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The case for HIV testing

Think HIV is not relevant to you? Think again...

If a patient has HIV, but is undiagnosed and unaware, then the infection will progress and may cause serious harm – and, sometimes, death.  If diagnosed in a timely fashion, HIV infection will respond extremely well to antiretroviral therapy (ART) and the prognosis is transformed.

People with HIV infection who are on treatment (also known as antiretroviral (ARV) medication) are also much less likely to transmit their infection (1).

(1) Cohen SM et al Prevention of HIV-1 Infection with early Antiretroviral Therapy. New England Journal of Medicine 365; 493-505. 2011


Key information

HIV infection responds extremely well to treatment

Antiretroviral therapy (ART) has been hailed as one of the most successful medical interventions ever.

This graph shows the impact of ART, introduce in the mid 1990s, on deaths of young adults from HIV in the USA.

TIPS_Leading_cause_of_death

Graph 1 Leading causes of deaths in USA (Male &Femail, aged 25-44)
 
Credit: Adapted (by Robin A Weiss) from data provided by the Centers for Disease Control & Prevention (CDC), Atlanta, USA.

Late diagnosis harms health

Despite the life-saving benefits of ART, deaths from HIV infection still occur. This is because of late diagnosis, is defined as diagnosis that occurs after a patient would normally have started treatment (ie when their CD4 count, white ‘T Helper ‘ cell count is below 350 cells/mm3). For more information on CD4 cells see HIV in Primary Care.

In 2011 47% of adults diagnosed with HIV in the UK were diagnosed late. They were ten times more likely to die within a year of diagnosis than those diagnosed earlier.

They were also at higher risk of permanent disability, acute serious illnesses and slower response to treatment.  Onward transmission of infection was also much more likely.

TIPS_PHE

Graph kindly provided by Public Health England and reproduced with their permission

GPs are missing opportunities to diagnose HIV

A quarter of the 100,000 people now estimated to be living with HIV in the UK are undiagnosed.

There is evidence that a large proportion of people with HIV are presenting to their GPs but opportunities for diagnosis are being missed (1, 2)

One study found that 76% of the newly diagnosed with HIV had seen their GP in the year prior to diagnosis. In 17% of these the issue of HIV, or HIV testing had been raised.

Around 50% of diagnoses in the UK are made late (3), in other words when their immunity is very low and they are prone to opportunistic infections.

The difficulties for GPs are highlighted by the fact that the worst late diagnosis rates tend to be in the lowest prevalence, often rural, areas (4).

(1) Burns FM, Johnson AM, Nazroo J, Ainsworth J, Anderson J, Fakoya A, et al. Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK. AIDS. 2008 Jan 2;22(1):115-22.

(2) Sudarshi D, Pao D, Murphy G, Parry J, Dean G, Fisher M. Missed opportunities for diagnosing primary HIV infection. Sex Transm Infect. 2008 Feb;84(1):14-6.

(3) Health Protection Agency. HIV in the United Kingdom: 2012 Report. London

(4) Sexual health balanced scorecard and PHE sexual health profiles

HIV transmission plummets with treatment

An international study published in 2011 (1) followed 1700 couples where one partner had HIV and one did not. The couples were selected on the basis that the HIV infected patient had a CD4 count above 350 cells/mm3 – ie above the threshold at which treatment is normally offered.

The couples were randomised so that the HIV infected patients either had no treatment (the control group), or had earlier than usual treatment. They found that, in the control group, the virus was transmitted in 28 couples. In the early treatment group the number was 1. A drop of 96%.

(1) Cohen SM et al Prevention of HIV-1 Infection with early Antiretroviral Therapy. New England Journal of Medicine 365; 493-505. 2011

HIV: the diagnostic challenge

Symptomatic HIV – a wolf in sheep’s clothing?

Symptomatic HIV infection may present with a number of common ‘harmless’ conditions – in other words it can be a wolf in sheep’s clothing for the GP. For example seborrhoeic dermatitis, shingles, diarrhoea and a flu-like illness are all HIV-associated conditions. Another presentation is slightly abnormal blood results - FBCs or LFTs.

Many of the presenting conditions resolve with treatment – or watching and waiting – even though the underlying HIV infection is progressing. There is therefore a major problem with differential diagnosis.  Even in areas with a high prevalence of HIV, the vast majority of patients with these conditions will NOT have HIV infection, so what strategies can GPs adopt to help distinguish the patient who might be immunocompromised?

