HIV Testing: Ultimate Guide To HIV Testing

HIV Testing - The ultimate guide to HIV Testing, including facts and information about HIV Testing.

HIV Testing - The Ultimate Guide To HIV Testing


HIV Testing: Introduction


In 2006, the US Centers for Disease Control and Prevention (CDC) issued expanded recommendations for HIV in the USA. In the UK, national guidelines on HIV testing were developed in 2008. These were endorsed by NICE guidance and a Parliamentary select committee on HIV and AIDS in 2011.



In the past, most HIV testing took place within Genito-Urinary Medicine clinics, with an emphasis placed on pre-test counselling to ensure that valid consent was obtained. This was appropriate in the earlier years of the HIV epidemic when HIV was rare and untreatable, with HIV-positive individuals facing widespread stigma and discrimination. However, HIV has now become a chronic treatable condition, and late diagnosis of HIV infection is now the most important factor associated with HIV-related morbidity and mortality in the UK.



Around a quarter of all HIV-positive individuals remain undiagnosed in the UK, and an estimated 30% of individuals are diagnosed very late (CD4 count <200 cells/µL). Late diagnosis is more prevalent in older age groups, heterosexual men and black and ethnic minority populations. Many of these patients have missed opportunities for earlier diagnosis in that studies have shown that a significant proportion have been seen for care by their general practitioners or other physicians with HIV-related symptoms but the diagnosis of HIV was overlooked. In addition to risks to their own health, undiagnosed individuals run the risk of unwittingly transmitting their infection to others and so fuelling the HIV epidemic.



The 2008 National Guidelines on HIV testing aim to reduce the proportion of HIV-positive individuals unaware of their infection. The guidelines recommend that HIV testing should be normalized to become a routine medical investigation carried out in many medical settings, and that obtaining consent for an HIV test should be within the competence of any healthcare professional.



In 2011 NICE issued separate guidelines on HIV testing aimed at black African communities and guidance aimed at men who have sex with other men. These recommend increased offers of testing in these populations, as both these communities bear a disproportionate burden of HIV disease.



HIV Testing: Who To Test For HIV


It is now recommended that an HIV test is offered on an opt-out basis to all patients presenting for care:



An opt-out test ensures that the test becomes a part of the routine standard of care while still allowing patients the right to decline a test.



The settings where an HIV test should be routine are those where patients are at increased risk of HIV infection, or, in the case of antenatal services, where it is important not to miss the diagnosis to prevent onward transmission to the baby.



HIV testing has been routinely offered to all patients attending sexually transmitted infection (STI) clinics since 1999, with uptake of over 70%, and in antenatal clinics since 2001 with uptake of over 90%. Women undergoing termination of pregnancy have a prevalence of HIV of up to 1%. High numbers of patients attending drug dependency programmes will have injected drugs. Over 5% of patients with tuberculosis (TB) in England and Wales are HIV positive and TB is often the first AIDS-defining condition.



Lymphoma is much more common in HIV infection than in the general population. Hepatitis B and C, like HIV, are blood-borne viruses and many individuals are dually infected.



Routine HIV testing should also be offered to all patients presenting to acute medicine or registering in primary care in parts of the country where the local HIV prevalence is greater than two per 1000 among 15–59 year olds. Routine screening at this prevalence or higher is known to be cost-effective.



Around a fifth of the population in England live in a high prevalence area, the majority of them in London. Published data from both the USA and the UK have shown that the routine offer of an HIV test in a variety of settings (which have historically been thought to be difficult to roll out HIV testing) have been shown to be cost-effective, acceptable to patients and effective in identifying previously undiagnosed individuals.



The groups of people who should be offered a routine HIV test are those known to be at increased risk of HIV infection.



Groups of people who should be offered a routine HIV test:





HIV Testing: Frequency Of HIV Testing


Most of the time a single negative test is sufficient to rule out the diagnosis of HIV. A repeat test may be necessary if testing for HIV occurred within the window period.



Certain groups of patients should be tested more frequently:





HIV Testing: Which Test To Use


Testing for HIV may be performed on laboratory-based blood tests or via rapid point of care tests. Rapid tests are becoming increasingly used as they are acceptable to patients and can overcome logistical issues in increasing HIV testing uptake in some settings. They rely on either serum from fingerprick or saliva from a mouth swab and can give the patient a result in a few minutes.



Occasionally an HIV test is inconclusive or gives an equivocal result and a laboratory-based blood test is required.



Consent should be obtained prior to an HIV test, as with any planned investigation. Advising the patient that a routine HIV test is recommended and the reasons why it is recommended, then asking for permission to do the test while giving the patient time to ask questions, is the most appropriate way of gaining consent. If a patient refuses a test, the reasons for this should be explored to ensure that they do not hold incorrect beliefs about the virus or the consequences of testing. For example, some individuals believe that having a routine HIV test affects future life insurance; this is no longer correct following the 1994 Association of British Insurers (ABI) Code of Practice.



HIV Testing: Pre-Test Discussion


Written consent is not necessary, but the offer of an HIV test should be documented in the patient's notes together with any relevant discussion that has taken place. If the patient refuses a test, the reasons for this should be recorded.



Some groups of patients may need additional help to make a decision, for example children and young people, those with learning difficulties or mental health problems, and those for whom English is not their first language. It is essential to take time to ensure that these patients have understood what is proposed, and why.



For young children in whom testing is indicated, there may be issues about parental acceptance of the need to test and a possible positive diagnosis. This is a complex area, but the overriding consideration is the best interests of the child, and multidisciplinary decision-making and expert advice should be sought where appropriate, including legal advice.



HIV Testing: Giving HIV Test Results


Arrangements on when and how the result will be received by the patient should be agreed at the time of testing. For the majority of individuals, if the result is not thought likely to be positive there is no need to deliver the result face to face.



Face-to-face provision of HIV test results is strongly encouraged for the following:





Post-Test Discussion For Individuals Who Are Negative


These individuals should be offered screening for sexually transmitted infections and advice around risk reduction and behaviour change, including discussion relating to HIV post-exposure prophylaxis (PEP) if at higher risk of repeat exposure to HIV infection. This is best achieved by onward referral to GUM/HIV services or voluntary sector agencies.



If the individual is still within the window period after a specific exposure (<12 weeks), the need for a repeat HIV test should be discussed.


HIV Testing: Post-Test Discussion For Individuals Who Test HIV Positive


Prior to giving a positive result, it is essential to have established a clear pathway for onward referral to the HIV specialist team.



The result of a positive HIV test should be given in a confidential environment face to face with the patient by the testing clinician or team. A result should not be given to any third party, including relatives or other clinical teams, unless the patient has specifically agreed to this. This is in line with the general principles of confidentiality for any medical condition as laid down by the General Medical Council.



If a patient's first language is not English, it is considered good practice to use a translation service rather than family member for purposes of confidentiality. Establish that the patient understands what a positive and a negative result mean in terms of infection with HIV, as some patients interpret 'positive' as good news.



The HIV team should then see the patient as soon as possible to assess disease stage, consider the need for treatment and carry out partner notification.



HIV Testing: Summary


The advent of effective treatment has transformed HIV infection into a chronic manageable disease with a near-normal lifespan. However, approximately one-quarter of individuals are unaware of their infection and are diagnosed late, with significant impact on individual and public health. Increasing the routine offer of HIV testing, normalizing the testing process, and improved recognition of clinical indicator diseases by hospital clinicians should significantly improve the current situation. All doctors, nurses and midwives should be able to obtain informed consent for an HIV test.



HIV Testing: References