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NICE to recommend more HIV testing in primary care and in community settings
Roger Pebody, 2010-10-08 09:10

In its first ever guidance related to HIV, the health watchdog NICE is likely to recommend that health services not concerned with sexual health take a greater role in offering HIV tests to black African people and to men who have sex with men. Moreover NICE envisages an increase in the number of testing projects occurring in venues such as bars and saunas, using rapid point-of-care tests.

NICE’s guidance is currently available in draft form and is open for consultation.

The National Institute for Health and Clinical Excellence (NICE) issues recommendations to the NHS about the most effective and cost-effective treatments and public health interventions to provide. In some cases, NHS bodies are legally required to fund medicines and treatments which are recommended by NICE. Unlike a number of other health quangos, NICE is not threatened with abolition by the new government.

Guidelines on HIV testing have been previously issued by organisations representing specialist clinicians such as the British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASHH). These guidelines have not been endorsed by the UK National Screening Committee or by NICE.

The most recent BHIVA and BASHH testing guidelines recommended that HIV testing should be offered to patients in a wide range of healthcare settings, including GP surgeries and most hospital departments. Implementation of this part of the guidelines has generally been limited.

The Department of Health asked NICE to produce public health guidance on increasing the uptake of HIV testing both among men who have sex with men and among black African communities. Their guidance does not replace or supersede the existing BHIVA / BASHH guidelines: in many cases it supports recommendations made by the HIV specialists, while in other cases it goes further.

NICE’s guidance is currently available in draft form and is open for feedback and comments until November 22. The final version of the guidance is likely to be published in March 2011.

One document covers measures to increase uptake of testing in men who have sex with men, and a separate document covers black African people.

For both population groups, NICE recommends that there is a local strategy for encouraging individuals to consider HIV testing, developed in consultation with local voluntary organisations and community members. These strategies should pay particular attention to groups who are less likely to access services.

Community engagement and involvement is particularly important for black African communities.

Community engagement and involvement is seen as particularly important in relation to black African communities. NICE recommends that community members should be recruited and trained to act as ‘health champions’ and ‘role models’. Programmes need to address misconceptions about HIV testing and treatment, promote the benefits of early diagnosis and tackle HIV-related stigma.

Health promotion interventions promoting testing to men who have sex with men should be encountered in venues, such as saunas or websites, which facilitate sex between men.

Moreover, the draft guidance supports testing programmes in venues where high-risk sexual behaviour between men occurs. This could include saunas, clubs and cruising areas. NICE appears to be more enthusiastic than BHIVA about such projects, although they do note that testing will not be appropriate in all such venues. In such settings, rapid tests (using mouth swabs or fingerprick blood samples) should be provided by trained staff, in a secluded or private area.

All testing services (including community testing) need to have clear referral pathways to confirmatory HIV testing, HIV treatment services and support groups. Moreover people who test negative may need referral to counselling and safer sex interventions, as well as repeat testing (for example, if a risk has been taken during a test’s window period).

In the guidance for black African communities there is an emphasis on providing HIV testing outside of sexual health settings. The literature review conducted to prepare the guidance had noted that HIV testing in sexual health clinics was seen as stigmatising, complicated and time-consuming by some black African people, whereas testing in other healthcare settings was welcomed.

NICE’s recommendation that testing should be offered outside sexual health settings is broadly in line with BHIVA’s current guidelines. NICE recommends that general practitioners should routinely offer an HIV test to black Africans who have not tested before or who have had a new sexual partner since the last negative test. In hospitals and other healthcare settings, an opt-out test should be routinely provided to black Africans who are having blood taken for other reasons.

However it is notable that NICE’s guidance concerning men who have sex with men encourages testing in primary care (GPs), but not in secondary care (hospitals). This is different from the BHIVA guidelines, which recommend that in all healthcare settings, an HIV test should be offered to any man who has disclosed sexual contact with other men.

NICE’s approach is to recommend that when a GP surgery is located in an area with a large gay community or with a high HIV prevalence, HIV testing should be recommended to all male patients, whether or not they have disclosed same-sex behaviour.

However Carl Burnell of the gay men’s health charity GMFA questioned whether this recommendation was workable, owing to the many other demands on healthcare workers’ time. “The strategy assumes that other services are running like clockwork and have capacity to offer HIV testing,” he said.

NICE conclude their documents with summaries of the many gaps in the research evidence, particularly UK-based evaluations of interventions aiming to increase the uptake of testing. However the draft guidance has been prepared in advance of the release of the results from a series of Department of Health funded pilot projects evaluating new testing strategies.

The consultation documents are available here and here.

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