Learn more about Diagnostic Testing for HIV

The major goal – the biggest challenge: Diagnosing asymptomatic HIV infection

Many of those with undiagnosed HIV are in the asymptomatic phase, which is usually years long. However, the virus will be causing progressive damage. No symptoms! What can be done to increase targeted HIV testing for those who may be at higher risk? How would that work in practice?

To learn about clinical approaches that will help you diagnose asymptomatic HIV infection see Opportunistic testing for HIV

Offering an HIV test

This is a simple process, and often integrated with offers of other diagnostic tests (such as sickle cell screening, glucose or hepatitis B, depending on the clinical circumstances).

UK National Guidelines for HIV Testing 2008 recommend two essential elements to discuss with the patient prior to testing:

i) The benefits of testing for the health of the individual

These should be clear to you from earlier parts of this section. For strategies for discussing this with patients see Opportunistic testing for HIV and Diagnostic testing for HIV

ii) Details of how the result will be given

See Offering tests, giving results for more information on this.

 



  An HIV test I wish I had offered – the GP’s story

My patient SK is a 37 year old single mother – her kids are about 17 and 15 years old. I was aware she had divorced 7 or 8 years ago. SK works as a secretary in a secondary school. She was diagnosed with HIV 12 days after admission to intensive care with a severe atypical pneumonia. I know the consultant who was caring for her, and, as I had admitted her, we discussed her case some time after she had been transferred to the ward and was recovering. Because of the severity of her illness, and the apparent delay in diagnosis of her HIV, her consultant was reviewing her care in the hospital. I agreed we would also review our own records to see if we had missed any diagnostic opportunities.

In the 2 years prior to her hospital admission the patient had attended the practice on several occasions:

TIPS_practice_attendances
 
I was quite shocked when I realised that, with the benefit of hindsight, each and every one of SKs symptoms and conditions were likely to be HIV related. I am embarrassed to recall that at one point she and I shared a joke about how she was having ‘a run of bad luck’ with respect to her health. Even the episodes of contraceptive care might have presented an opportunity to discuss sexual health.

SK’s admission was stormy and she remained in hospital for over 5 weeks, during which time her kids were looked after by her sister. SK was not fit to return to work for over 4 months. She is now well established on antiretroviral therapy, has regained her original weight, and is feeling better than she has for a long time.

I am well aware that, had the practice generally been more proactive in offering HIV tests, we might have spared her that terrible, debilitating illness and prolonged admission. Her kids would not have gone through the horror of seeing their mum in ITU.

It was a crystal clear, adverse, significant event. We ran a clinical meeting on HIV and looked to see if we could find ways to increase HIV testing appropriately by both GPs and practice nurses. I was particularly keen to increase the use of HIV tests as a diagnostic tool, especially by doctors, when symptoms or conditions might be HIV related. I was also concerned to help all of us increase testing with asymptomatic people where there was some indication, because of course people diagnosed at an asymptomatic stage are likely to do so much better.

I think one of my colleagues had been pretty unsure about HIV testing in the past, but we were all shocked by this story and so made sure we overcame any obstacles to testing. I suppose I feel I owe it to SK not to let that happen to any other patients.

  An HIV test I wish I had offered – the practice nurse's story

Our patient SK is a 37 year old single mother with two teenage kids. She works as a secretary in a school. I have got to know her quite well over the years, and was shocked when I heard that she was in intensive care with severe pneumonia.

When it turned out that this had been due to HIV, one of our GPs, Dr BB, used a clinical meeting to update us all on HIV and we reviewed SKs case. We learned that, in general, patients do much better if their HIV infection is picked up early before the damage to their immunity is too severe.

We concluded that opportunities had been missed by almost every doctor and nurse in the practice. Including me.

SK had consulted a practice nurse on four occasions – for repeats of oral contraception (2 occasions, 16 months and 5 months prior to her admission]. She had seen me about her recurrent vaginal candida. She had also had a cervical screening test and been found to have severe dyskariosis. None of the three of us practice nurses had been aware that HIV increases the risk of vaginal thrush and also of progression to cervical cancer and that, in a sense, this might have alerted us.

Me and my nurse colleagues found out quite quickly that there is no barrier to practice nurses offering HIV tests. In fact we found out that in areas with higher prevalence than here, schemes are being run where health care assistants offer HIV tests to newly registering patients! At least one of our doctors was pretty surprised when we pointed that out. We started to explore means of offering HIV tests in a range of clinical situations and have increased our testing substantially. We now review the cases of those women referred for colposcopy.

It wasn’t so much that I was scared in some way of offering HIV tests before (though some of my colleagues were). It was more a question of ‘out of sight out of mind’. I am happy we have all changed our practice and taken this on board.

