TIPs Home

Offering tests, giving results

It is generally extremely quick to offer a patient an HIV test, particularly once HIV testing is normalised alongside other investigations. ‘Pre test counselling’ is no longer required.

UK National Guidelines for HIV Testing 2008 recommends two essential elements to discuss with the patient prior to testing. We have added a third issue for clinicians to consider when testing:

1 The benefits of treatment

It is important that patients understand the advantages to their health of knowing their HIV status, and this should be discussed in a little more depth if they seem unsure whether they would like to go ahead and test.

In general, a brief mention of the effectiveness of antiretroviral therapy (ART) will often suffice.

2 How the patient will obtain their test result

The systems for giving HIV test results should be consistent with your current practice systems for giving results, assuming this is robust.

3 Safety-netting

If you are especially concerned that your patient is high risk but may not actually have their test (for example may not attend for phlebotomy) put a note in your diary or safety-net system to check that you have indeed obtained a result. As with so many other clinical areas, it is often the patient about whom you are most concerned who is least likely to get the test done the first time!


Individual patients may benefit from discussion of other aspects of HIV testing according to their need.

The patient who declines an HIV test

Patients may decline to have an HIV test for excellent reasons (they may not be at risk, or they may have had no risks since their last test) or for poor reasons (they may not want to test because of fear, denial or stigma for example).
Being able to take a sexual history and assess risk is important, as is the ability to listen to the patient’s views.

If the patient has relevant symptoms of HIV and especially if they also have possible risk of HIV, it is important to spend time trying to address the patient’s barriers to testing.  A patient about whom you have great concerns should be actively followed up if they have not agreed to have a test so that you can continue to monitor their health. Working with the patient to build trust over time will normally result in them agreeing to have a test in due course.

What other tests should be done?

Depending on the clinical circumstances, other tests may be appropriate:

For sexual health risks tests for syphilis or Hepatitis B and C may be appropriate (and don’t forget that microbiology samples for other STIs may be important).

The differential for some patients who may be immunosuppressed might be diabetes or a haematological cancer and so an HbA1c or FBC may be indicated.

Some patients from high prevalence countries for HIV may benefit from Hepatitis B and C tests, rubella immunity screens or haemoglobinopathy screening.

Those who have injected drugs should also be offered tests for Hepatitis B and C.

Key information

HIV tests and window periods
Venous sample HIV tests

What is being tested?

The huge majority of labs in the UK use ‘fourth generation’ HIV tests, which test for HIV antibody as well as an HIV antigen (p24 antigen). These combined tests make it easier to detect HIV shortly after infection.

The window period

The p24 antigen component of the test may become positive 5 to 10 days after infection, and the great majority of people will have a positive HIV test by 4 weeks after infection when HIV antibody will usually be detected. Current guidance states that patients should be strongly reassured by a negative test at 4 weeks after the most recent risk for HIV transmission, but that a follow up test at 3 months should be still offered because a tiny number of HIV positive patients would otherwise be missed.

It is important that patients understand the advantages to their health of knowing their HIV status, and this should be discussed in a little more depth if they seem unsure whether they would like to go ahead and test.

In general, a brief mention of the effectiveness of antiretroviral therapy (ART) will often suffice.

Point of Care Testing (POCT)

What is being tested?

Currently point of care HIV tests test use finger prick or saliva samples and test for HIV antibody only, therefore these tests should not be relied upon if there has been a risk of exposure to HIV in the preceding 3 months. POCTs for HIV are generally used for population screening and results are available, and given, within a couple of minutes.

The window period

The window period for point of care tests is 3 months.

Giving results
Negative

 Clearly the vast majority of tests will be negative and such results do not need to be given face to face.

When a patient is found to be HIV negative it is important to consider:

•    If there is a need for repeat testing (eg due to the window period, see ‘HIV tests and window periods’)

•    Whether any other tests are needed (see ‘What other tests should be done?”), or need to be repeated (depending on their own window periods).

•    Whether the patient needs to be immunised against hepatitis B

•     Whether the patient has sufficient information to protect themselves against HIV infection in the future.

All these points generally form a natural component of a consultation when the HIV test is offered and arranged, so there is usually no need to review a patient with a negative HIV test result.

However HIV negative patients who you feel remain at ongoing high risk of contracting HIV may be best referred to a sexual health clinic health advisor for further advice and support.

Positive

 Upon finding an HIV test is reactive, the laboratory will call your practice with the result.

•    Sometimes the result is strongly positive and will be a true positive - the patient should be told they have HIV and should be referred to the HIV clinic.  A confirmatory test will be done as a matter of routine alongside the other ‘new HIV positive’ battery of investigations.

