Related separate articles include: Acquired Immune Deficiency Syndrome (AIDS), Complications of HIV infection, HIV and Skin Disorders, Human Immunodeficiency Virus (HIV), Managing HIV Positive Individuals in Primary Care, HIV Post-exposure Prophylaxis and Primary HIV Infection.
Many GPs have been reluctant to undertake HIV testing with associated counselling, as it is seen as complicated and time-consuming. However, if the uptake of testing is to be increased, this needs to change. With the help of the content and references of this article, there is no reason why practices should not write a protocol for counselling and testing that fulfils the various conditions.
Practices that treat drug abusers may add this to their services but any practice can offer it to anyone at risk. It may form part of an enhanced service for sexual health. It does not have to be performed by a doctor and, in most situations, it is a nurse who gives the counselling. The easier it is for the patient to get counselling and testing, the more likely they are to take up the offer.
There have been significant developments in the treatment of HIV in recent years. This progress and up-to-date knowledge about HIV and the epidemiology of HIV infection have informed new guidelines on counselling and testing for HIV.
New guidance is prefaced by a number of important assertions:
- It is possible, with the advent of new and improved treatment, for the majority of those living with HIV to remain fit and well on treatment.
- It is estimated that around 33% of all HIV infections acquired heterosexually are currently undiagnosed. Many heterosexuals remain undiagnosed until testing is prompted by HIV-related symptoms late in the course of illness. Around two thirds of those with heterosexually acquired infection are being diagnosed late with a CD4 count of less than 350 cells/mm3.
- Patients should therefore be offered and encouraged to accept HIV testing in a wider range of settings than is currently the case.
- Patients with specific indicator conditions should be routinely recommended to have an HIV test.
- The consensus is that doctors, nurses and midwives should be able to obtain informed consent for an HIV test in the same way that they currently do for any other medical investigation.
- There were an estimated 83,000 adults aged over 15 with HIV in the UK in 2008 - 27% of whom were unaware of their infection.
- There were 7,298 new diagnoses in 2008 in the UK. This represents a slight decline on previous years, predominantly due to fewer diagnoses among young people who acquired their infection abroad.
- The number of deaths among HIV-infected people has remained stable over the past decade, and a total of 525 people (387 men and 138 women) infected with HIV were reported to have died in 2008.
- The number of new cases of AIDS acquired from heterosexual intercourse is greater than from homosexual activity. However, most of these cases were not acquired in this country. Almost 82% are recorded as having been acquired abroad with around 70% of the total from Africa.
- 38% of infections in the UK have occurred through sex between men and this group remains at greatest risk. There has been no evidence in recent years of a decline in the numbers of new infections in this group and over 1,800 new diagnoses of HIV are currently occurring each year.
Who should be offered a test?
Despite World Health Organization (WHO) guidelines there is a lack of consensus on testing strategy across Europe. However, in the UK:
- Universal HIV testing (where all individuals are offered and recommended an HIV test routinely but can refuse testing) is recommended in all the following:
- HIV testing should be routinely offered and recommended to the following patients:
- All patients presenting for healthcare where HIV, including primary HIV infection, enters the differential diagnosis (see separate Primary HIV Infection article).
- All patients diagnosed with a sexually transmitted infection.
- All sexual partners of men and women known to be HIV positive.
- All men who have disclosed sexual contact with other men.
- All female sexual contacts of men who have sex with men (MSM).
- All patients reporting a history of injecting drug use.
- All men and women known to be from a country of high HIV prevalence (>1%) - see up-to-date UN AIDS list in 'Internet and further reading' section, below.
- All men and women who report sexual contact abroad or in the UK with individuals from countries of high HIV prevalence (as above).
- HIV testing should also be routinely performed in the following groups in accordance with existing Department of Health guidance:
- Blood donors.
- Dialysis patients.
- Organ transplant donors and recipients.
- Members of staff with a needlestick injury.
- An HIV test should be considered more widely when there is a particularly high HIV prevalence in the local population. Local PCT data should be consulted. If the HIV prevalence exceeds 2 in 1,000 population then testing should be offered to all registered patients. The introduction of universal HIV testing should be considered in such circumstances.
