Guidelines for HIV testing in non-specialist settings not being followed in the UK

UK guidelines issued in 2008 concerning HIV testing in general medical and primary care settings are not being followed, results of a meta-analysis published in Sexually Transmitted Infections show. Overall, only 27% of eligible patients (those with indicator diseases or in high-prevalence areas where routine testing is recommended) seen in these settings were tested for HIV.

“The low level of testing suggests that adherence to the 2008 UK guidelines for HIV testing is poor in recommended populations and settings,” comment the authors.

Approximately a quarter of people with HIV in the UK are undiagnosed. People who are diagnosed late (with a CD4 cell count below 350 cell/mm³ – the threshold for starting HIV treatment in the UK) have an increased risk of developing AIDS and death. Reducing the rate of undiagnosed HIV is also a public health priority.

Most people have HIV tests in specialist settings such as genitourinary medicine (GUM) and sexual health clinics, or in antenatal settings. In 2008, guidelines were issued to increase levels of HIV testing in non-specialist settings. The guidelines recommend that all patients presenting with a disease indicating possible HIV infection – for example TB or glandular fever – should be offered an HIV test. The guidelines also state that all adult patients registering with a GP in areas with a local HIV prevalence above 2 per 1000 should be offered testing. Similarly, hospital doctors in high-prevalence areas should offer testing to new patients.

Investigators wanted to assess adherence to these guidelines. They therefore conducted a meta-analysis, reviewing studies published since 2008 that reported on HIV testing in general medical and primary care settings. They also gathered data on the percentage of patients in these non-specialist settings who were identified as HIV positive.

Thirty studies were included in the meta-analysis. Ten studies involved people with indicator diseases and 20 were in people who were attending services where routine testing is recommended because of the local HIV prevalence.

Overall, 27% of eligible patients were tested for HIV. But testing levels varied considerably between studies, ranging from just 0.5% to a high of 83%.

Only 22% of patients with indicator diseases were tested for HIV. “Testing in this group is a long-standing recommendation of guidelines prior to 2008, so these results are disappointing,” write the authors. “The lack of adherence to guidelines in this group…is likely to be hindering timely identification of HIV greatly.”

The overall testing rate for patients in high-prevalence settings was marginally higher at 30%.

Fourteen studies reported both the number of eligible patients offered tests and the number of patients who underwent testing. The pooled results showed 40% of individuals were offered a test and that 71% accepted this offer. Uptake of testing was higher among people with indicator diseases than in people offered routine screening in high-prevalence areas (87 vs 69, respectively).

A total of 23 studies reported on test results. Overall, 0.5% of tested patients were identified as HIV positive. “The seroprevalence estimates exceed the threshold deemed as cost-effective,” note the investigators, “indicating that HIV testing in these settings and populations is cost-effective and is likely to continue to be so with increased test coverage.”

There was an approximately 3% seroprevalence rate among patients who had a test because they had an indicator disease. This compared to a 0.4% rate among patients undergoing routine testing.

“The results of this review and meta-analysis indicate adherence to 2008 national guidelines for HIV testing in the UK is poor and that low levels of provider test offer appear to be a major contributor to this,” the investigators conclude. “Failure to adhere to testing guidelines is likely to be contributing to late diagnosis with implications for poorer clinical outcomes and continued onwards transmission of HIV.”