HIV Testing -- what we need to know Dr Madhusree Ghosh ST6 Community Sexual and Reproductive Health

Why it is important HIV is a treatable medical condition A significant number of people in the United Kingdom are unaware of their HIV infection. Late diagnosis is the most important factor associated with HIV- related morbidity and mortality in the UK. Patients should therefore be offered and encouraged to accept HIV testing in a wider range of settings. Patients with specific indicator conditions should be routinely recommended to have an HIV test. All doctors, nurses and midwives should be able to obtain informed consent for an HIV test in the same way that they currently do for any other medical investigation.

Background A national audit by the British HIV Association (BHIVA) showed that 24 per cent of deaths occurring amongst HIV-positive adults in the UK in 2006 were directly attributable to the diagnosis of HIV being made too late for effective treatment. Many of these ‘late presenters’ have been seen in the recent past by healthcare professionals without the diagnosis having been made.

Background continued Late diagnosis of HIV infection has been associated with increased mortality and morbidity impaired response to HAART and increased cost to healthcare services. From a public health perspective, knowledge of HIV status is associated with a reduction in risk behavior and reduced onward transmission.

National Strategy for Sexual Health and HIV (2001) Recommendations All attendees at GUM clinics should be offered an HIV test -- the proportion of infections which remain undiagnosed has reduced but still remains significant [25% in heterosexuals, 47% in men who have sex with men (MSM)]. A universal ‘opt–out’ approach to HIV testing in antenatal patients.

Confidentiality and HIV testing Results should be given directly by the testing clinician to the patient and not via any third party

Recommendations for testing Who can test? It should be within the competence of any doctor, midwife, nurse or trained healthcare worker to obtain consent for and conduct an HIV test.

Who should be offered a test? Universal HIV testing is recommended in all of the following settings: GUM or sexual health clinics antenatal services termination of pregnancy services drug dependency programmes healthcare services for those diagnosed with tuberculosis, hepatitis B, hepatitis C and lymphoma.

Who should be offered a test? continued An HIV test should be considered in the following settings where diagnosed HIV prevalence in the local population (PCT/LA) exceeds 2 in 1000 population all men and women registering in general practice all general medical admissions. HIV testing should also be routinely performed in the following groups in accordance with existing Department of Health guidance: blood donors dialysis patients organ transplant donors and recipients.

How often to test? Repeat testing should be provided for the following groups: all individuals who have tested HIV negative but where a possible exposure has occurred within the window period men who have sex with men (MSM) – annually or more frequently if clinical symptoms are suggestive of seroconversion or ongoing high risk exposure injecting drug users – annually or more frequently if clinical symptoms are suggestive of seroconversion antenatal care – women who refuse an HIV test at booking should be re-offered a test, and should they decline again a third offer of a test should be made at 36 weeks. Women presenting to services for the first time in labour should be offered a point of care test (POCT).

Clinical indicator diseases for adult HIV infection

Which test to use? Two types: Venepuncture (screening assay where blood is sent to a laboratory for testing) or Rapid point of care test (PoCT).

Blood tests The recommended first-line assay is one which tests for HIV antibody AND p24 antigen simultaneously. These are termed fourth generation assays, and have the advantage of reducing the time between infection and testing HIV positive to one month Laboratories undertaking screening tests should be able to confirm antibody and antigen/RNA.

Point of care testing (PoCT) Advantage : Result from either a finger-prick or mouth swab sample within minutes. Ease of use when venepuncture is not possible. Due to the low specificity of PoCT results must be confirmed by serological tests as there will be false positives.

Recommendations for PoCT Clinical settings where a rapid turnaround of testing results is desirable Community testing sites Urgent source testing in cases of exposure incidents Circumstances in which venepuncture is refused.

PoCT in LLR PoCT is available in the community at ISH, Saunas, TRADE (representing the organisation for LGBT), LASS (Leicestershire AIDS Support Service), an independent voluntary organization providing service for people affected by HIV/AIDS in Leicester city. ISH, TRADE and LASS also link into the HIV clinical governance group. The test.hiv service is the Nationally commissioned provider of HIV home-sampling screening, and offers free HIV tests in participating regions.

Pre test discussion The benefits of testing to the individual Details of how the result will be given

Post-test discussion Arrangements for communicating the results should always be discussed and agreed with the patient at the time of testing Face-to-face provision of HIV test results is strongly encouraged for: ward-based patients patients more likely to have an HIV-positive result those with mental health issues or risk of suicide those for whom English is a second language young people under 16 years those who may be highly anxious or vulnerable.

Post-test discussion for individuals who test HIV negative Offer screening for sexually transmitted infections and advice around risk reduction behavior change including discussion relating to post-exposure prophylaxis (PEP) -- - onward referral to GUM or HIV services or voluntary sector agencies. Repeat HIV test if still within the window period.

Post-test discussion for individuals who test HIV positive Result should be given face to face in a confidential environment and in a clear and direct manner. If a positive result is being given by a non-GUM/HIV specialist, it is essential, prior to giving the result, to have clarified knowledge of local specialist services and have established a clear pathway for onward referral. Individual testing HIV positive for the first time is seen by a at the earliest possible opportunity, preferably within 48 hours and certainly within two weeks of receiving the result. More detailed post-test discussion will be performed by the GUM/HIV specialist team.

Suspected Primary HIV infection Primary HIV infection (PHI) or seroconversion illness occurs in approximately 80 per cent of individuals, typically two-to-four weeks after infection Must be recognised to prevent onward transmission. Features of PHI are non-specific frequently the diagnosis is missed or not suspected. The typical symptoms include a combination of any of: fever rash (maculopapular) myalgia pharyngitis headache/aseptic meningitis. These resolve spontaneously within two-to-three weeks and therefore if PHI is suspected, this needs to be investigated at the time of presentation.

Audit on Late Diagnosis of HIV Aim: To identify newly- diagnosed HIV positive patients between rates of ‘late’ diagnosis missed opportunities for testing Results: Out of 180 new HIV positive cases 85 were diagnosed late. The actual number of late diagnosis cases during the audit period is 47. Therefore, the actual late diagnosis rate in this period was 26%, instead of the reported 61% % cases had pre-existing HIV indicators, and 46% cases had missed opportunities of early diagnosis. Conclusions: Actual late-diagnosis rate is lower than that reported previously. There is a high percentage of missed opportunities, which warrants increasing the awareness of clinicians and general population for early detection of HIV.

Recommendations For Clinicians HIV testing must be undertaken rigorously as per the UK National guidelines. Regular update sessions for primary care clinicians by HIV specialists to recognise the symptoms that may signify primary HIV infection or illnesses that often co-exist with HIV. Missed cases must be discussed MDT meetings to raise awareness amongst tertiary care clinicians to identify high risk factors. Importance of partner notification and partner testing should be discussed with patients. Record keeping must be improved HIV treatment centers need to follow up all HIV positive patients and ensure continuity of care.

Recommendations For Commissioners GP practices in Leicester should be commissioned to offer screening to all new registrants. Outreach service and community HIV testing specifically targeted towards the high risk communities should be commissioned.

Thank you