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Opportunistic testing for HIV

The ideal time foo diagnosing HIV is before our patient progresses to symptoms - the chances or early diagnosis are higher and so the potential health benefits greater.

To support this we need to offer HIV tests to people who do not have any symptoms of HIV but who might be at risk. How, realistically, can this be done in a practice?

There are two strategies.

HIV screening is one approach that is appropriate for high prevalence areas for HIV. Examples of screening include offering a test to all newly registered patients or all women seeking contraception or an abortion. For more information on this see the HIV screening section of the toolkit.

Opportunistic testing for HIV of those at risk is the strategy we explore in this section. It depends on sexual history-taking.  Clinicians should be aware of the benefits of diagnosing HIV early, and should be able to:

- introduce the topic of HIV with patients in a way that makes no assumptions

- take a sexual history and ask other relevant questions to assess risk 

Knowledge of risk groups and of risk behaviours helps us to offer HIV tests to those at higher risk.


Key information

The advantages of routine sexual history-taking

No clinician in primary care would take a sexual history every time they see every patient. However those who are comfortable with sexual history-taking and ready to use their skill find it invaluable in a whole range of aspects of clinical care, even aside from picking up opportunities to test someone at risk for HIV.

Conducting a careful sexual health risk assessment helps:

- raise patient awareness and understanding and so forms the basis for sexual health promotion

- assess asymptomatic patients for risk of additional infections (eg Hepatitis B and C or chlamydia)

- avoid misjudgments and wrong assumptions (who needs time discussing sexual health – and who doesn’t!).

- support differential diagnosis in the symptomatic patient (could that patient with persistent diarrhoea or shingles have HIV?)

- support clinical decisions (such as choice of contraceptive method, use of pH paper to assess vaginal discharge).

- clarify why a screening test (eg HIV, chlamydia, or viral hepatitis) has been declined – has the patient got good reasons? Or poor ones?

To learn more about how to take a sexual history and assess risk see e-GP e-Learning (e-GP 3.08).

Risk groups for HIV

We should be aware of which groups of people have a higher than average risk of having HIV. Countries with the highest prevalence of HIV are in sub-Saharan Africa. Some Eastern European countries, the Caribbean and some parts of South East Asia also have relatively high prevalence. Click here for more information.
 
Men who have sex with men are, as a group, at higher risk of having HIV.

People who have injected drugs are also at higher risk, although viral hepatitis is a much more substantial risk in the UK.
  
Some risk groups may be apparent without conducting a sexual health and HIV risk assessment (eg people who are from a high prevalence country: there will often be strong clues such as their name and accent – it is a simple matter to clarify).

Another example is a patient attending for methadone.
 
Some risk groups only become apparent when we discuss sexual health and conduct an HIV risk assessment, for example men who have ever had sex with another man. Or someone who once or twice injected drugs in the past. Or someone who has had sex with someone from a country with a high prevalence of HIV.
 
If we do establish that someone is in a risk group, and wish to raise the subject of HIV, it is best not to make assumptions about the risk of the individual patient.  For example, someone attending a methadone clinic may never have injected drugs and may have had a negative HIV test 6 months ago without risks since. Or a middle-aged patient from a country with a high prevalence of HIV may never have had sex or injected drugs. For strategies for raising the subject of sexual health or HIV when the patient may not be expecting it, see e-GP e-Learning

Risk behaviours for HIV

Risk behaviours for HIV include

- Unprotected sexual intercourse

- Unsafe injecting practices

- Multiple sexual partners
 
Combinations of one or more risk group with one or more risk behaviour are the most concerning. However it’s best to have a very low threshold for offering HIV tests – if in doubt, test.   

Barriers to opportunistic testing of those at risk

Listed below are some of the reasons given for not testing patients.

I have a patient from an African country who keeps being offered HIV tests and who feels offended.

Some practice teams and hospital doctors are getting very good at offering HIV tests. As a consequence of this, a few patients feel inappropriately singled out. In the Opportunistic testing for HIV section you can learn more about how to discuss HIV testing with individuals from high prevalence countries - and how to tailor follow up that is appropriate to them.

How do I know which of my male patients is having sex with other men?

You may not! However it is good for clinical members of the team to create an environment where patients feel comfortable to talk about sex. Team members should also be able to take sexual histories in a wide range of clinical circumstances, including with new patients.

There isn't much HIV around here

You may work in an area with a low or medium prevalence of HIV. The catch for these areas is that HIV is less likely to be thought of as a cause for symptoms, and so HIV is more likely to be diagnosed at a late – even life-threatening – stage.

You can check the prevalence of HIV in your area by doing our audit. The section Diagnostic testing for HIV will help you and your colleagues correctly identify the conditions associated with HIV infection.

It is quite a difficult thing to ask about, isn't it?

If you are not used to talking or asking patients about HIV it can feel difficult at the start. The first step is for you to appreciate the clinical value of HIV testing by reading The case for HIV testing: you will see that HIV testing can be life saving.

When you are clearer about why to test, then the section on Opportunistic testing for HIV will discuss how you can learn to offer tests. Consider how you might help members of your team meet this challenge.

HIV testing is quite complicated

The complications of HIV testing (including the supposed need for counselling and also insurance and confidentiality issues) have been completely overstated; the benefits to health are often overlooked. See The case for HIV testing for a reminder of these.

The HIV test is an incredibly valuable clinical tool and clinicians should not allow other issues to act as obstacles to its use. Offering tests, giving results should reassure you that the process is simple.

I don't think our service is confidential enough

All practices should provide a confidential service – backed up by regular training, including the induction of new staff. The practice should have an up-to-date confidentiality policy and should advertise its existence to patients in, for example, the practice leaflet or on the website.

HIV testing should be normalised in practices. Many patients who need to be offered an HIV test have never been to a sexual health clinic and would prefer to consult their own GP. See The case for HIV testing and Offering tests, giving results.

My patient doesn't have HIV - they have already had a negative test

Be cautious when caring for patients who are at continuing risk; tests will need to be repeated over time. For example it has been suggested that HIV negative pregnant women in higher risk groups should be offered a second HIV test later on in their pregnancy.

See also Offering tests, giving results for verbal strategies when offering repeat tests.

There just isn't time

Working in primary care is certainly more and more pressured! But there is evidence that the early diagnosis of HIV can save lives.

Have a look at The case for HIV testing. Staff in practices that have normalised HIV testing find it is generally quick to discuss. Sometimes people blame lack of time when, on reflection, other issues are playing a part.


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.

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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I wouldn't know where to start to take a sexual history

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Many practitioners find taking sexual histories very valuable in their clinical work. This sexual health risk assessment will help identify when tests for STIs such as Chlamydia or Gonorrhoea need to be taken, but also tests for Hepatitis B & C - and HIV.

Taking a history can inform and educate the patient and help the clinician avoid assumptions. The process also indicates who may be at ongoing risk, and so need advice.

For more resources to help practitioners learn about sexual history-taking see Opportunistic testing for HIV.

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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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