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HIV screening

Some clinical circumstances should trigger an offer of an HIV test as a matter of routine, for example as part of antenatal care.

In high prevalence areas, there is a good case for even more extensive testing, including strategies for population screening.

Key information 

Screening by clinical circumstance

Screening offers the potential to detect HIV in people without HIV-related symptoms. Testing asymptomatic people should increase early diagnosis and so improve outcomes for patients. In the Opportunistic testing for HIV section we discuss the role of risk assessment – sexual history-taking – with asymptomatic individuals and the importance of offering tests to those with risk behaviours. In addition there are several clinical situations that are associated with higher risk of HIV and when an HIV test should be offered as a matter of routine.

Clinical situations associated with a higher risk of HIV infection include:

All patients with a diagnosis of a sexually transmitted infection
All patients with a diagnosis of a viral hepatitis

Any patient with an STI is, almost by definition, also at risk of HIV. A substantial proportion of those with Hepatitis B or C may also have been at risk of HIV infection. Therefore anyone diagnosed with any of these conditions should be offered an HIV test. This includes any patient diagnosed with chlamydia, genital warts, genital herpes or Trichomonas as well as gonorrhoea or syphilis. Those with pubic lice may or may not have had unprotected sex.

I saw a patient in her mid 50s and from Egypt. She presented with a single genital wart. She had had one on and off sexual partner for 9 years. I was actually most interested in the opportunity to test her for viral hepatitis, because we had never done this for her despite the high prevalence of Hepatitis C in Egypt. Because of the genital wart I also offered a test for HIV. To my surprise she was HIV positive. She has taken the diagnosis incredibly well and her blood results are so good she doesn’t need treatment yet. She disclosed that she was raped 9 years ago; we don’t yet know her on-off partner’s HIV status. That’s the second time I have diagnosed HIV on the basis of a ‘minor’ STI. Thank heavens I did.

Women undergoing an abortion

There is evidence that women undergoing abortions have a relatively higher prevalence of HIV (1). All women who have been referred for an abortion or undergone one should be offered an HIV test.
 
We work in an area with a very high prevalence of HIV. We did an audit of all those patients who were coded as having an abortion in the last year to check if they had been offered tests for chlamydia and HIV. We found our local services were good at notifying us of chlamydia tests taken and the results. However they did not appear to be offering HIV tests. As a team we agreed we would raise this with women presenting for an abortion, so we added it to our template. We also decided to add to the template a reminder to check contact details at presentation and ask each woman if we can call her a week after the procedure. Our nurse then calls and checks the woman is OK and has her contraception plan in place; she also makes sure she has had her HIV test and result. Finally we have emailed our CCG suggesting that the local services commissioned to provide abortions should be expected to offer HIV tests as a matter of routine.
 
(1) HIV testing in abortion clinics, Bates SM J Fam Plann Reprod Health Care 2011;37:198–200. doi:10.1136/jfprhc-2011-100136

Pregnant women in antenatal care

In the UK, all pregnant women will be offered an HIV test because medical interventions such as antiretroviral therapy and avoidance of breast feeding cut the risk of transmission from mother to baby to below 1%  (from perhaps 20% if untreated, although risks vary widely). NB management advice differs in resource-poor settings, where breast-feeding is recommended.
Some women become infected during the course of their pregnancy and so, especially in high prevalence areas, provision of repeat testing in late pregnancy and/or testing of partners at booking is being considered.

Two of my patients found out about their HIV status in the antenatal clinic. I must admit that seeing what they have been through has made me much more active in offering HIV tests to women before they conceive – it is especially hard getting the diagnosis antenatally. Nevertheless they are both doing fine, as are the babies (all three of them!). 

High prevalence area: women seeking contraception

Because of the routine offer of HIV tests to women antenatally, many practices in higher prevalence areas consider it ideal to discuss HIV testing with women seeking contraception: “All women are offered an HIV test when they are pregnant, but we think it is much better to know if you have HIV BEFORE you get pregnant”.

All patients having an acute medical admission

As has been discussed in The case for HIV Testing late diagnosis – especially very late diagnosis – can be dangerous for patients. Some of these patients have been missed by both primary and secondary services. Therefore there have been pilots of HIV testing in patients being admitted to acute medicine and this has resulted in new diagnoses being made.