•    From time to time the result may only be weakly reactive and in this case a repeat test will be required, as it may be a false positive. (The lab will often explain this if the situation arises.) It may be appropriate to be somewhat reassuring to the patient in this situation. If the result is weakly reactive you will need to judge whether it is best for the patient to arrange the confirmatory test yourself, or to refer to the HIV clinic for confirmation. 

A phoned-through positive is therefore likely to arrive well before the patient is expecting to receive the result and this gives you a little thinking time, and time to seek advice if you wish.
 
Giving a patient news of their HIV infection has parallels with other instances when you give bad news and as such you will be drawing on your training and experience. In this instance you can be very encouraging of the benefits of treatment and the advantages of knowing about the infection. You will be referring the patient on to the HIV clinic for management of their HIV and for partner notification.
 
Different approaches will be appropriate in different situations. Here are some strategies that have been used:

I was quite shocked when I heard the result was positive, although we had established the patient had a small degree of risk. However it had not been particularly difficult to discuss HIV and my patient had been quite calm, so I called him and checked it was OK to talk. I said I was concerned because the test appeared to be positive and said I would like to discuss it with him more fully – he was able to come to the practice at the end of my evening surgery. By this time I had obtained him an HIV clinic appointment for a couple of days time. He was actually surprisingly calm about the whole thing and is doing well.
 
I asked my receptionist to call the patient and arrange an appointment with me in the next couple of days – then I didn’t have to be vague over the phone with the patient myself and could manage giving the positive result face to face. The receptionist of course didn’t know what the appointment was going to be about so made the booking as a matter of routine.
 
My patient had been pretty anxious throughout the consultation about HIV testing, I also knew he had an alcohol problem and I established he had quite a bit of risky sexual behaviour. I decided to review him in a week in any case, because if the test was negative I wanted to reinforce some of the sexual health advice. Therefore when the test was positive I was well placed to give the result face to face and I had managed to arrange an urgent HIV clinic appointment for him the next day. He was upset but the clinic were very good in those difficult early weeks and he had a lot of support.


Clinical measures in HIV positive patients
Viral Load

The viral load is the measure of the amount of copies of virus in the bloodstream (number of copies of virus per ml expressed in a logarithmic scale).  As can be seen from the graphs of untreated HIV infection:

TIP Viral Load and CD4

TIPS viral load


•     The amount of HIV in the blood may be very high in the early weeks after infection and at this stage the patient is very infectious

•     As the body begins to use strategies against HIV the amount of virus decreases

•     Over years the immune response cannot contain the infection and the viral load starts to rise
 
Viral load is not used to detect HIV infection (ie it is not appropriate as a diagnostic test) but it is used to monitor how effectively the virus is being suppressed by antiretroviral therapy (ART). The goal of ART is to render the viral load undetectable, and so protect the CD4 count.

For more information see HIV in primary care

CD4 count

CD4

CD4 cells are the lymphocytes that HIV infects and destroys. As can be seen from the graph of the course of untreated HIV infection:

•    The normal CD4 count may be over 500 cells/mm3

•    The CD4 count may drop, sometimes markedly, in the very early stages of infection but then recovers as the body makes replacement CD4 cells

•    The CD4 count may then be well sustained for several years.

•    Ultimately, typically at 8 to 10 years, the CD4 declines and the patient becomes much more vulnerable to infections, tumours and the direct effects of HIV. Patients become susceptible to infection at levels below 350 cells/mm3 but in untreated HIV they may drop well below 100 leaving the patient highly vulnerable to overwhelming infection or to HIV-associated tumours.

•    While the CD4 count is an important measure of patient wellbeing, HIV infected individuals with normal counts who are not on ART are recognised as having higher morbidity. It is increasingly clear that some chronic diseases (such as cardiovascular disease) and some cancers are commoner in those with HIV, whatever their CD4 count. 

The CD4 count remains an important factor in deciding when to start ART, although there is a now a tendency to starting treatment earlier in the course of infection and at higher CD4 counts.

For more information see HIV in primary care

Offering tests, giving results - resources for your practice

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 I don't know how to manage HIV

+ See more

If you diagnose HIV you should refer the patient to the appropriate specialist. Your involvement will be valuable in the future providing primary care services to the patient. The booklet HIV in Primary Care gives useful information on the primary care team role with the HIV positive patient.

Have a look at The case for HIV testing to make sure you are aware of the benefits of testing for the patient. 

– See less

I am a nurse - and our local lab requires a doctor's signature before it will do an HIV test

+ See more

It is no longer considered good practice for a laboratory to make a requirement of having a doctor’s signature for an HIV test. It is probably a good idea for you or one of your GPs to contact a consultant microbiologist or virologist (and copy in an HIV specialist) to ensure that practice changes in your lab.

To help you make your case look at The case for HIV testing.

– See less

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

+ See more

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.

For more information on who is at highest risk of HIV see Opportunistic testing for HIV.

– See less

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

+ See more

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.

– See less