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Overcoming the challenges

Listed here are all the challenges to HIV testing mentioned throughout the TIPs site.

Coloured challenges are those often raised by health professionals.

Grey challenges are those raised by patients.

But I don't know how to manage HIV

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. 

But I wouldn't know what to tell the family members

If you diagnose HIV you should refer the patient to the appropriate specialist. The specialist team will address partner notification (contact tracing), including family members.

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

But what would I do if I found a positive?

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.

General practice is not funded to provide HIV testing

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.

GPs should not offer HIV tests because of their role in completing insurance reports

Current guidance on insurance makes it clear that negative HIV test results should not affect insurance, and in addition, GPs should not include them in an insurance report. Being HIV positive may affect insurance, but it is still possible to obtain this because the prognosis is now so good.

Insurance issues should not be a bar to HIV testing in general practice – see The case for HIV testing to remind yourself of the clinical importance of testing.

HIV is quite a difficult thing to ask about

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 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. 

HIV testing is too expensive

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.

How on earth 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.

For more information on sexual history-taking see Opportunistic testing for HIV.

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

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.

I am not at risk of HIV

Patients who conclude they are not at risk of HIV might be right. And they might be wrong. The more the GPs and practice nurses in a team discuss sexual health and assess risk with them, the more informed individual patients will be as to how STIs, including HIV, are transmitted. 

See Opportunistic testing for HIV.

I am not sure the service is confidential

Does your practice have a confidentiality policy? Are all staff trained to protect confidentiality and aware of the policy? Does the induction of new staff include this?

Finally, are your patients made aware that your practice values confidentiality, and do you make them aware of the existence of your policy?

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

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.

I am not very confident about which conditions are associated with HIV, so I think I might miss it

GPs should be familiar with the conditions associated with HIV and then have strategies for raising the subject of HIV and assessing the need for a test. For more information on this see Diagnostic testing for HIV.

For a list of conditions associated with HIV infection, click here. You can also find more information in the UK National Guidelines for HIV testing.

I can't influence the number of HIV tests my colleagues do

This website is here to help you do exactly that. It has practical ideas for change within your team.

You can get a measure of the issues for your practice by going straight to our audit, before using the toolkit. You'll need to sign up to the TIPS site first. (It only takes a minute!).

Or go to Update yourself pages to get motivated.

I don't think I can get an HIV test at the practice

You can make it clear to patients that HIV tests are available at the practice through your practice leaflet and website. You can also make this clear through posters or display screens in the waiting area.

I don't want them to know I am gay

A patient with this concern may be reassured if they feel your practice offers a confidential and non-judgmental service.

See also I am not sure the service is confidential

Many practices display relevant information or statements in their leaflets or other patient information resources such as waiting room displays.

I don't want to scare my patient when their symptoms probably aren't HIV-related

At first it does feel daunting to raise the subject of HIV with, for example, a patient who has a lower respiratory tract infection or pneumonia. However most patients understand that doctors need to consider rare and/or serious causes for problems.

If we can’t change our practice in this respect, we risk missing HIV.

For help with tried and tested verbal strategies see Diagnostic testing for HIV which is all about symptomatic patients.

I have heard of a patient from a high prevalence country who was offended at repeatedly being offered HIV tests

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.

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

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).

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

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.

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.

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

Patients never ask for an HIV test

Please remember that the majority of patients with undiagnosed HIV might have no idea at all that they have it, and may not feel they are at risk: therefore they will not ask for a test.

Staff in practices with high HIV testing rates observe that patient-requested tests are only a small proportion of the total. Most HIV testing is clinician-initiated. Tests may be done to aid differential diagnosis (see Diagnostic testing for HIV).  The chapter Opportunistic testing for HIV’ will also give you ideas for times to test. Both of these appear in the Update Yourself section of TIPs.

There are a number of reasons why patients might be inhibited from asking for an HIV test in your practice – in the Change Practice in Your Team section you will find a team exercise that considers this (‘Feel Free to Ask’].

Practice nurses shouldn't be offering HIV tests to patients

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.

Sexual health clinics are more confidential, and patients should get their tests there

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.

That receptionist is from my community and she would be shocked if I had HIV

Might a patient in your practice be right to have this concern? Involving your team in the ‘Feel free to ask’ exercise may help. Does your practice make clear it is open to discussing HIV, and take a de-stigmatising approach? If there is clear information in the waiting area on HIV this might help reassure this patient. Having an explicit approach to confidentiality may also help.

See also I am not sure the service is confidential.

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 visiting Public Health England's Sexual and Reproductive Health Profiles (select the indicator Prevalence of diagnosed HIV infection per 1.000 persons aged 15 to 59). You can also try doing our audit. You'll need to sign up to the TIPS site first. (It only takes a minute!).

The section Diagnostic testing for HIV will help you and your colleagues correctly identify the conditions associated with HIV infection.

There isn't time to discuss HIV

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.

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

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.

Changing practice:
the challenges