How often to test?
Repeat testing should be provided for the following:
- All individuals who have tested HIV negative but where a possible exposure has occurred within the window period (the time between infection and a positive test result).
- Men who have sex with men (MSM) - annually (more frequently if clinically suspect seroconversion or ongoing high-risk exposure).
- Injecting drug users - annually (more frequently if clinically suspect seroconversion).
- Antenatal care:
- If HIV test at booking is refused, a further offer of testing should be made.
- If they decline again, a third offer of a test should be made at 36 weeks.
- Women presenting to services for the first time in labour should be offered a point of care test (POCT).
- A POCT test may also be considered for the infant of a woman who refuses testing antenatally.
- In areas of higher seroprevalence, or where there are other risk factors, women who are HIV negative at booking may be offered a routine second test at 34-36 weeks of gestation.
Which test to use?
Testing including confirmation should follow the standards laid out by the Health Protection Agency. All acute healthcare settings should expect to have access to:
- Urgent HIV screening assay result within eight hours (definitely within 24 hours), to provide the best support for exposure incidents.
- Routine results within 72 hours.
There are two methods in routine practice for testing for HIV, involving either venepuncture and a screening assay where blood is sent to a laboratory for testing or rapid point of care testing (POCT).
- The recommended first-line assays:
- Fourth-generation assay tests for HIV antibody and p24 antigen simultaneously - have the advantage of reducing the time between infection and testing HIV positive to one month.
- Third-generation assay detects antibody only - has the disadvantage of giving a positive result after a longer (6- to 7-week) interval.
- HIV RNA quantitative assays (viral load tests):
- These are not recommended as screening assays because of the possibility of false positive results. They offer an only marginal advantage over fourth-generation assays for detecting primary infection.
Laboratories undertaking screening tests should be able to confirm antibody and antigen/RNA. The requirement is for:
- Three independent assays (able to distinguish HIV-1 from HIV-2).
- Ideally, these tests could be provided within the primary testing laboratory but may be sent to a referral laboratory.
- All new HIV diagnoses should be made after appropriate confirmatory assays and after testing a second sample.
- This testing offers the advantage of a result from either a fingerprick or mouth swab sample within minutes.
- The tests have advantages of ease of use when venepuncture is not possible but these must be balanced against the disadvantages of a test which has reduced specificity and sensitivity (compared with fourth-generation laboratory tests).
- All positive results must be confirmed by serological tests (as there will be false positives).
- POCT is recommended only in:
- Clinical settings where a rapid turnaround of testing is required.
- Community testing sites.
- Urgent source testing in cases of exposure incidents.
- Circumstances where venepuncture is refused.
The primary purpose of pre-test discussion is to establish informed consent for HIV testing. Lengthy pre-test HIV counselling is not a routine requirement.
This discussion should cover:
- The benefits of testing to the individual.
- Clear details of how the result will be given.
- Why the test might be particularly recommended in some patients (see 'Who should be offered the test?', above).
- Issues raised by the patient about the test and HIV infection. Written information can help. Such issues often include:
- Risk and lifestyle.
- Benefits of knowing HIV status and treatment possibilities.
- What tests are available and which is recommended.
- The window period for testing.
- The difference between HIV and AIDS.
- High-risk behaviour (multiple partners, drug injection, HIV symptoms, positive partner).
- A patient refusing the test.
- Some patients who may need additional help to make a decision. Examples include:
- Language difficulties when English is not the first language.
- Children and young people.
- Those with learning difficulties or mental health problems.
- If the patient is still uncertain about wanting a test, give time to consider and return. They may wish to talk anonymously in confidence to a trained telephone advisor on one of the national helplines. These are the Sexual Health Information Helpline (0800 567123) and the Terrence Higgins Trust Helpline (0845 1221200).
Is further counselling advisable?
- A patient refusing the test:
- Explore to ensure the reasons are valid and beliefs correct.
