sessions total around £3000 including teaching delivery by peer educators, teaching resources and take away resources (but excluding room and catering costs, as these are usually covered by commissioners). Some of the sessions were not fully attended; if implemented in future it would be good to have the backing of commissioners to help ensure maximal attendance.

In order to evaluate our training we looked at the following outcome measures for the study period of 2008-2016:

• attendance at training
• practice population (list) sizes
• monthly HIV test numbers (from hospital laboratories processing the tests)
• results by practice (from hospital laboratories processing the tests).

These were chosen as a meaningful measure of the effect of training on GPs on sexual health care.

As described above, our published papers (Pillay et al, 2018, Pillay et al, 2012) demonstrate significant sustained increases in HIV testing following SHIP training. Positivity rates are substantially higher than found in London screening pilots.

As-yet unpublished data from the London Borough of Islington demonstrates impact of SHIP on both HIV and viral hepatitis. Most importantly, our updated data from Haringey (Pillay et al, 2018), shows that SHIP significantly increased HIV testing in general practice; for every additional GP trained HIV testing rates increase by 16%. This statistically highly significant effect was sustained over the 6 year observation period. Detail has been submitted for peer review publication.

The increase in HIV testing rates was driven by practices located in high HIV prevalence areas, i.e. those with more than 2 HIV-infected persons per 1000 adult population.

Overall GP HIV testing rates in Haringey rose 600% during the period of observation. Compared with that expected from population screening, HIV tests used in routine clinical care in Haringey have a high positivity (roughly 1% positive average).

This was not an RCT. The results were generated through routine data collection mechanisms. This routine and real-life characteristic of our study avoids the artificiality of the study context that is typically introduced by prospective controlled intervention studies. The external validity of our findings is likely high, and higher than the external validity of findings that a randomized controlled trial would have generated. As mentioned above further analysis has been submitted for peer reviewed publication and will be referred to here once published.

It is notoriously difficult to produce interventions that demonstrate impact on GP behaviour. Interventions that have not had impact on testing for chlamydia or HIV in primary care include the STIF course (Bailey et al, 2008) and PHE 3Cs and HIV intervention. (Town et al, 2016, Allison et al 2017).

We believe that the aspects of our training which have lead to the clear and impressive results described above are that it is:

• Peer developed & delivered
• Tailored to primary care
• Tailored to team role
• Tailored to locality
• Evidence-based content
• Evidence-based educational methodology
• Resources tailored to primary care setting
• Integrated approach across SRH and HIV.

In terms of teaching content we illustrate with relevant evidence that patients attending the GP setting have a spectrum of risk (from zero to very high) and that many of those at high risk are not accessing other relevant services. This shows the value of rapid risk assessment for SRH and BBVs. Unique to SHIP training we teach how to carry out and safely interpret rapid risk assessments. We have a strong focus on communication skills and verbal strategies, including those needed to overcome barriers to testing.