New UK HIV testing strategy ‘urgently needed’

The UK requires a new approach to HIV testing, according to two articles in the June 29^th issue of the British Medical Journal. However, although both articles agree that routine opt-out HIV testing is necessary in certain settings, they disagree on whether this should be focused primarily on the people at the highest risk of having undiagnosed HIV, or expanded to include people at lower risk. A new report from the National AIDS Trust examines the arguments in greater depth, and also concludes that a “new HIV testing strategy is urgently needed.”

Since last December, when the United States adopted a new policy of routine opt-out HIV testing for all sexually active adults in all healthcare settings, experts have debated whether the approach is an efficient and cost-effective way of detecting undiagnosed HIV infections, and whether this will prevent more HIV infections than targeting populations considered to be at high risk.

In addition, more recent guidelines from the World Health Organization (WHO) and UNAIDS have recommended that a low HIV prevalence country, like the UK, where HIV is primarily focused on particular groups within the population, opt-out testing should be only offered to patients with symptoms suggestive of HIV infection, as well as to individuals accessing pregnancy, tuberculosis and sexual health services.

Nevertheless, with one in three HIV infections undiagnosed in the UK, experts have been debating how to change the UK’s HIV testing culture.

A year ago, opt-out testing for all attendees of sexual health (GUM) clinics was firmly recommended by the British Association for Sexual Health and HIV (BASHH) .

And this March, the British HIV Association (BHIVA) went further when it recommended that “all general practices and acute medicine services should provide diagnostic HIV testing, and such testing should routinely be considered for patients coming in contact with secondary care.”

Does routine testing reduce stigma and increase diagnoses?

In a new BMJ analysis article, Dr M Hammill and colleagues argue that “the effectiveness and feasiblility of expanded opt-out testing [in the UK] should be seriously assessed.”

They quote former UN Secretary General Kofi Annan who declared in March 2006 that “countries should promote, through global and national campaigns, the ideal that person knows his or her HIV status and has access to AIDS information, counselling and related services, in a social and legal environment that is supportive and safe for confidential testing and voluntary disclosure of HIV status”.

They argue that it should now be easier to offer opt-out HIV testing in “general practice surgeries, accident and emergency departments, and hospital wards” and that this could become routine.

They add that in the era of rapid HIV tests and effective treatments time can be saved in these settings by eliminating pre-test counselling. Instead, post-test counselling can focus on “people found to be infected or on risk reduction strategies for those who test negative.”

They also argue that “routine opt-out testing, which makes no judgment about an individual’s risk, could also help reduce the stigma associated with testing.”

However, an accompanying editorial by Catherine Dodds and Peter Weatherburn of Sigma Research, argues that HIV-related stigma – and a reluctance to test – is “drive[n by]...racism, xenophobia and homophobia”, and that “huge increases in the number of people testing negative for HIV will not change those attitudes or practices that maintain the social inequalities that reinforce HIV related stigma.”

They also point out that there are major barriers to introducing routine HIV testing into general practice and emergency care, notably because research by Sigma and by others has found much HIV-related discrimination within non-HIV NHS services. “Opt-out testing policies would exacerbate this,” they write,” and substantial investment in training and staff support would be needed” in order to achieve the UN goal of a “safe and supportive” environment.

They stress instead that there is still much room for improvement for HIV testing strategies that are focused on current antenatal and GUM services and point out that “the possibilities for targeting and diagnosing people at highest risk of HIV have not been exhausted.”

They conclude by arguing that “intensified targeting” would have much more of an impact on a critical outcome - reducing the time between infection and diagnosis - compared with scaling-up testing “in people who are less likely to have HIV.”

Updating strategies

The two BMJ articles reflect an ongoing debate within the wider HIV sector about how best to tackle HIV testing and prevention. Today, the National AIDS Trust (NAT) launched their report from a recent expert seminar on these subjects, entitled Updating Our Strategies.

The March 2007 seminar brought together representatives from the Department of Health, the NHS, the Health Protection Agency and leading HIV organisations, and the report summaries the key issues as well as including NAT’s own recommendations on HIV testing and prevention.

Key recommendations include:

• A new HIV testing strategy is urgently needed.
• The Department of Health must tackle the continuing high level of HIV stigma and discrimination within the NHS.
• HIV testing should be available in GP's surgeries on the basis of request or in response to possible symptoms and/or reporting of risk.
• The case for ring-fenced funding available for HIV prevention needs to be revisited: too often money for HIV prevention is delivered to meet other immediate and short-term health needs.

The full report is available from the National AIDS Trust website.