Strategies and challenges to reduce undiagnosed infection

Delegates at the British HIV Association conference in Liverpool this week presented the findings of pilot projects that helped increase the uptake of HIV testing, highlighted the continuing problem of the untested children of HIV-positive parents, and identified a limited awareness of HIV testing guidelines among non-HIV doctors.

Palwasha Khan from Homerton Hospital reported that a pilot project to offer rapid testing in a sexual health clinic resulted in an increase in acceptance of HIV testing from 67% to 78%. People thought to be ‘high risk’ (i.e. with links to a high prevalence country, men who have sex with men, etc.) were recommended to take both the rapid test and a confirmatory venous blood test. Those who were ‘low risk’ were recommended the conventional test, but if they refused, were offered the rapid test as an alternative.

Results from the first four months of the pilot appear to show a higher HIV prevalence in those taking the rapid test, and of the three positive diagnoses already made, two were in people who had refused conventional testing at previous clinic visits. Those taking the rapid test tended to do so because of the possibility of receiving results immediately, with a smaller number doing so because of dislike of venupuncture.

Nicky Perry and colleagues piloted a project in Brighton where gay men were offered a home sampling kit to test for HIV and other sexually transmitted infections (STIs). This was not a home HIV testing kit, but users took a sample of their saliva for later analysis in a laboratory.

Kits were offered over an eight-month period to all men who had sex with men who requested testing, had no symptoms and had previously used the clinic. Of 128 kits offered, 69 were accepted by HIV testers, and a further 11 by men wanting STI tests only. Around three quarters of kits were returned for analysis. No new diagnoses were found in this small group, and there are indications that HIV prevalence is lower in asymptomatic men than in other clinic users, but the researchers concluded that the approach is acceptable to gay men and warrants further evaluation.

Sarah Creighton from Homerton Hospital reported on an initiative to systematically offer HIV testing to women attending termination of pregnancy (TOP) services, as was recommended for the first time in UK testing guidelines last September. As has previously been shown, her study found that HIV prevalence in those attending TOP services is comparable to that found in women attending sexual health clinics, and is therefore considerably higher than in antenatal clinics. In Homerton, the TOP staff were generally willing to offer the test (blood tests are already performed in this setting, and many staff had previous experience of testing in antenatal clinics).

Moreover the number of women accepting the test (49%) was encouraging for a new project, and compares to 63% and 96% in sexual health and antenatal clinics respectively. Creighton concluded that testing in these services is feasible and acceptable.

Another initiative to encourage testing in East London was less successful. Newham University Hospital ran a pilot project in which the male partners of pregnant women were offered HIV tests. Because of antenatal testing, African women tend to be diagnosed earlier than heterosexual African men, so the project aimed to reduce late diagnosis of men by offering tests at week 20 of their partners’ pregnancies.

But whereas over 6000 women were tested as part of their antenatal care during a one year period, only 16 of their partners took up the offer. Barriers to testing may have included the fact that it involved referral to another hospital department, and the results not being available immediately. The authors commented that a separate community testing project in Newham, using rapid tests, has had more uptake with African men.

Moreover two audits, in Leeds and Glasgow, shed further light on the problem of children of HIV-positive adults not being tested, with both suggesting that clinics need to do more to address this issue. Both studies were reviews of clinic case notes, and both found that in a number of cases, there was no documentation in the notes of whether the patient had a child or not, and if they did, of whether the child had been tested. In the Leeds audit, this was particularly the case for adult men. In both studies, a majority of the children identified were currently living in Africa. However, in Leeds, of those resident in the UK, 58% of children remained untested (a similar figure to a previous study in Luton). Looking at UK-resident children in the Glasgow study, 42% of children of African parents and 12% of children of British parents were untested.

The Glasgow audit concluded that “it is essential that there is a robust method of assessing for at-risk children, and that formal pathways and support systems are in place for managing women who are resistant to testing their children”. Their colleagues in Leeds added that once children have been identified, it should be recommended that testing happens within 6 months, as their experience is that if the issue is not raised in the first few clinic visits, it is rarely re-addressed later on.

Last September’s national guidelines recommend that HIV tests are performed in a wide range of medical settings, and in a wide variety of circumstances. In order to see whether doctors were aware of the guidelines, a survey was conducted with non-HIV clinicians at Sunderland Royal Hospital. The lack of engagement with the issue was already suggested by the low response rate (22%), and even amongst those who replied, two-thirds had not heard of the guidelines. Just two of 70 doctors had read the guidelines. The majority of doctors underestimated the scale of undiagnosed HIV, and when presented with a list of 17 clinical indicator diseases that should prompt HIV testing, 30% said they would not test for HIV in any of the scenarios.

Moreover, a similar study by Amelia Hughes of GPs in London found that few recalled receiving a September 2007 letter from the Chief Medical Officer which outlined the new approach to HIV testing and their role within it. Moreover, few were aware of the full range of clinical indicator diseases.

Tanya Welz from Kings College Hospital investigated the outcome of HIV tests that were not done in the sexual health clinic, but in other hospital departments. This number is likely to increase as the guidelines are implemented, but already one quarter of HIV-positive test results at Kings come from tests arranged by other departments.

They were particularly concerned by the 3% of people with a positive result who did not return for their positive result, and this was more common when the test was performed outside the sexual health clinic. Reviewing the individual cases where this happened, the researchers identified problems such as clear follow-up arrangements not being made, contact details not being checked and not having a named staff member responsible for co-ordinating the follow-up.