Making a case - resources for your practice

Publications

The MEDFASH booklet HIV in primary care has a Core Information on HIV section.

Educational material

The e-GP e-Learning sessions: GPS 3.08-20 HIV and Why Early Diagnosis Matters. To access e-GP, see e-GP e-Learning.

Research & reviews

These papers show the impact of HIV treatment (antiretroviral therapy, ART) on mortality and confirm that it is highly cost effective

Walensky RP, Paltiel AD, Losina E, et al. The survival benefits of AIDS treatment in the United States. J. Infect. Dis. 2006;194(1):11–19

Sendi P, Butcher H, Harr T et al. Cost effectiveness of highly active antiretroviral therapy in HIV infected patients: Swiss HIV Cohort study. AIDS 1999; 13: 1115–1122.

Miners AH, Sabin CA, Trueman P et al. Assessing cost effectiveness of highly active antiretroviral therapy for adults with HIV in England. HIV Med 2001; 2: 52–58.

Freedberg KA, Losina E, Weinstein MC et al. The cost effectiveness of combination antiretroviral therapy in HIV disease. N Engl J Med 2001; 344: 824–831.

These papers show that late diagnosis of HIV is associated with higher costs:

Beck EJ, Mandalia S, Sangha R et al. The cost effectiveness of early access to HIV services and starting cART in the UK 1996–2008. PLoS ONE 2011; 6: e27830.

Beck EJ, Mandalia S, Lo G et al. Cost-effectiveness of early treatment with first-line NNRTI-based HAART regimens in the UK, 1996–2006. PLoS ONE 2011; 6: e20200.

This study showed that people whose HIV is treated are much much less likely to transmit HIV to their partner:

Cohen SM et al Prevention of HIV-1 Infection with early Antiretroviral Therapy. New England Journal of Medicine 365; 493-505. 2011

These studies give evidence that HIV is being missed in general practice:

Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK Burns FM, Johnson AM, Nazroo J, Ainsworth J, Anderson J, Fakoya A, et al.. AIDS. 2008 Jan 2;22(1):115-22.

Missed opportunities for diagnosing primary HIV infection Sudarshi D, Pao D, Murphy G, Parry J, Dean G, Fisher M.. Sex Transm Infect. 2008 Feb; 84(1):14-6.

Action checklist: have you made the case for HIV testing to your clinical team?

- used the quiz?
- shared the slideset?
- set aside time for discussion and questions?

Did anyone miss the opportunity (eg due to annual leave)?
How will you address this topic with new clinical staff, including those in training?

Changing practice:
the challenges

There is a clinical need to normalise HIV testing, alongside all our other investigations. However many GPs and practice nurses remain unsure about conducting HIV tests themselves.  

Despite a strong clinical case for testing, barriers still exist.

Click on any of the challenges below to find ways to meet them. Which challenges are relevant to your practice?

You will find other challenges, and ideas for overcoming them, throughout the HIV TIPS website. Or see Overcoming the challenges.

But what would I do if I found a positive?

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The short answer is – congratulate yourself! You would have done something very valuable for your patient’s health. See The case for HIV testing for more information on this. These days this is certainly not the worst news that GPs have to break to patients.

If a result is positive you will always have time to think and obtain advice because the lab will call you. 

The HIV specialist and their team will be responsible for partner notification (contact tracing) and also the management of HIV.

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I am not sure there is any evidence to support widespread HIV testing

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The scientific evidence to support increased HIV testing in general practice is compelling enough for it to be recommended in NICE guidance and UK National Guidelines for HIV testing. 

Audits have shown that people with HIV related symptoms present in general practice, but their HIV is missed. Ensure your team are aware of the benefits to health of HIV testing.

See Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings and Opportunities for earlier diagnosis of HIV in general practice.

See also The case for HIV testing.

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Practice nurses shouldn't be offering HIV tests to patients

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Practices that perform well on HIV testing will certainly be involving their nursing team. In many such practices Health Care Assistants (HCAs) are also offering HIV tests.

Many aspects of the HIV TIPs website will be relevant to practice nurses. Look especially at The case for HIV testing and Opportunistic testing for HIV.

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You need to be able to do special counselling to do an HIV test

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This is not the case. UK National Guidelines for HIV testing specify two essential elements to the pre-test discussion:

- summarise the benefits of testing for the individual patient

- clarify how the patient will obtain results.

See The case for HIV testing for benefits of testing. Check your colleagues are aware that counselling is not needed.

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