- If refusing because of implications for insurance or criminal prosecution. Again, this requires further exploration to ensure the reasons are valid and correct. For example:
- Insurance implications:
- The Association of British Insurers (ABI) code of practice 1994 states that questions regarding whether an individual has ever had an HIV test or a negative result should not be asked.
- Applicants should, however, declare any positive results if asked (as with any other medical condition).
- Criminal prosecution for transmission:
- Concern about this issue should not be a barrier to testing.
- There have been a number of prosecutions of individuals under the Offences Against the Person Act 1861 for reckless HIV transmission. This has included a prosecution of an individual who had not been HIV tested. More detailed guidance on the legal implications of this may be needed from others.
- Insurance implications:
As with any other investigation, the following should be recorded in the notes:
- The offer of an HIV test, together with any relevant discussion or written information.
- The reasons for refusing a test, which should be documented.
Usually, written consent is unnecessary and may discourage HIV testing by exceptionalising it.
Of prime importance is to give clear instructions as to how the patient will receive the result, with particular attention as to how a positive result will be given to the patient. Arrangements should always be discussed and agreed with the patient at the time of testing.
In person or in writing?
Arrange to give the HIV test results in person for patients:
- Likely to have an HIV-positive result.
- With mental illness or at risk of suicide.
- For whom English is a second language.
- Under 16 years old.
- Who may be highly anxious or vulnerable.
- In hospital.
Post-test discussion for individuals who test HIV negative
Counselling should incorporate:
- Advice to reduce the risk of acquiring sexually transmitted infections (STIs).
- Advice relating to post-exposure prophylaxis (PEP) to individuals at high risk of repeat exposure to HIV infection. This is best achieved by onward referral to GUM or HIV services.
- The need for a repeat HIV test, if still within the window period after a specific exposure, should be discussed. Fourth-generation tests shorten the time from exposure to seroconversion but a repeat test at three months is still recommended to exclude HIV infection.
- Advice on equivocal results. Occasionally, HIV results are reported as reactive or equivocal. Such patients should be promptly referred to specialist care (as patients may be seroconverting).
Post-test discussion for individuals who test HIV positive
This needs to be done with care and consideration that befits the importance of such a result.
- Follow good clinical practice when breaking bad news:
- Give the result face to face in a confidential environment.
- Give the information and result in a clear and direct manner.
- Use an appropriate confidential translation service if there are any language difficulties.
- If a positive result is being given by a non-specialist (in HIV or GUM) establish a clear pathway for specialist referral prior to giving the result.
- Any individual testing HIV positive for the first time should be seen by a specialist (HIV clinician, specialist nurse or sexual health advisor or voluntary sector counsellor) within 48 hours (certainly within two weeks) of receiving the result. The specialist will address:
- Assessment of disease stage
- Treatment plan
- Partner notification
Non-attendance for positive results
It is recommended:
- To have an agreed recall process following failure to return for a positive result (as with any other medical condition).
- It is the responsibility of the healthcare professional requesting the test to ensure that all results of investigations requested be received and acted on appropriately.
- If attempts to contact the patient are unsuccessful, advice be sought from the local GUM/HIV team.
Low uptake of testing
Reasons for low testing rates and hence low detection rates include:
- Concerns about confidentiality, legal and insurance issues.
- Self perceptions of low risk in those who would test positive.
- Dislike of counselling.
- Wishing to avoid anxiety when waiting for results.
Fear and denial are the most common obstacles to HIV testing among those acknowledging that they have been at risk.
However, the most common reason is lack of time for pre-test counselling, even in GUM clinics.
- Average times for counselling are at least 21 minutes with 18% of people requiring two sessions.
- The longer a person is positive but undiagnosed, the longer they have to transmit the disease to others.
- Uptake of voluntary counselling and testing is poor, even in those with high-risk sexual practices.
- Many infected people never attend GUM clinics for voluntary counselling and testing, even if referred.
- It also seems that pre-test counselling is not dramatically effective in reducing high-risk sexual activity.
Early diagnosis of HIV now clearly improves prognosis. There are benefits of early diagnosis, to both the individual and the community.
