Screening for STIs within general practice, whether as part of an enhanced service or not, has become more common in the UK. Yet for many reasons this 'screening' stops at taking swabs.
At a time when treatment for HIV and AIDS is at a peak and outcomes improve when HIV is diagnosed early, it is questionable whether there is valid justification for not testing for HIV more routinely.
There is also mounting pressure for GPs to take on more genitourinary work. Evidence from the US supports HIV screening in the general population as cost-effective.
In 2005 there were an estimated 63,500 people aged 15-59 living with HIV in the UK, of whom 20,100 (32 per cent) had not been diagnosed. Unpublished 2007 figures state that the total number of people with HIV is now 84,730.
If present registers of HIV patients are to be considered, this means that a third again are undiagnosed.
HIV tests should be offered to those most at risk, bearing in mind that anyone who has sex is exposed to some element of risk. Particular attention should be focused on risk groups: men who have sex with men, people born in areas of high HIV prevalence, IV drug users and sex workers.
Patients can choose to have an HIV test in general practice or at a GUM clinic. Testing in GUM clinics can be anonymous and the result is never shared with GPs without patient consent. In general practice the test will be linked to the patient's notes.
GPs are obliged to inform insurance or mortgage companies of a positive HIV test when requested. It should be stressed to the patient that a positive diagnosis, wherever it is made, should be declared to their insurers or they risk forfeit.
There is a window period of three months between contracting HIV and it appearing on serology. The British Association for Sexual Health and HIV (BASHH) suggests a 16- week window. However, most people have seroconverted by six weeks and it is rare to seroconvert any later than three months.
The pre-test discussion should be carried out by the healthcare practitioner requesting the test and does not need to take much time. It should include the issues outlined in the box below.
Documenting the pre-test discussion and that the patient has consented to the test is regarded as good practice.
If the clinician deems the patient to be of very high risk or has concerns that a vulnerable patient would react badly to news of a positive diagnosis, referral to a GUM clinic for more detailed discussion with a health adviser before taking a test may be appropriate.
BASHH guidelines encourage patients to receive their results in person, but for low-risk groups, negative results could be given over the phone or even by text message, with prior consent. This has the added advantage of keeping appointments free and reducing barriers to testing, because patients are often put off by the need to attend for a second visit.
A positive result must be repeated; this is ideally performed in a GUM setting. This is an opportunity for the patient to engage with local HIV service providers.
It is imperative that suitable contact details and consent to contact the patient are acquired as part of the pre-test discussion in case a patient does not attend again.
It is necessary to contact the patient quickly, for example by writing letters (with prior consent) to advise that test results are now available.
If these methods fail, contacting GUM services or consultants in public health is recommended.
HIV testing is confidential, according to GMC guidance. However, in exceptional circumstances it may be necessary to breach confidentiality. The MDU states that this can sometimes be justified, ethically and legally, in the public interest, for example if failure to disclose the result would expose the patient or others to death or serious harm. The GMC also stresses the importance of persuading the patient to inform others put at risk.
If a GP decides to make a disclosure, they should first inform the patient and must be prepared to justify their decision. Disclosure by doctors is still evolving in case law and legal advice from a defence organisation is recommended.
Coding the HIV diagnosis
There is much debate about coding the diagnosis of HIV. Some health professionals take the view that HIV should not appear on the problem summary as this would breach the patient's confidentiality - receptionists and admin staff opening the patient's notes, or relatives accompanying them are able to see the diagnosis. Patients may also want the doctor to withhold the diagnosis from their records.
Yet no distinction is made for other sensitive information such as erectile dysfunction or injected drug abuse. To continue to conceal diagnoses of HIV or refer to the infection obliquely perpetuates stigma.
When the NHS spine becomes active, more healthcare personnel will have access to patients' records. This may add complexity to how GPs code HIV on the electronic records. It is not yet clear how records held at GUM clinics will be dealt with on screening in the NHS spine data.
Confidentiality issues aside, a diagnosis of HIV is important in clinical management of patients.
HIV infection continues to spread and is now regarded as a chronic disease.
More routine screening as part of STI swabs should be established.
The concept of patients 'opting out' of HIV tests, as adopted by GUM and antenatal clinics aims to widen the numbers tested. Perhaps this should similarly apply to patients attending for sexual health problems in general practice, in order to make the impact that is definitely needed.
GPs should consider carefully how best to approach HIV testing and its effect on the practice workload. If it is deemed unfeasible within the practice then providing information on GUM clinic testing should be discussed routinely as part of swab screening for STIs.
Dr Van Ginneken is a GP registrar and Dr Doshi is a salaried GP in Stoke Newington, London
What to discuss before a HIV test
- How risk is assessed in each patient.
- Explain the three-month 'window period'.
- Provide information about HIV transmission: vaginal, anal and oral sex, mother to child.
- Advocate use of condoms to reduce risk.
- HIV is a treatable infection.
- Discuss confidentiality. Life insurance companies can only ask if a patient has ever tested positive for HIV.A positive diagnosis will be recorded in the notes.
- Offer the option of testing in GUM clinics.
- Ask how the patient would react to a positive diagnosis, who they would tell and explain the importance of partner notification.
- How and when results will be given.
- Check address and contact telephone numbers are correct.
- Rogstad K E, Palfreeman A, Rooney G, Hart G, Lowbury R, Mortimer P, et al. United Kingdom national guidelines on HIV testing 2006. Clinical Effectiveness Group, British Association of Sexual Health and HIV, 2006. (www.bashh.org/guidelines/2006/hiv_testing_june06.pdf)
- HPA. A distribution of HIV and other STIs across UK 2006. In: A Complex Picture 2006. www.hpa.org.uk/publications/2006/hiv_sti_2006/default.htm
- UNAIDS. Report on the global AIDS epidemic 2006. www.unaids.org/en/HIV_data/2006GlobalReport/default.asp.