The elimination of human immunodeficiency virus (HIV) transmission in the UK is now considered to be an achievable ambition. To attain this target all individuals living with undiagnosed HIV will need to be offered testing and commenced on antiretroviral therapy (ART). The early initiation of ART, regardless of CD4 cell count, has clear benefit for the individual (with avoidance of morbidity and mortality), their partners (avoidance of transmission by having an undetectable viral load) and public health (reduced community viral load and HIV transmissions). Although significant progress has been made in the UK, with falling HIV incidence and near universal ART coverage in those diagnosed, there remains a significant proportion who are undiagnosed (7% in 2018), present late (43% in 2018), and continue to experience morbidity and mortality and contribute to the ongoing transmission of HIV.
These guidelines include a number of recommendations regarding HIV testing. The approaches described need to be adopted and adapted based on local HIV prevalence data, populations and services. Not all approaches are relevant in all areas (e.g. seroprevalence-based testing). In areas of lower prevalence some approaches (e.g. indicator condition testing, risk groups and home sampling/testing) become increasingly important to ensure all those at risk are offered/able to request a test. However, in areas of high and extremely high prevalence, the other approaches should also be instigated in order to widen the potential reach of testing those with undiagnosed HIV. While cost-effectiveness of testing programmes is relevant for some approaches (e.g. indicator condition testing and high local seroprevalence), it should not be universally applied as the cut-off threshold for testing programmes as we work towards the elimination of HIV. All stakeholders should engage in devising a comprehensive approach best suited to their local situation.
Main changes included in the present guidelines:
Indicator condition testing recommendations now have a broader evidence base;
New recommendation to offer testing in emergency departments in areas with high/extremely high HIV seroprevalence;
Recommendation for testing based on local diagnosed HIV seroprevalence now divided into two categories (high and extremely high) with different recommendations, in line with National Institute for Health and Care Excellence guidance;
Change to the window period for fourth-generation serology to 45 days.
The comments received during the public consultation can be found below. All comments were reviewed and discussed and the guidelines amended where appropriate.