New UK guidelines recommend normalisation of HIV testing in a wide range of healthcare settings

New guidelines for HIV testing, issued on September 18^th, urge healthcare workers of all specialities to consider HIV testing in a wide range of situations and settings. It is part of a package of recommendations to reduce the number of late and undiagnosed HIV infections in the UK. Moreover, in local areas where HIV prevalence is high, testing is recommended for all adults in all healthcare services.

The guidelines have been jointly produced by the British HIV Association (BHIVA), the British Association of Sexual Health and HIV (BASHH) and the British Infection Society (BIS). At the same time, the Medical Foundation for AIDS and Sexual Health (MEDFASH) have released a practical guide for healthcare professionals who do not specialise in HIV, to help them implement the new guidance.

While the 2001 National Strategy for Sexual Health and HIV highlighted a role for GPs in providing HIV testing and other sexual health services, development of that role has been limited. The strategy also recommended that all patients at genitourinary medicine (GUM) clinics be offered an HIV test on their first visit, and the 2006 BASHH guidelines recommended that all GUM patients should be offered HIV tests on an ‘opt-out’ basis. Opt-out means that a test is recommended to the patient and carried out if he or she gives consent.

The 2008 guidelines go much further in envisaging that HIV testing is not only offered as part of a sexual health screen, but during a wide range of other potential encounters with health services. The guidelines aspire to put an end to the ‘AIDS exceptionalism’ which suggested that HIV testing could not be handled by mainstream health services, and that specialised pre- and post- test counselling was required. The guidelines state that: “It should be within the competence of any doctor, midwife, nurse or trained healthcare worker to obtain consent for and conduct an HIV test”.

It is recommended that a pre-test discussion concentrate on the benefits of testing and how the results will be given. Positive results must be given face to face, and the patient should normally be seen by a specialist HIV service within 48 hours of receiving the result. The guidelines recommend that detailed post-test discussions are handled by the specialist HIV team.

The guidelines provide an overlapping set of criteria for when opt-out tests should be proposed, based on healthcare setting, local prevalence, other diagnoses, and the lifestyle and demographic characteristics of the patient.

Testing in specified healthcare settings

Testing is recommended for all patients in the following settings:

• GUM and sexual health clinics
• Antenatal services
• Termination of pregnancy services
• Drug dependency programmes
• Tuberculosis, hepatitis B, hepatitis C and lymphoma services
• Dialysis, blood donation and organ transplant services.

Testing in areas with high HIV prevalence

In local areas where there is already a recognised high prevalence of diagnosed HIV infection, it is assumed that there will also be a high prevalence of undiagnosed infection. In these cases, it is recommended that HIV tests should be offered to all people aged 15 to 59 who register at primary care services or who are admitted to hospital as inpatients.

The Health Protection Agency have analysed existing data on those attending HIV treatment and care services (data come from the Survey of Prevalent HIV Infections Diagnosed, known as SOPHID) to identify those parts of the country where the HIV prevalence is high – in other words, where more than 2 people in 1000 have diagnosed HIV infection.

This is the case for 25 of the 31 Primary Care Trust areas in London, as well as areas such as Brighton & Hove, Manchester, Blackpool, Salford, Bournemouth and Eastbourne that have historically had high HIV prevalence. However there are other areas which have experienced more recent increases in HIV prevalence, including Luton, Watford, Harlow, Southend-on-Sea, Reading, Slough and Crawley.

In total 20% of the English population live in areas where universal opt-out testing is now recommended. However given the novelty of this policy, the guidelines urge that the introduction of universal testing is thoroughly evaluated for acceptability and feasibility.

Testing for patients with specified symptoms or conditions

There are a number of health conditions which may be caused by HIV infection itself, be more common in people with weakened immune systems or, for behavioural reasons, be more common in HIV-positive people than in the general population. At present, many people attending healthcare settings with these conditions are not offered HIV tests and their infection remains undiagnosed.

As well as AIDS-defining conditions such as tuberculosis and cerebral toxoplasmosis, the list of 49 conditions includes:

• Peripheral neuropathy
• Dementia
• Recurrent herpes zoster (shingles)
• Chronic diarrhoea of unknown cause
• Weight loss of unknown cause
• Anal cancer or pre-cancer
• Lung cancer
• Testicular cancer
• Head and neck cancer
• Any sexually transmitted infection

In all of these cases, an offer of an HIV test is recommended.

MEDFASH’s publication provides more information on the links between these conditions and HIV, and also suggests non-stigmatising ways in which clinicians can raise the subject of HIV and gain consent for testing. For example: “We always screen for HIV in patients who have shingles, because very occasionally this can be associated with HIV and we want to make sure we don’t miss anything.”

Clinicians are reminded that the symptoms of primary HIV infection (seroconversion illness) include fever, rash and muscle pain. However these symptoms can have many different causes. The guidelines recommend that whenever a patient presents with such symptoms and is “perceived to be at risk of infection”, an HIV test should be offered.

Testing for patients with specific lifestyle or demographic characteristics

Testing is recommended for all patients who fall into the following groups:

• Sexual partners of HIV-positive people
• Men who have disclosed that they have sex with other men
• Female sexual partners of men who have sex with men
• People reporting a history of injecting drug use
• People from countries of high HIV prevalence (above 1%)
• Sexual partners of people from countries with high HIV prevalence

Other issues

The guidelines do not recommend repeat testing for most groups of patients, except when a recent infection may not have been identified because of the ‘window period’ (the time after HIV infection when tests are unable to detect infection).

Nonetheless men who have sex with men and injecting drug users should be offered an annual HIV test. However, annual tests are not specifically recommended for people from high prevalence countries.

In terms of testing technology, fourth generation assays (which test both for HIV antibody and p24 antigen) are recommended. These tests have the advantage of reducing the ‘window period’ to one month. The guidelines recommend that results should be available within 72 hours.

The guidelines discuss the use of rapid point-of-care tests which give results in 15 minutes. Because the tests have a high rate of false positive results, their use should not be routine, but is recommended in specific situations, including at community testing sites where HIV prevalence is high and “clinical settings where a rapid turnaround of results is desirable”.

The guidelines also address the testing of infants, children and young people. A separate list of conditions which should prompt HIV testing is provided for use in paediatric settings. The guidelines also highlight cases of vertically infected children whose infection was only identified during their teenage years, and so urges testing of children whose parents are known to have or are suspected to have HIV infection. If a parent does not want the child to be tested, consent issues are complex, but “the overriding consideration must be the best interests of the child”.