Testing for HIV should no longer be accorded special status, says BMJ editorial

HIV testing should not be accorded special status and doctors should test for HIV using the same approach as they use for any other illness with serious implications, according to an editorial in the March 5^th edition of the British Medical Journal. An article to be published in the April 1^st edition of Clinical Infectious Diseases (now on-line), argues that HIV testing should become routine for all sexually active individuals in the USA.

According to the authors of the BMJ editorial, the changing epidemiology of HIV in the UK, the large number of late diagnoses, and the improved prognosis of HIV-positive individuals since the advent of HAART provide grounds for lowering the threshold for HIV testing and reducing the emphasis on pre-test counselling.

The authors, clinicians in the Department of Genitourinary Medicine at the Royal Infirmary, Edinburgh, argue that current UK guidelines requiring pre-test counselling before HIV testing were developed when there were few effective anti-HIV treatments. Testing relied on people “who were obviously at risk presenting themselves... such groups included injecting drug users and men who have sex with men and their sexual contacts.”

However, this approach will, the authors suggest, have less effect as the epidemiology of HIV in the UK changes and HIV spreads into populations not conventionally regarded as being at risk of HIV. They note that heterosexual transmission accounts for the majority of new HIV diagnoses in the UK.

A quarter of HIV diagnoses in the UK in 2002, observe the authors, involved individuals who were already seriously immunosuppressed, and they argue that unless steps are taken to increase HIV testing “the epidemic will worsen.” The authors add “low detection rates imply longer duration of infections, which imply increased risk of transmission.”

Lowering the threshold for HIV testing would, the Edinburgh doctors argue, “lead to earlier diagnosis and treatment of infected individuals and may prevent the development of AIDS and the transmission of infection.”

They also question the value of the current practice of voluntary counselling and testing, noting that uptake is poor, even amongst individuals who have engaged in activities that involve a high risk of HIV infection. They also note that a large number of individuals at risk of HIV never attend sexual health clinics and that pre-test HIV counselling does not appear to influence subsequent high-risk behaviour.

Routine testing would, suggest the authors, increase the number of early HIV cases detected and allow for time to be spent counselling patients and their partners about ways to reduce the spread of HIV.

HAART has made HIV like any other serious illness, maintain the authors, and they therefore suggest that testing should be widely accepted without counselling. “Patients at risk of cancer do not receive counselling”, write the authors.

Voluntary testing and counselling was a product of the 1980s conclude the authors, adding, “times have changed. The benefits of early diagnosis of HIV are multiple. HIV testing should not now be accorded any special status. Doctors should now undertake the test using the same approach as used in any other test with serious implications.”

US approach

Investigators in the US are also arguing for an expansion in HIV testing. Approximately 250,000 cases of HIV are undiagnosed in the US, and routine HIV testing within the context of primary care should become routine for all sexually active individuals. The investigators also advocate a streamlining of counselling practices and an expansion in the use of rapid HIV tests. Last month two papers published in the New England Journal of Medicine and reported here on aidsmap maintained that routine testing for HIV was economically justified and would cut the transmission of HIV.