Dramatic improvements in HIV testing are possible – local leadership and multiple initiatives required

In Brighton & Hove the proportion of new HIV diagnoses which are made outside of sexual health and antenatal clinics has increased from 25.7% in 2000 to 57.8% in 2012, driven by improvements in HIV testing in primary care and community settings. Moreover, there has been a dramatic improvement in the diagnosis of recent HIV infection.

Brighton & Hove is the area of the UK with the highest HIV prevalence after London. The analysis was presented to the British Association of Sexual Health and HIV (BASHH) conference in Bristol yesterday.

Since 2008, UK testing guidelines produced by sexual health and HIV specialists have urged healthcare workers of all specialities to consider HIV testing in a wide range of situations and settings, including GP surgeries and most hospital departments. In 2011, the National Institute for Health and Clinical Excellence (NICE) issued recommendations which endorse large parts of the 2008 guidelines.

However, health professionals from other specialities have not always supported the guidelines and implementation has been patchy. Only a few parts of the country are likely to have results as encouraging as Brighton & Hove.

HIV clinicians there, led by Martin Fisher of Brighton & Sussex University Hospitals NHS Trust, have placed a strong emphasis on expanding HIV testing in recent years. There have been numerous educational interventions for non-specialist clinicians, service innovations and research studies.

General practitioners have been trained to recognise the symptoms of primary HIV infection and are offered free HIV testing kits. Pilot projects have attempted to make HIV testing universal for new patients admitted to hospital and in primary care. A pilot has demonstrated the merit of automatic prompts for HIV testing when a ‘clinical indicator disease’ is recorded in the electronic patient record system.

Rapid testing has been in offered in community settings, such as gay bars, a gay sauna and Terrence Higgins Trust premises. A walk-in sexual health service has been opened next to Brighton station.

The data presented to the BASHH conference concern positive test results (rather than all tests conducted) in Brighton & Hove between 2000 and 2012. During that time, 1359 people have been diagnosed, predominantly men who have sex with men (72.9%) and people of white ethnicity (77.1%). Nonetheless, 15% of diagnoses have been in women.

In 2000, three-quarters of diagnoses were made in the ‘traditional’ settings of sexual health clinics, antenatal clinics and blood transfusion services. However, since 2010, a majority of diagnoses have been made elsewhere – in 2012, 57.8% were made in ‘non-traditional’ settings.

Diagnoses made by general practitioners have increased from 2.7 to 21.2% (p<0.001). Those made in community settings have risen from 0 to 12.9% (p<0.001).

Hospital outpatient diagnoses have increased to a lesser extent, and the proportion of diagnoses made in inpatient settings has actually dropped slightly. However, actual numbers of diagnoses were not shown, so it is possible that this is an artefact of increased diagnoses elsewhere.

Late diagnosis rates have gone down. In 2000, 52% of newly diagnosed people had a CD4 cell count below 350/cells³, with this dropping to 33% in 2012. The reduction in late diagnoses was most marked in the group of patients diagnosed through sexual health clinics.

The number of people diagnosed with recent infection (infection within the past year) has increased from 24.3 to 45.2% (p=0.005), as did the proportion testing with symptoms of seroconversion (16.7 to 55.3%, p=0.011). These improvements have been driven by testing in general practice, with GPs now being more aware of symptoms.

Clinicians also seem to be increasingly aware of the possibility of HIV infection in older people. The proportion of people over the age of 50 who are diagnosed outside of sexual health clinics has steadily increased from around half in 2000 to almost all in the last two years.

The researchers say that the city’s multiple HIV testing initiatives have been associated with changes in the settings of HIV diagnoses. Moreover, sexual health clinicians need to work with and support colleagues in primary care, secondary care and voluntary organisations in order to improve testing practices.