1. HIV Testing in General Practice
Change the Face of HIV:
HIV Testing in General Practice
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GP Education Session
UK/HIV/0036/16c(1), July 2017

2. DISCUSSION TOPICS * Exploration of the barriers to HIV testing
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* Exploration of the barriers to HIV testing
* NICE guideline on HIV testing
* The role for primary care in HIV
* How to offer the test
* What happens after diagnosis?
* Key questions
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3. **********************************************************
Change the Face of HIV
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Run film from
un video

4. Prevalence
What is the prevalence of diagnosed HIV in xxxx per 1,000 aged years (average in the UK is 2.3)?
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1.1
3.2
5.8
8.5
14.6
Visit PHE fingertips website for up to date information on HIV prevalence and late diagnosis. Amend response options accordingly
Fingertips.phe.org.uk
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5. Late Diagnosis
What % of patients are diagnosed at a late stage of infection in xxxx ?
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16%
26%
36%
46%
56%
Visit PHE fingertips website for up to date information on HIV prevalence and late diagnosis. Amend response options accordingly
Fingertips.phe.org.uk
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6. Late Diagnosis
Heterosexuals are less likely to be diagnosed late than men who have sex with men
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True
False
False, heterosexuals are more likely to be diagnosed late
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7. Black Africans are more likely to be diagnosed late than anyone else
Late Diagnosis
Black Africans are more likely to be diagnosed late than anyone else
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True
False
True, black Africans are more likely to be diagnosed late
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8. Primary HIV infection
Glandular fever-like symptoms can be a sign of Primary HIV infection*?
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True
False
True, glandular fever-like symptoms can be an important sign of Primary HIV infection.
Primary HIV infection (PHI) or seroconversion illness is a self-resolving syndrome that occurs typically 2 to 4 weeks after infection in approximately 80% of individuals. This symptomatic period usually lasts 2 to 3 weeks and often represents the only clinical manifestation of HIV infection before more advanced immunosuppression many years later. Characterised by a combination of nonspecific symptoms, including fever, myalgia, headache and rash, it is well recognized that individuals with PHI often present with a clinical picture of a glandular fever (GF)-like illness.
Low levels of HIV testing in patients presenting in primary care with GF-like illness are resulting in a significant number of missed HIV and seroconversion diagnoses
Reference
Diagnosing HIV infection in patients presenting with glandular fever-like illness in primary care: are we missing primary HIV infection? HIV Med Jan;14(1):60-3. doi: /j x. Epub 2012 May 11
*Primary HIV infection: The first few months following infection with HIV are known as primary HIV infection, or acute HIV infection
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9. Transmission
Which bodily fluids do not contain enough HIV to infect someone else?
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Semen
Vaginal fluids, including menstrual blood
Sweat
Breast milk
Blood
Saliva
Rectal secretions
Urine
Sweat, saliva and urine do not contain enough HIV to infect someone else
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10. Testing
Under what circumstances would you typically offer an HIV test to a patient?
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‘High-risk’ HIV population e.g. men who have sex with men (MSM) or black African
A patient presenting with symptoms that could be indicative of HIV
New patient registrant
IVD user
Anyone you diagnose with a STI
If I am doing a blood test anyway and I’m not sure of the diagnosis
All the above options are correct
The National Institute for Health and Care Excellence (December 2016) Guideline, HIV testing: increasing uptake among people who may have undiagnosed HIV, recommends testing in GP surgeries as follows:
In all areas, offer and recommend HIV testing to everyone who has not previously been diagnosed with HIV and who:
Has symptoms that may indicate HIV or HIV is part of the differential diagnosis (for example, infectious mononucleosis-like syndrome)
Is known to be from a country or group with a high rate of HIV infection
If male, discloses that they have sex with men, or is known to have sex with men, and has not had an HIV test in the previous year
Is a trans woman who has sex with men and has not had an HIV test in the previous year
Reports sexual contact (either abroad or in the UK) with someone from a country with a high rate of HIV
Discloses high-risk sexual practices, for example the practice known as 'chemsex'
Is diagnosed with, or requests testing for, a sexually transmitted infection
Reports a history of injecting drug use
Discloses that they are the sexual partner of someone known to be HIV positive, or of someone at high risk of HIV (for example, female sexual contacts of men who have sex with men).
In areas of high and extremely high prevalence, also offer and recommend HIV testing to everyone who has not previously been diagnosed with HIV and who:
registers with the practice or
is undergoing blood tests for another reason and has not had an HIV test in the previous year.
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11. HIV Testing:What are the barriers?
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Barriers to testing may be greater for the healthcare professionals than for patients.
Reasons for not testing include:
insufficient time
fear/concern of offending the patient
Dealing with a positive diagnosis (impact on the patient)
cost
competing priorities
inadequate knowledge/training,
perceived burdensome consent process and pre-test discussion
low-risk populations
Some still perceive requesting an HIV test as a specialist role that cannot be offered outside a specialist setting, such as GUM, despite BHIVA guidelines (2008) stating that no special competencies are required to consent for and conduct an HIV test.

