Most sexual health commissioners for areas in England with a high HIV prevalence have introduced some form of expanded HIV testing, a study published in the online edition of HIV Medicine shows. However, only a small minority were following national guidance, with just a third having commissioned testing for new registrants in general practice and 14% commissioning testing for people admitted to hospital.
“The results of this audit confirm that routine HIV testing in these settings has been commissioned in only a minority of high-prevalence areas”, comment the authors. “Prioritizing the introduction of routine testing in these settings will be necessary to fully implement national testing guidelines.”
Late diagnosis of HIV is a major concern in the UK. Approximately half of people newly diagnosed with HIV have a CD4 cell count below the threshold for the initiation of antiretroviral therapy (350 cells/mm3) recommended by the British HIV Association (BHIVA) and between a fifth and a quarter of all HIV infections are undiagnosed. Improving HIV diagnosis rates is key to strategies to reduce rates of HIV-related illness and also the continued spread of the virus.
National HIV testing guidelines were issued in 2008 and were endorsed in 2011 by the National Institute for Health and Care Excellence (NICE). These recommend that HIV testing should be expanded beyond traditional settings (sexual health clinics and antenatal services) in areas with a high HIV prevalence – an infection rate of above 2 per 1000. In these circumstances, the guidelines recommend the universal testing of all patients newly registering with a GP, the screening of all new medical admissions to hospital and targeted outreach programmes.
Investigators wanted to assess the level of adherence to these guidelines and to see if there were any obstacles to the expansion of testing.
Between May and June 2012, the investigators contacted sexual health commissioners in the 40 English primary care trusts (PCTs) with a HIV prevalence above 2 per 1000. There was an 88% response rate (35 of 40).
All the respondents were aware of the testing guidelines and the majority (80%; 23 of 35) has introduced some form of expanded testing.
In most cases, this was testing in the community (51%; 18 of 35), followed by testing in general practice (49%; 17 of 35) and testing in hospitals (37%; 13 of 35). However, only four PCTs (11%) had commissioned expanded testing services in all three settings.
Areas with especially high prevalence were more likely to have commissioned services. All but one of the PCTs with a prevalence above 5 per 1000 (92%, 11 of 12) had commissioned some form of expanded testing. More worryingly, a third of PCTs with background prevalence between 2-3 per 1000 had commissioned any form of expanded testing and only 33% had introduced testing at GPs, with just one commissioning testing in hospitals.
When the investigators examined adherence to the specific recommendations of the guidelines, they found that only 31% of PCTs (11 of 35) had commissioned routine testing of new registrants at GPs. Moreover, only a small minority (10 to 20%) of GP practices in these areas participated in expanded testing. In a fifth of PCTs, testing was limited to high-risk groups. PCTs in London, compared to PCTs elsewhere in England, were somewhat more likely to have commissioned the routine testing of new GP registrants (38 vs 18%). HIV testing was incorporated into general sexual health screening at GPs in 17% of PCTs (6 of 35).
An even lower proportion of PCTs had commissioned the routine testing of new admissions to hospital (14%; 5 of 35).
Over half of PCTs (51%) had commissioned community testing via outreach programmes carried out by charities and the voluntary sector. This testing targeted high-risk or marginalised populations including men who have sex with men (six PCTs), African people (four), sex workers (two), people who inject drugs (one) and the homeless (one). Settings for community testing included saunas, polyclinics, pharmacies, prisons, churches and health centres.
Almost all PCTs (94%; 33 of 35) cited lack of resources as a barrier to introducing expanded testing, with two-thirds (23 of 35) also stating that the re-organisation of the NHS was an obstacle. Approximately 75% of commissioners (26 of 35) expected the rate of HIV testing carried out in their area to increase over the next year. None expected a decrease.
“Modelling of the UK HIV epidemic has shown that higher rates of testing combined with timely initiation of antiretroviral therapy can result in reduced HIV incidence”, write the authors. They note that most respondents had introduced some form of expanded testing, “however, only a minority covered the two medical settings mentioned in national testing guidelines…new registrants in general practice…and general medical admissions.” The authors conclude that recent organisational changes in the NHS make it important to monitor “changes in the commissioning of testing over time”.
Hartney T et al. Expanded HIV testing in high-prevalence areas of England: results of a 2012 audit of sexual health commissioners. HIV Med, online edition. DOI: 10.1111/hiv12099, 2013.