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MPS Opinion: Spreading the use of HIV testing

By Gareth Gillespie and Dr Sonya McCullough

Late diagnosis of HIV in adults continues to be an important issue in the UK but for too long it has been absent from healthcare’s topical agenda. With national audit data showing that 24% of deaths of HIV-positive adults in the UK in 2006 were due to a diagnosis of HIV being made too late for effective treatment,1 and further data showing that around one third of all HIV infections in UK adults remain undiagnosed, and approximately 25% of newly-diagnosed individuals have a CD4 count of less than 200 – an indicator of late diagnosis – there is clearly a lack of timely opportunity to improve early diagnosis.2

“Normalising” HIV testing in patients with clinical indicator diseases, by moving testing beyond the traditional antenatal and sexual health settings, is one way of tackling problems surrounding late diagnosis. The benefits of early diagnosis of HIV go beyond the obvious, such as decreased mortality and morbidity.

HIV testing is already a routine antenatal booking test and more than 95% of women in the UK accept this – and there is no extensive pre-test counselling carried out

The chances of a more effective response to HAART (highly active antiretroviral therapy) treatment are increased3 and there is a link between awareness of HIV status and a curb on risk behaviour,4 suggesting that earlier diagnosis reduces the likelihood of further transmission.5

HIV testing is already a routine antenatal booking test and more than 95% of women in the UK accept this – and there is no extensive pre-test counselling carried out.

The UK National Guidelines for HIV Testing 2008, which were released by the British HIV Association (BHIVA) to recommend expanding HIV testing beyond the antenatal and sexual health settings, list a number of clinical indicator diseases that should prompt a test for HIV infection in adults; these include tuberculosis, cervical cancer and cytomegalovirus retinitis – the full list is available at the BHIVA website, www.bhiva.org

Undoubtedly, there are still barriers to encouraging the wider use of HIV testing. Even 30 years on, there are traces of the fear that was embedded in the nation’s psyche by the infamous “tombstone” adverts of the 1980s. Sections of the community are still unaware of the enormous advances in effective treatment for HIV since those early days.

The despondency around the prognosis for those who were diagnosed as HIV positive in the 1980s and early 1990s also discouraged individuals from testing. Contact tracing helps identify if an individual’s current or previous partners have contracted HIV but this has an obvious impact on relationships and puts an additional strain on an individual coming to terms with a new diagnosis.

Sections of the community are still unaware of the enormous advances in effective treatment for HIV since those early days

All of these factors are deterrents to undergoing a test. Patients can also be uncomfortable about attending their GP for testing, especially if they have personally known their doctor or practice staff for a number of years, and they may be embarrassed to provide a sexual history or have concerns over confidentiality.

Reservations among healthcare professionals were highlighted in a survey carried out by the Health Protection Agency (HPA) in 2010, which investigated awareness of the UK National Guidelines for HIV Testing 2008. Of the 17 medical royal colleges, faculties and professional organisations that responded, 11 reported awareness – but only four knew of any work being done in their own specialty to address HIV testing, and only five had covered HIV testing in their own clinical guidelines.6

Between 2009 and 2010, the Department of Health piloted the expansion of HIV testing outside traditional settings, by funding eight demonstration projects across primary and secondary care, and in community/outreach settings. In hospitals, the pilots were carried out in an emergency department, three acute admissions units and a dermatology outpatients department. The exercise was particularly interesting when measuring the shift in staff attitudes to testing before and after the pilots were conducted. Staff initially reported perceived barriers such as the need for additional training, the challenges of dealing with difficult questions from patients, and not having enough time to obtain informed consent for an HIV test.

Testing was found to be operationally feasible and the majority of patients found the prospect of a routine test to be feasible

Other concerns from secondary care staff related to the impact on service delivery. In primary care, some clinicians were anxious about managing reactive results. However, when analysing the results of the project, many of these concerns were unfounded. Testing was found to be operationally feasible and the majority of patients found the prospect of a routine test to be feasible.

Staff training was acknowledged as an additional requirement, while in primary care there were still some concerns about the impact on consultation times. The full findings can be read in the HPA’s report, Time to Test for HIV: Expanding HIV Testing in Healthcare and Community Services in England.

It is important that we refocus our efforts to start the fight against HIV as early as possible

The Department of Health pilots demonstrated how misconceptions and anxieties can be challenged and overcome. With therapy to treat HIV more effective than ever before, it is important that we refocus our efforts to start the fight against HIV as early as possible.

References
  1. Lucas SB, Curtis H, Johnson MA, National Review of Deaths among HIV-infected Adults, Clin Med 8:250-2 (2008)
  2. Health Protection Agency, HIV in the United Kingdom: 2008 Report, London: HPA (2008)
  3. Stöhr W, Dunn DT, Porter K et al, CD4 cell count and initiation of antiretroviral therapy: trends in seven UK centres (1997-2003), HIV Med 8:135-41 (2007)
  4. Marks G, Crepaz N, Janssen RS, Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA, AIDS 20:1447-50 (2006)
  5. Vernazza P, Hirschel B, Bernasconi E et al, An HIV-infected person on antiretroviral therapy with completely suppressed viraemia (‘effective ART’) is not sexually infectious [French], Bull Méd Suisses 89:165-9 (2008)
  6. Health Protection Agency, Time to Test for HIV: Expanding HIV Testing in Healthcare and Community Services in England, London: HPA (2011)
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