HPA urges further action on HIV testing to reduce numbers undiagnosed and diagnosed late

The Health Protection Agency (HPA) issued its annual epidemiological report yesterday, and drew particular attention to the need for improvement in HIV testing rates – six of its eight recommendations concern testing.

The headline findings concerning new HIV diagnoses were reported on Aidsmap six weeks ago, but to recap:

• In 2011, there were 3010 new diagnoses among gay men, the highest annual figure ever.
• There were 2990 new diagnoses among heterosexual men and women.
• While the number of heterosexual infections has decreased in recent years, the proportion of infections acquired in the UK has increased.
• An estimated 96,000 people were living with HIV, but 24% of them were unaware of their infection.
• HIV prevalence in the general population was 0.15%, but was considerably higher in the black African community (3.7%) and among men who have sex with men (4.7%).

Among those who are newly diagnosed, 47% were diagnosed late (with a CD4 cell count below 350 cells/mm³). While this statistic is an improvement on 2002’s figure of 60%, the UK still performs poorly in comparison to some other countries.

Inequalities are apparent too – while 35% of gay and bisexual men were diagnosed late, 56% of heterosexual women and 64% of heterosexual men were diagnosed late. Amongst the heterosexual people, late diagnosis rates were highest in those of black African ethnicity.

Whereas people who attend sexual health clinics usually have an HIV test during their visit (70% of all attendees, 84% of gay and bisexual men) and coverage is extremely high at antenatal clinics (97%), the same cannot be said for other settings.

An HPA audit done with 40 sexual health commissioners in high-prevalence areas found that only 31% had commissioned HIV testing for some new patient registrations at GP surgeries, and just 14% had commissioned routine HIV testing as part of general medical admissions to hospitals. Guidelines from both the BHIVA and NICE recommend testing in these settings.

The HPA include the following in their recommendations:

• In areas of high prevalence, implementation of routine HIV testing for all general medical admissions and new GP patients.
• Clinicians should take every opportunity to offer and recommend HIV testing to men who have sex with men and people of black African or Caribbean ethnicity.
• Every effort should be made to reduce health service barriers to HIV testing.

Commenting on the report, Deborah Jack of the National AIDS Trust (NAT) made a connection between the higher rates of late diagnosis in black African people and the poor provision of HIV testing in GP surgeries. “We know that African people are three times more likely to be diagnosed through their GP than a sexual health clinic,” she said, urging more commissioning of HIV testing in general practice. “We are seeing huge inequalities in accessing HIV tests.”

In terms of inequalities, the HPA’s report also draws attention to the uneven geographical spread of HIV around the country, with particular concentrations in areas with more socioeconomic problems.

In 2011, there were 58 local authorities in which more than 2 in 1000 residents had diagnosed HIV, and 30 of these local authorities were in London. There were 22 local authorities with a prevalence above 4 in 1000, and 18 of these were also in London. (The non-metropolitan areas were Brighton & Hove, Manchester, Salford and Luton).

Within London, in the most deprived boroughs (defined with reference to a range of economic, social and housing indicators), 8 in 1000 people had diagnosed HIV. In the least deprived boroughs, 1.5 in 1000 had HIV. The same pattern could be seen in England as a whole, although the figures were not as stark.

The HPA have also begun to publish data for each local authority on rates of late diagnosis, in order to put the spotlight on areas which perform relatively poorly. They recommend that local authorities and NHS bodies prioritise HIV testing in Joint Strategic Needs Assessments in order to address this.

Returning to HIV testing within sexual health clinics, the report includes a new analysis, showing that almost two-thirds (63%) of gay and bisexual men who were newly diagnosed with HIV at a sexual health clinic had not attended that clinic for testing in the previous three years. This, the HPA says, strongly suggests that there is room for improvement in the frequency of testing by those at highest risk.

To that end, they recommend that men who have sex with men should test for HIV and sexually transmitted infections at least annually, and every three months if having unprotected sex with new or casual partners. Black African and Caribbean people who have unprotected sex with new or casual partners are advised to test regularly, although the frequency is not defined.

The HPA also report high rates of sexually transmitted infection amongst gay men who are newly diagnosed with HIV – 21% of new HIV diagnoses were accompanied by an STI (compared to 3-4% in heterosexual people).

And the National AIDS Trust point to HPA data which suggest that having a sexually transmitted infection can be a predictor of future HIV acquisition. Gay men diagnosed with chlamydia were three times more likely to acquire HIV in the following year and gay men diagnosed with gonorrhoea were nearly two and half times more likely to get HIV in the following year.

This is essentially because STIs are indicators of risk behaviour which may lead to HIV transmission in the future. In addition, those who have both HIV and an STI are much more likely to pass on HIV than they otherwise would be.

“A key lesson from the HPA report is that if you don't take STIs seriously you're not taking HIV seriously,” Deborah Jack of NAT said. “Most STIs may be treatable and curable but they are not just some 'occupational hazard' of gay life – they are inextricably connected to the spread of HIV.”

“HIV negative gay men diagnosed with an STI should really treat it as a 'wake up call',” she continued. “You are at serious risk of getting HIV in the near future and need to take steps to prevent that happening.”