There are some special cases that merit discussion or further comment:
Post-exposure prophylaxis (PEP)
See separate HIV Post-exposure Prophylaxis article.
Infants and young children
- Mother has HIV, or may have died of an HIV-associated condition.
- Those born to mothers known to have HIV in pregnancy.
- Those born to mothers who have refused an HIV test in pregnancy.
- Those who are presented for fostering/adoption where there is any risk of infection.
- Those newly arrived in the UK from high-prevalence areas.
- Those with signs and symptoms consistent with an HIV diagnosis.
- Those being screened for congenital immunodeficiency.
- In circumstances of PEP.
- In cases where there has been sexual abuse.
See the separate article Congenital HIV and Childhood AIDS.
Testing where the patient lacks capacity to consent
This includes, for example, when the patient is unconscious. Detail can be found in appendix 4 of the guidance.
Denial and spread of acquired immune deficiency syndrome
Ignorance and denial are important contributory factors to the spread of HIV in Africa and elsewhere.
At a national level, leaders do not like to admit that their country has a problem. Even the great Nelson Mandela denied the problem when he was president of South Africa but he has acknowledged his mistake and expended much time and energy to promote awareness of the disease that has so devastated his country. However, he was succeeded by President Mbeki who denied that HIV was the cause of AIDS.
The Roman Catholic Church has been strongly criticised for its policy with regard to condoms and contraception, although some may defend the argument.
This infection has killed millions and devastated entire communities. It needs to be fought with education and information, particularly about how it is spread and how it can be curtailed. This requires efforts at a global and national level but, for the individual, the first step must be to reduce the risk of spread. We need more testing at an asymptomatic stage to implement early treatment and to prevent spread.
Further reading & references
- Markham WA, Bullock AD, Matthews P, et al; Sexual health care training needs of general practitioner trainers: a regional survey. J Fam Plann Reprod Health Care. 2005 Jul;31(3):213-8.
- Manavi K, Welsby PD; HIV testing no longer needs special status; studentBMJ 2005;13:133-176 April
- UK national guidelines for HIV testing, British HIV Association (September 2008)
- HIV and STIs, Health Protection Agency
- HIV, Health Protection Agency
- Mounier-Jack S, Nielsen S, Coker RJ; HIV testing strategies across European countries. HIV Med. 2008 Jul;9 Suppl 2:13-9.
- Increasing the uptake of HIV testing among men who have sex with men, NICE Public Health Guideline (March 2011)
- Spielberg F, Branson BM, Goldbaum GM, et al; Overcoming barriers to HIV testing: preferences for new strategies among clients of a needle exchange, a sexually transmitted disease clinic, and sex venues for men who have sex with men. J Acquir Immune Defic Syndr. 2003 Mar 1;32(3):318-27.
- Koblin B, Chesney M, Coates T; Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomised controlled study. Lancet. 2004 Jul 3-9;364(9428):41-50.
- Guidelines for the treatment of HIV-infected adults with antiretroviral therapy, The British HIV Association (2008)
- Jones D; Understanding why women decline HIV testing. RCM Midwives. 2004 Aug;7(8):344-7.
- Management of HIV in Pregnancy, Royal College of Obstetricians and Gynaecologists (June 2010)
- Don’t forget the children: guidance for the HIV testing of children with HIV-positive parents, British HIV Association (July 2009)
- Kamerow D; The papal position on condoms and HIV. BMJ. 2009 Mar 25;338:b1217. doi: 10.1136/bmj.b1217.
- O'Brien J; O'Brien J; Was the Pope wrong? Lancet. 2009 May 9;373(9675):1604.
- McCarthy A; The Pope, condoms, and HIV. Why the Pope may be right. BMJ. 2009 Apr 14;338:b1498. doi: 10.1136/bmj.b1498.
|Original Author: Dr Richard Draper||Current Version: Dr Hayley Willacy||Peer Reviewer: Dr Colin Tidy|
|Last Checked: 19/08/2011||Document ID: 2266 Version: 25||© EMIS|
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