UK study shows opt out HIV testing at GPs is feasible and acceptable

Routine, opt-out HIV testing at GPs in the UK is feasible and acceptable to large numbers of patients, a study published in the online edition of Sexually Transmitted Infections suggests. Conducted at an inner-London practice serving an ethnically diverse population, the research showed that 45% of patients agreed to have a rapid HIV test as part of a health check when registering with a GP.

It is estimated that between a quarter and a third of the 77,000 infections in the UK are undiagnosed. A recent editorial in The Lancet described this as “appalling.” Late diagnosis of HIV is an important factor underlying many of the AIDS-related deaths seen in the UK, and there is accumulating evidence that a significant proportion of onward HIV transmissions originate in undiagnosed individuals.

Rapid, point of care oral HIV tests have the potential to open up new opportunities for testing. Their use in the UK is currently restricted to sexual health clinics and community-based settings.

Investigators wished to determine the feasibility and acceptability of offering rapid HIV tests to new patients registering with a GP in London.

The test was offered to patients aged between 18 and 55 as part of their registration health check with the practice nurse or healthcare assistant.

A total of 85 patients took part in the study, which was conducted between December 2007 and March 2008. These individuals came from 34 different countries. The patients were asked to say why they accepted or refused a test. A group of 20 patients participated in interviews to obtain their views on the appropriateness of HIV testing in primary care.

In total 38 patients (45%) agreed to have a rapid HIV test. One individual’s test was positive and this was confirmed by blood tests at the local sexual health clinic. Reasons given for not accepting an HIV test were “I’m not at risk of HIV” (36%) and “I’ve had a recent HIV test” (19%).

The main reason why patients agreed to have an HIV test was because it was being offered as part of a routine health screen (79%).

Black African and Black Caribbean patients were significantly more likely to accept the offer of a test than white individuals (p = 0.014).

All 20 individuals who took part in interviews agreed that it was appropriate to offer rapid HIV tests in general practice. Nevertheless, three of these individuals declined the offer of a test.

A number of advantages of HIV testing at GPs were identified by the patients. These included:

• Reduced waiting time.
• HIV testing made to seem routine.
• Opportunity for testing for individuals reluctant to use sexual health services.

However, some disadvantages were also identified, including:

• Not enough time to prepare for a positive result.
• A busy GP practice would find it difficult to support an individual testing positive.

Most patients agreed that HIV tests should be offered as part of the registration health check, however six individuals said that they should only be used if requested by a patient, or after the specific recommendation of a doctor.

Most of the interviewed patients agreed that practice nurses or healthcare assistants could administer the HIV test, but there was a strong consensus that a positive test result should be given by a doctor.

“Our study provides preliminary evidence that rapid HIV tests may be acceptable to patients attending primary care. Rapid testing was seen as appropriate both when requested by patients and as part of a ‘check up’ initiated by primary care staff”, write the investigators.

Offering rapid HIV tests in primary care will involve four key feasibility issues, suggest the investigators, however all are “potentially resolvable with appropriate training and resource allocation”:

• Giving positive results. Adequate training needs to be provided and there need to be established procedures to ensure that individuals testing positive are referred to expert HIV care.
• Regular quality control checks by qualified staff are needed to ensure the accuracy of rapid tests.
• Patient checks do not include enough time to adequately prepare patients for a positive result.
• New patient checks do not always provide a confidential environment.

The investigators suggest that the roll-out of HIV testing at GP’s surgeries should be guided by local HIV prevalence. They conclude, “our study shows that the offer of rapid HIV tests is potentially acceptable to patients and staff in primary care. Future work should focus on evaluating the effectiveness and cost-effectiveness of this strategy on a larger scale.”