The proportion of eligible people who received an HIV test in a non-specialist setting is low and late diagnosis remains a problem in the UK
Citation: Jacques H (2015) Extending the provision of HIV testing in non-specialist clinics. Nursing Times; 111: 25, 23.
Author: Helen Jacques is medical writer, Evidence Information Services, National Institute for Health and Care Excellence.
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An estimated 107,800 people in the UK were living with HIV in 2013 (Public Health England, 2014) and 42% of people diagnosed with HIV in 2013 were diagnosed late. National guidelines (British HIV Association, 2008) recommend that universal HIV testing should be offered in:
- Genitourinary medicine and 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.
An HIV test should be considered for all men and women registering in general practice and for all general medical admissions in settings where diagnosed HIV prevalence in the local population exceeds two cases per 1,000 population. HIV testing should also be routinely offered and recommended to people diagnosed with sexually transmitted infections or illnesses for which HIV is considered in differential diagnosis. Testing should also be offered to:
- Sexual partners of people who are HIV positive;
- All male and female sexual contacts of men who have sex with men;
- People with a history of injecting drug use;
- All men and women from a country of high HIV prevalence (>1%) or who have had sexual contact with people from such a country.
Elmahdi et al (2014) conducted a systematic review and meta-analysis of HIV testing in at-risk populations in settings other than GUM, sexual health and antenatal clinics in the UK. The authors searched for quantitative studies from after the UK National Guidelines for HIV Testing 2008 were published. The two patient groups covered were people diagnosed with a disease indicative of HIV infection, such as TB or Kaposi’s sarcoma, and those who should have been routinely screened for HIV according to the 2008 guidelines.
A total of 30 studies measuring HIV testing in recommended settings were identified. The proportion of people eligible for HIV testing who were offered and accepted an HIV test was estimated to be 27%. Among those tested, 0.5% were positive for HIV infection. Less than a quarter of people diagnosed with a disease indicative of HIV infection received an HIV test.
Almost a third of people attending settings where screening should have been routinely offered had an HIV test. Among studies reporting the number of tests offered, fewer than half of eligible people were offered an HIV test; however, almost three-quarters of people who were offered a test decided to take it. The authors suggest that the low proportion of eligible people who received an HIV test in settings other than specialist clinics indicates that adherence to the UK National Guidelines for HIV Testing 2008 is poor.
This analysis was limited by the varying quality of the included studies and their wide variety of populations, settings, duration and methods.
- Reproduced with permission; adapted from: National Institute for Health and Care Excellence (2015) Eyes on Evidence: Expert Commentary on Important New Evidence.
Box 1. Commentary
The evidence presented by Elmahdi et al (2014) reinforces the difficulties of expanding HIV testing to general medical services.
Expanding HIV testing in general medical services is one part of a public health strategy to reduce these unacceptably high rates of late diagnosis. However, progress is slow, despite recommendations in national HIV testing guidelines. Worryingly, Elmahdi et al (2014) found low coverage of HIV testing even in individuals with clinical indicator diseases, where there is both a clinical and public health imperative to offer an HIV test. The rate of HIV diagnosis in this group was 2.7% - equivalent to that seen among the highest-risk individuals being tested in sexual health clinics.
The excess costs of treating a late HIV diagnosis, both in the short and long term, continue to inflate the HIV treatment budget. Data presented here indicate that routine HIV testing in services, and for clinically indicated diseases, is a cost-effective intervention.
Anthony Nardone is head of sexual health promotion, HIV and STIs Department, Public Health England
British HIV Association (2008) UK National Guidelines for HIV Testing 2008.
Elmahdi et al (2014) Low levels of HIV test coverage in clinical settings in the UK: a systematic review of adherence to 2008 guidelines. Sexually Transmissed Infections; 90: 119-124.
Public Health England (2014) HIV in the United Kingdom.