Tuesday 1 April 2014
The current system of HIV-testing on the NHS is failing patients and should be radically overhauled, according to new research presented at the joint British HIV Association (BHIVA) and British Association for Sexual Health and HIV (BASHH) Conference in Liverpool (1-4 April 2014).
There are almost 100,000 people in the UK living with HIV, but approximately a quarter remain undiagnosed.1 Late diagnosis of HIV is associated with eight times greater mortality than when the disease is identified early.1
One study group from Guy's and St Thomas' Hospital in London concludes: "We have a duty of care to diagnose HIV patients early to reduce onward transmission and improve patient outcomes. We have failed to achieve this in the UK through ineffective HIV testing strategies."2
This and a number of other studies investigating the value of more pro-active HIV testing and delays to diagnosis were presented at the BHIVA/BASHH Conference. These studies found that whilst intensive education and incentives for patients and professionals can increase the number of people being tested, the rates often remained below national guidelines or declined rapidly after these trials ended.1,2 Two audit studies also found that a substantial number of people were being seen in hospital with a disease which might indicate an infection with HIV, but did not receive testing for the virus.
There is debate amongst experts about the best way to overhaul the system, with two options being widely discussed; opt-out and notional consent. An opt-out system of testing is one under which all relevant patients would be offered a test with the option to withdraw their consent before it is conducted. Notional consent means an HIV test would be conducted on a routine basis without the patient being asked or counseled before testing is conducted. This system, whilst likely to increase HIV diagnoses, may be controversial on ethical or cost-efficacy grounds.
A group of researchers based at Queen Elizabeth Hospital, Woolwich asked whether an 'opt-out' system should now be implemented following a three month trial of greater testing in primary care. The author, Dr S Baillie concludes: "HIV testing can be greatly improved with appropriate interventions. However, even following intervention the results in this study still did not meet national guidelines. With time restraints and stigma is it time for HIV testing to be an opt out system?"1
Dr Golaleh Haidari and colleagues at Guy’s and St Thomas’ Hospital investigated the opt-out system, and found that whilst testing uptake doubled (23.6% to 57.5%), this only lasted as long as doctors were incentivised to offer testing, and rates of testing feel back to their initial level after the trial ended. The groups conclude: “We propose using the concept of ‘notional’ consent where HIV information is visible at the time of admission phlebotomy and HIV testing is performed as part of routine blood tests without the need for pre-test counselling."2
A new audit of HIV testing at Monklands District General Hospital in Glasgow, presented at the BHIVA/BASHH Conference, showed that only a small minority of people with an indicator condition for HIV were offered an HIV test. A second audit of diagnosed patients found numerous missed previous opportunities for testing. On one occasion a diagnosis could have been made nine years earlier.3
A related review, amongst newly diagnosed HIV patients in Manchester, indicated that 45% had either previously presented at a hospital with an HIV clinical indicator disease in the two years prior to their diagnosis or had another risk factor which should have triggered testing (20% and 25% respectively). The authors, led by Dr H Parry of Manchester Medical School comment: "It is clear that several years after the introduction of HIV testing guidelines, opportunities are still being missed and patients continue to be diagnosed late. In our audit, missed opportunities were clearly observed more commonly outside of an HIV clinic setting. As late diagnosis is the most important predictor of mortality and morbidity, it is extremely important that we continue to raise awareness and educate our colleagues in other specialties about the importance of HIV testing."4
A study of GP attitudes carried out by a group at the Liverpool School of Tropical Medicine indicated that just 14% of GPs felt that HIV testing should be routinely offered to everyone aged 18-44 years, with lack of time and skills being cited as reasons, along with concerns about patient acceptance. Additionally, despite stating they were happy to offer HIV testing, a significantly smaller proportion had actually carried out testing. The authors call for better education of GPs on HIV and the development of primary care guidelines on testing.5
Dr David Asboe is Chair of BHIVA and a Consultant in HIV Medicine and Sexual Health at Chelsea and Westminster Hospital. He commented: "This year we see a strong focus on HIV testing at the BHIVA Conference, which illustrates the importance British HIV experts accord to this topic.
"Early diagnosis such a crucial element of safeguarding the health of people with HIV, we need to be doing all we can to encourage people to present for testing and to consider how the systems we use might need to change to better diagnose cases. On behalf of HIV professionals and patients, BHIVA will work to ensure the NHS and Government act to put in place the most robust HIV testing regime possible."
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BHIVA is the leading UK professional association representing professionals in HIV care. Founded in 1995, it is a well-established and highly respected organisation with national influence committed to providing excellence in the care of those living with and affected by HIV. BHIVA acts as a national advisory body to professions and other organisations on all aspects of HIV care. BHIVA also provides a national platform for HIV care and is represented on international, national and local committees dealing with HIV care. In addition, BHIVA works to promote undergraduate, postgraduate and continuing medical education within HIV care. Visit www.bhiva.org for more information about BHIVA, and follow us on Twitter @BritishHIVAssoc
The British Association for Sexual Health and HIV (BASHH) is the lead professional representative body for those managing STIs and HIV in the UK. It seeks to innovate and deliver excellent tailored education and training to healthcare professionals, trainers and trainees in the UK, and to determine, monitor and maintain standards in provision of sexual health and HIV care. http://www.bashh.org/
1. Baillie S. HIV testing in primary care. Abstract P286, BHIVA/BASHH joint conference, 1-4 April 2014
2. Haidari G et al. Opt-out testing for HIV is flawed: it’s time for change. Abstract P245, BHIVA/BASHH joint conference, 1-4 April 2014
3. Acquah R et al. HIV testing in a district general hospital. Abstract P287, BHIVA/BASHH joint conference, 1-4 April 2014
4. Parry H et al. HIV testing: are we doing enough? Abstract P302, BHIVA/BASHH joint conference, 1-4 April 2014
5. Milligan R et al. Attitudes of general practitioners to the introduction of routine human immnunodeficiency virus testing in United Kingdom primary care. Abstract P289, BHIVA/BASHH joint conference, 1-4 April 2014