The specialist opinion
Dr Iain Reeves, consultant physician in genitourinary medicine, Homerton University Hospital NHS Foundation Trust, London
Undiagnosed HIV remains an important problem in the UK. Those who are unaware of their infection cannot access life-prolonging treatment and face a much greater risk of mortality and morbidity because of late diagnosis.
In 2012, about two-thirds of black African adults were diagnosed with a CD4 count <350, where treatment is recommended, compared with 47% overall.1
In its recent report, HIV and Black African Communities in the UK, the National AIDS Trust has called for urgent action to address this health inequality.
HIV-positive people who do not know their status may also be more likely to transmit the virus to others, because they are unable to use this knowledge to modify risk behaviour and importantly, cannot take advantage of the now clearly demonstrated, very significant reduction in the risk of transmission with successful treatment.2
This may be particularly relevant for GPs, who might also be looking after members of the patient's family, or children born in countries where antenatal testing is not routine.
HIV testing broadly falls into two strategies: diagnosing someone with symptoms as part of a set of investigations, and diagnosing asymptomatic individuals in a more routine testing approach.
The 'Time to Test' report summarised the findings of a number of studies investigating routine, opt-out HIV testing conducted outside traditional sexual health settings.3
The main finding from these studies was that routine HIV testing was generally very acceptable to most patients across all settings, including primary care.
The RHIVA2 study, conducted in primary care in inner London, also demonstrated the feasibility of routine, near-patient HIV testing as part of a new patient check when people register with a general practice.4
Concerns about the feasibility and acceptability of routine testing are more often voiced by healthcare staff, often focusing on lack of resources, training and fear of giving a positive result. Some of these fears are based on misconceptions about pretest counselling.
A simple pretest discussion, where a patient is made aware that an HIV test is being carried out as part of routine practice, with an opportunity to withdraw consent, is all that is required.
This approach also removes the risk of patients feeling they are being targeted because of their ethnicity or other characteristics.
Including an HIV test as part of a set of investigations for a particular presenting problem is easily done, especially when blood tests are already planned.
However, it does require thinking about the condition and making an HIV test part of the usual order set, when clinicians may not have it at the forefront of their minds.
For example, acute HIV infection presents as a viral illness and GPs are likely to see many of these individuals. In a study in south London, a significant proportion of those investigated for infectious mononucleosis in fact had acute HIV infection.5
A list of illnesses and other conditions where HIV may be part of the differential or important to exclude can be found in the UK national HIV testing guidelines.6
The use of audit, or case review, to investigate missed opportunities to test for HIV, for example when someone is diagnosed with an opportunistic infection as an inpatient, may also be a helpful tool for reflection and changing practice.7
GPs should be clear about support and treatment services available to newly diagnosed patients.
Support around testing should be readily available from local GUM/sexual health services and there must be pathways for rapid access to HIV care. The support that can be provided by voluntary sector agencies is also invaluable.
|How to make HIV testing more acceptable
The GP opinion
Dr Richard Ma, GP with an interest in sexual health, London
GPs often consider gay men or men who have sex with men (MSM) as a key risk group in the context of HIV testing. Despite being a risk group, current evidence suggests there may be unmet needs when it comes to HIV testing for black Africans.
According to 2012 data from the Health Protection Agency (now Public Health England), almost 31,800 black African men and women were living with HIV in the UK.
This represents an overall prevalence of 26 per 1,000 for African-born men and 51 per 1,000 for African-born women. Of the 1,522 black Africans who were newly diagnosed with HIV in 2012, 66% of men and 61% of women were diagnosed at a late stage of infection.1
Newly diagnosed black Africans reported that in the 12 months preceding their diagnosis, 76% had presented to healthcare services and 15% to inpatient services.8
An audit conducted by the British HIV Association found there had been missed opportunities for earlier HIV diagnosis in a quarter of newly diagnosed individuals.9
The role of early diagnosis
Earlier diagnosis of HIV can save lives because antiretroviral treatment can rapidly suppress HIV disease, resulting in reduced infectiousness as well as near-normal life expectancy.
This is why NICE has recommended expanded HIV testing for MSM and black Africans.10
According to the NICE costing template, a shift of 1% of patients being diagnosed at an earlier stage could produce savings of about £0.22m a year for MSM and £0.27m a year for black Africans in England.
There appears to be plenty of opportunities for more HIV testing to be carried out in general practice.
For example, there is evidence to suggest that black Africans attend general practice, especially those who have had undiagnosed HIV.11
Opt-out testing for HIV was also broadly acceptable to a sample of patients in one study which included MSM and black Africans.12
We understand that special issues, such as stigma about HIV in black African communities, may deter people from having HIV tests. Black Africans are also less likely to find support in their own communities.
MSM and black Africans mention a perceived lack of confidentiality as one of the main barriers to test for HIV in general practice settings.
Some clinicians may find it difficult to offer HIV testing opportunistically to black Africans for fear of perceived racial stereotyping. There may also be perceived difficulties for those who test positive, for example, lack of support, problems within the community, immigration problems and entitlement to HIV care.
1. Public Health England. HIV in the United Kingdom: 2013 Report. London, PHE, November 2013.
2. Cohen M, Chen Q, McCauley M et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365: 493-505.
3. Health Protection Agency. Time to test for HIV: Expanding HIV testing in healthcare and community services in England. London, HPA, September 2011.
4. Leber W, McMullen H, Marlin N et al. Point-of-care HIV testing in primary care and early detection of HIV (RHIVA2): a cluster randomised controlled trial. Lancet 2013; 382: S7 (conference abstract).
5. Hsu D, Ruf M, O'Shea S et al. Diagnosing HIV infection in patients presenting with glandular fever-like illness in primary care: are we missing primary HIV infection? HIV Medicine 2013; 14: 60-3.
6. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008.
7. Whittle A, Wellesley R, Griffiths C et al. Increasing opportunities for HIV diagnosis in primary care: a borough-wide evaluation of HIV testing and pre-diagnosis care in general practice. British HIV Association Spring Conference April 2013. Oral abstract O2.
8. Burns FM, Johnson AM, Nazroo J et al. Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK. AIDS 2008; 22(1): 115-22.
9. Ellis S, Curtis H, Ong EL. HIV diagnoses and missed opportunities. Results of the British HIV Association (BHIVA) National Audit 2010. Clin Med 2012; 12(5): 430-4.
10. NICE. Increasing the uptake of HIV testing among black Africans in England. PH33. London, NICE, March 2011.
11. Rice B, Delpech V, Sadler KE et al. HIV testing in black Africans living in England. Epidemiol Infect 2013; 141(8): 1741-8 doi: 10.1017/S095026881200221X
12. Glew S, Pollard A, Hughes L. Public attitudes towards opt-out testing for HIV in primary care: a qualitative study. Br J Gen Pract 2014; doi: 10.3399/bjgp14X677103
- National AIDS Trust. HIV and Black African Communities in the UK. June 2014: a policy report. London, National Aids Trust, June 2014.