HIV Counselling

Related articles include:

• AIDS (Acquired Immune Deficiency Disease)
• Childhood HIV
• Complications of HIV infection
• Congenital HIV infection and its prevention
• HIV and skin disorders
• HIV virus
• Management of HIV in pregnancy
• Managing HIV positive individuals in Primary Care
• Post Exposure Prophylaxis
• Primary HIV infection

Historically not all doctors were aware of the effectiveness of early intervention with modern treatments.¹ Since the publication of this paper in 1998 the need for early recognition remains and the benefits of treatment have dramatically improved. There is an even greater need for doctors to be informed about HIV and to have the skills to counsel patients about HIV infection.

It is important for doctors (including GPs), nurses and midwives to be able to obtain informed consent for HIV testing. 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 for this. However counselling after testing can involve the much more demanding task of counselling patients with a positive result.

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 has informed new guidelines on counselling and testing for HIV.²

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.
• A significant number of people in the United Kingdom are unaware of their HIV infection and thereby put at risk their own health and the health of others by transmitting infection unknowingly.
• Late diagnosis is the most important factor associated with HIV-related morbidity and mortality in the UK. For example in the UK 24% of deaths in HIV-positive patients in 2006 were directly attributable to late diagnosis of HIV.
• 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.

Some of the following points may be of value to the patient:

• Men having sex with men (MSM) remain the group in the UK at highest risk of acquiring HIV with evidence that transmission is continuing at a substantial rate.
• The estimated number of people infected through heterosexual contact within the UK has increased from 540 new diagnoses in 2003 to 960 in 2007, and has doubled, from 11% to 23%, as a proportion of all heterosexual diagnoses during this period.³
• In 2005, 70% of diagnoses were in people aged 15 to 39 and 73% of heterosexual cases were in people of African origin or were acquired there.⁴
• The Health Protection Agency estimates that 77,400 people were living with HIV in the UK at the end of 2007, of whom over a quarter (28%) were unaware of their infection.³
• In 2005, 34% of newly diagnosed patients were diagnosed late with serious immunosuppression and 11% had progressed to AIDS. The figure for late diagnosis was 31% in 2008.³

• Universal HIV testing (where all individuals are offered and recommended an HIV test routinely but can refuse testing) is recommended in all the following:
  • GUM or sexual health clinics
  • Antenatal services
  • Termination of pregnancy services
  • Drug dependency programmes
  • Healthcare services for those diagnosed with tuberculosis, hepatitis B, hepatitis C and
    lymphoma.
• 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 article on primary HIV infection)
  • 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
  • All patients reporting a history of injecting drug use
  • All men and women known to be from a country of high HIV prevalence (>1%*)
  • All men and women who report sexual contact abroad or in the UK with individuals from countries of high HIV prevalence (see up to date UN AIDS list in Internet and Further REading section below)
• 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
• 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 1000 population then testing should be offered to all registered patients. The introduction of universal HIV testing should be considered in such circumstances.

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’ gestation.

Testing including confirmation should follow the standards laid out by the Health Protection Agency.⁵ 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 a rapid point of care test (POCT).

Blood tests

• The recommended first-line assays:
  • Fourth generation assay tests for HIV antibody and p24 antigen simultaneously and have the advantage of reducing the time between infection and testing HIV positive to one month.
  • Third generation assay detects antibody only and has the disadvantage of giving a positive result after a longer (6 to 7 week) interval.
  The better fourth generation tests are not offered by all primary screening laboratories.
• HIV RNA quantitative assays (viral load tests):
  • These are not recommended as screening assays because of the possibility of false positive results. They offer and only marginal advantage over fourth generation assays for detecting primary infection.

Confirmatory assays

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.

Point of care testing (POCT)

• These offer the advantage of a result from either a fingerprick or mouth swab sample within
  minutes.
• They 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 to 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.

Is further counselling advisable?

Examples include:

• 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 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.

Documentation

As with any other investigation the following should be recorded in the notes:

• The offer of an HIV test should together with any relevant discussion or written information.
• The reasons for refusing a test should be documented.

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

Post-test discussion for individuals who test HIV positive

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).
• t is the responsibility of the healthcare professional requesting the test to ensure that all results of investigations requested are received and acted on appropriately.
• If attempts to contact the patient are unsuccessful advice be sought from the local GUM/HIV team.

Reasons for low testing rates and hence low detection rates include:⁶

• Concerns about confidentiality, legal and insurance issues
• Self perceptions of low risk in those who would test positive
• Denial
• Dislike of counselling
• Wishing to avoid anxiety when waiting for results

Fear and denial are the commonest obstacles to HIV testing among those acknowledging that they have been at risk.

However, the commonest reason is lack of time for pre-test counselling, even in genitourinary medicine 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.⁷

Early diagnosis of HIV now clearly improves prognosis. There are benefits of early diagnosis to both the individual and the community.⁸ New guidance encourages more testing and wider availability of testing. Old fashioned ideas on this now have no place in good guidance.^9,10

There are some special cases that merit discussion or further comment:

Pregnancy

Testing in pregnancy poses additional questions.¹¹ It is now recommended routinely as above. If positive counselling should incorporate advice, for example, on:

• Risk of transmission to baby.¹² Appropriate steps can reduce the risk of mother to baby transmission from around 25% to 2%.¹³
• Caesarean section and no breast feeding.^14,15

Blood donors: people who donate blood are routinely screened for a number of infections including HIV but they do not receive counselling. In 2005, amongst new donors in the UK there were 24 who tested positive and amongst repeat donors the figure was 15.¹⁶

Post exposure prophylaxis

See separate Post Exposure Prophylaxis article.

Infants and young children²

This raises additional questions about consent and can pose additional problems with post-test counselling.² The following infants and children should be considered for HIV testing:

• 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 post-exposure prophylaxis
• In cases where there has been sexual abuse

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.²

Many practices have been reluctant to undertake HIV testing with associated counselling as it is seen as complicated and time-consuming.¹⁷ 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. Wider availability of testing away from the medical setting may help the uptake of HIV testing.²

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 also been strongly criticised for its policy with regard to condoms and contraception.^18,19 Whilst condoms are not 100% effective against preventing infection²⁰ it has been totally misleading to suggest that they are ineffective and should not be used.²¹ The dean of Pope John Paul II's influential Institute for Marriage and Family Studies at the Vatican, said that when one partner of a married couple is positive for AIDS, it is preferable to risk catching the AIDS virus than to use condoms.²²

This infection that has killed millions and devastated entire communities 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.