Population screening

Many of the clinical circumstances that should trigger an HIV test target women (eg those having abortions or contraception advice). Heterosexual men with HIV are at higher risk of being diagnosed in late stage illness than other groups. Practices need to promote awareness of this issue and strategies to address it. The aim of population screening is to diagnose HIV early, ie avoid waiting for symptomatic presentations.
  
Screening of newly registering patients in high prevalence areas

It was proposed in the 2008 UK HIV Testing Guidelines that screening for HIV should be piloted in areas of high prevalence (where >2 / 1000 population aged 15-55 are diagnosed with HIV). In the general practice context the focus has been on offering HIV tests to newly registering patients. It is thought that cost-effectiveness is likely to be achieved at positivity rates above 1/1000.

You can find out the prevalence of HIV in your area by doing our audit or by clicknig here.

NICE guidance on HIV testing for Africans, and for men who have sex with men also endorsed this.

HIV screening projects in high prevalence areas have used both point of care tests and also normal venous samples.

Point of care tests are quick and easy to use and give instant results, helping to ensure patients are not lost to testing or follow up. Screening pilots supply practices with such tests.

Venous samples enable other relevant tests to be offered as appropriate (such as haemoglobinopathy screens, Hepatitis B or C, rubella immunity tests or lipids). Some practices find this helps normalise HIV testing within the context of general healthcare. See the Key information section in the Offering tests, giving results  section.

You can find out more about the evaluation of the screening pilots here.

 



  A practice in a pilot area for screening

Our practice was in a pilot area for HIV screening and we were very impressed by how our healthcare assistants (HCAs) incorporated it into their routines. Once we had coped with our first positive result and recognised it as the success that it was we seemed to gain confidence and testing uptake increased further. We use point of care (fingerprick) tests and have had one false positive since - with the benefit of hindsight the HCA could see it was only weakly positive. The situation was handled well and the patient was quickly confirmed as HIV negative. False positives will occur from time to time, and may form a significant proportion of positives when testing in lower prevalence populations.

  A practice in a high prevalence area

We are in an area with a high HIV prevalence. HIV screening is not commissioned here and we only perform new registration checks on a minority of our patients. However our healthcare assistants have been taught about HIV testing and are encouraged to offer tests alongside other things (such as hepatitis screening for those from high prevalence countries). They have been pretty good at doing this and HIV testing rates in our practice are high. I think having HCAs able to offer HIV tests normalises testing within the practice and improves uptake of testing across the whole team.

Making a case - resources for your practice


Research & reviews

HIV testing in abortion clinics, Bates SM J Fam Plann Reprod Health Care 2011;37:198–200. doi:10.1136/jfprhc-2011-100136

HIV testing for acute medical admissions: evaluation of a pilot study in Leicester
, England,  Adrian Palfreeman, Farai Nyatsanza, Helen Farn, Graham McKinnon, Paul Schober, Paul McNally Sex Transm Infect 2013;89:308-310 doi:10.1136/sextrans-2011-050401

 

Changing practice:
the challenges

Patients may not request HIV tests for a number of reasons. 

Click on any of the challenges below to find out more.

MIght any of these be especially relevant to your own patient population?

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

General practice is not funded to provide HIV testing

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HIV testing is a standard diagnostic test to be integrated into clinical care, along with the full blood count and the chest X-ray. With improved clinical knowledge, the HIV test is recognised as a valuable tool.

See The case for HIV testing.

With respect to HIV screening in high prevalence areas, practices will usually be funded – for example, to support the offer of an HIV test to all newly registering patients.

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HIV testing is too expensive

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When persuaded of the clinical value of HIV testing (see The case for HIV testing) then GPs and practice nurses will increase their testing rates substantially. See this study, based on work with a group of GPs in an area of North London.

Too much HIV is diagnosed late in the UK and the cost benefits of HIV testing are well recognised due to the health benefits of earlier diagnosis and the avoidance of (sometimes multiple) unnecessary investigations, referrals and even admissions.

With respect to the costs of the actual tests, block contracts between commissioners and pathology often allow for great flexibility in the number of tests done. There are economies of scale if HIV testing numbers increase.

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I think it affects your insurance if have had an HIV test

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Negative HIV test results should not be included by GPs in insurance reports. If a patient has tested positive for HIV, as with all other important conditions, they will need to inform the insurance company (but, in general, they will still be able to obtain insurance cover).

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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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