New, greatly expanded HIV testing guidelines for the United Kingdom have been published this month, and are now open for public consultation until June 30th. Although they fall short of US-style universal opt-out testing, they recommend opt-out HIV testing at GP practices and in hospitals where local prevalence of undiagnosed HIV infection is greater than 1 in 1000, as well as providing a list of indicator diseases where HIV testing should be offered alongside any other tests.
The guidelines are a joint project of the British Association for Sexual Health and HIV (BASHH), the British HIV Association (BHIVA) and the British Infection Society (BIS). However, the writing committee also includes representatives from a broad range of other professional, governmental and community organisations.
Since the UK’s last HIV testing guidelines were published, in June 2006 – which, for the first time, recommended opt-out HIV testing for everyone attending sexual health clinics – HIV testing culture has changed even more dramatically in other countries, notably the United States, where, in December 2006, the US Centres for Disease Control recommended routine opt-out HIV screening for everyone aged 13-64 in all health-care settings.
Since then, there has been a public debate about how a new UK HIV testing culture could be cost-effective and benefit both personal and public health, culminating in these new guidelines.
The 2008 guidelines note in their introduction that they are “intended to facilitate an increase in HIV testing in all health-care settings as recommended by the UK Chief Medical Officers and Chief Nursing Officers in order to reduce the proportion of individuals with undiagnosed HIV infection with the aim of benefiting both individual and public health.”
Their aim is to “encourage ‘normalisation’ of HIV testing” by doing away with lengthy pre-test counselling. “The discussion only needs to cover the benefits of testing to the individual; discussion of window period and whether repeat testing is needed; and details of how the result will be given,” it says. “Written consent should be discouraged,” it adds, “as this exceptionalises the test and discourages health care providers from offering it.”
However, the guidelines note, “for this change in approach to be beneficial and ethically acceptable, it is imperative that following a positive HIV diagnosis, a newly diagnosed individual is immediately linked into appropriate HIV treatment and care,” within 48 hours of receiving the result at the very latest.
The guidelines also say that, “it should be within the competence of any doctor, midwife, nurse or trained heath care worker – to obtain consent for an HIV test.”
They emphasise, however, that “HIV testing remains voluntary and confidential” and that “this is entirely possible within any health-care setting if these guidelines are followed.”
They point out that unlike in the United States, “the vast majority of patients have access to healthcare free at the point of delivery,” including access to GPs, and since “there are pressures upon [hospital accident and emergency (A&E)] departments to achieve four hour waiting targets, we believe universal opt- out testing in all settings may not be the most feasible approach but support the use of opt-out testing in certain situations.” (However, a recent study from Brighton, which found a 1 in 40 undiagnosed HIV prevalence at A&E, suggests that there is still scope for ‘opt-out’ HIV testing to be introduced in some emergency settings.)
In addition to all men and women attending sexual health clinics and all women attending antenatal services, the guidelines now recommend that opt-out HIV testing should also be performed in the following settings:
- All women attending termination of pregnancy services
- All men and women registering with drug dependency programmes reporting a history of injecting drug use
- All individuals known to be from a high prevalence country and/or men that have disclosed sexual contact with other men
- All men and women who report sexual contact with individuals from areas of high HIV prevalence, abroad or in the UK.
- All men and women registering in primary care where undiagnosed HIV prevalence estimates in the local population exceed 1 in 1000 (likely to be relevant only in London, Brighton and Manchester)
- All general medical admissions from a population where the local undiagnosed HIV prevalence exceeds 1 in 1000
- All men and women diagnosed with Tuberculosis, Hepatitis B, Hepatitis C and lymphoma
- Any other patients presenting for health-care where HIV enters the differential diagnosis including primary HIV infection (see indicator conditions list below).
The guidelines also include a list of indicator conditions, similar to those proposed by the EACS last October and discussed during a major European meeting on reducing late diagnosis last November.
As well as all AIDS-defining illnesses, other illnesses and conditions associated with HIV are listed. These include:
- Peripheral neuropathy
- Dementia
- Recurrent herpes zoster (shingles)
- Chronic diarrhoea of unknown cause
- Weight loss of unknown cause
- Anal cancer or pre-cancer
- Lung cancer
- Testicular cancer
- Head and neck cancer
- Glandular fever-like syndrome (Primary HIV Infection)
- Any sexually transmitted infection
They also recommend that all men who have sex with men, and injecting drug users should have annual HIV tests, but these should be more frequent than once a year “if clinical symptoms are suggestive of seroconversion”.