12. Pre-test counselling is required before offering a HIV test?
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True
False
False, lengthy pre-test counselling is not required before offering an HIV test
HIV is now a manageable long term condition. The outlook for individuals testing positive for HIV is now better than for many other serious illnesses for which clinicians routinely test. Consequently guidance on the need for exceptional pre-test counselling before offering an HIV test is outdated.
The National Institute for Health and Care Excellence (December 2016) Guideline, HIV testing: increasing uptake among people who may have undiagnosed HIV, refers to the benefit of normalising HIV testing so that it is not seen differently from any other blood test.
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13. You have to take a sexual history to determine likely level of risk to HIV before offering a test
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True
False
False, you do not need to take a sexual history to determine likely level of risk to HIV before offering a test.
The National Institute for Health and Care Excellence (December 2016) Guideline, HIV testing: increasing uptake among people who may have undiagnosed HIV, refers to the benefit of normalising HIV testing so that it is not seen differently from any other blood test. .
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14. Commonly cited barriers
Insufficient time
Fear/concern of offending the patient
Dealing with a positive diagnosis (impact on the patient)
Cost
Competing clinical priorities
Inadequate knowledge/training
Perceived burdensome consent process and pre-test discussion
Low-risk populations

15. 1. 2. 3. “I’m not sure what to look out for”
THERE ARE THREE STAGES OF HIV INFECTION:
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Primary infection (seroconversion)
First 1-4 weeks post exposure, typically associated with flu-like or glandular fever-like symptoms. 1.
Asymptomatic stage (post-seroconversion)
Many people start to feel better and some may live symptom-free, this can last up to 10 years. Over time significant immunological damage will result. 2.
Symptomatic stage
During this stage there is usually a lot of damage to the immune system. Now, people are much more prone to serious, ‘opportunistic’ bacterial and fungal infections that a healthy person would be able to fight off.. 3.

16. “I’m not sure what to look out for…”
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Think about testing for HIV as part of your differential diagnosis when:
A patient presents with these signs or symptoms:
e.g. weight loss, herpes, persistent diarrhoea, oral thrush, glandular fever-like symptoms1
* The risk of underlying HIV is higher if these signs and symptoms are unusually severe or recurring or are difficult to treat
If you don’t know the cause for the patient’s presentation, or
When you are considering a blood test for any other reason

17. “I don’t have time to offer the test”
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Offering an HIV test is simple and straightforward, and won’t take up much of your time
Offer the test as part of differential diagnosis – as you would with any other test
No need for sexual history taking
No need for lengthy pre-test counselling
And… as with any other test, there is no need for written consent, verbal is sufficient
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18. What about the cost? NICE says….
* Late diagnosis of HIV is substantially more costly than early diagnosis, because of the costs of inpatient admission and treatment.
* Prompt diagnosis of HIV is cost saving per person, and there could be further cost savings through averting transmission
* In areas of high prevalence, offering HIV testing to everyone undergoing blood tests for another reason would be cost effective, because of the low incremental cost and high HIV prevalence
The average cost of an HIV test in secondary and primary care is typically quoted at about £5-£7

19. I’m worried about her reaction
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There’s often a discrepancy between GPs’ perceived patient acceptability and real-life patients’ attitudes to being offered a test
Research has shown that the majority of patients are happy to be offered an HIV test in primary care and would react positively to the offer, even when they are not expecting it1
If a patient reacts negatively or has any concerns, it’s important to normalise the offer, explain why you’re offering and reassure them on any of their specific concerns
References
1. Rayment M, Thornton A, Mandalia S, Elam G, Atkins M, Jones R, et al. (2012) HIV Testing in NonTraditional Settings – The HINTS Study: A MultiCentre Observational Study of Feasibility and Acceptability. PLoS ONE 7(6): e doi: /journal.pone

20. *************************
NICE Guideline:
HIV testing: increasing uptake among people who may have undiagnosed HIV.
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21. Increasing uptake among people who may have undiagnosed HIV
NICE HIV Testing Guideline
Increasing uptake among people who may have undiagnosed HIV
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Recommendations are based on the local HIV prevalence
High prevalence: a diagnosed HIV prevalence of between 2 and 5 per 1,000 people aged 15 to 59 years.
Extremely high prevalence: a diagnosed HIV prevalence of 5 or more per 1,000 people aged 15 to 59 years.

22. Increasing uptake among people who may have undiagnosed HIV
NICE HIV Testing Guideline
Increasing uptake among people who may have undiagnosed HIV
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1.1.8 In all areas, offer and recommend HIV testing to everyone who has not previously been diagnosed with HIV and who:
has symptoms that may indicate HIV or HIV is part of the differential diagnosis (for example, infectious mononucleosis-like syndrome), in line with HIV in Europe's HIV in indicator conditions
1.1.9 In areas of high and extremely high prevalence, also offer and recommend HIV testing to everyone who has not previously been diagnosed with HIV and who:
registers with the practice or
is undergoing blood tests for another reason and has not had an HIV test in the previous year. [new 2016]
Additionally, in areas of extremely high prevalence, consider HIV testing opportunistically at each consultation (whether bloods are being taken for another reason or not), based on clinical judgement. [new 2016]

23. NICE and simple!

24. HIV Testing: Why Primary Care?
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25. HIV Testing: Addressing an important public health issue
* With early diagnosis and prompt treatment, people living with HIV can lead normal lives.
* A major challenge for the UK remains the timely diagnosis of HIV in order to start lifesaving treatment and prevent onward transmission.
* Two out of five people newly diagnosed with HIV are diagnosed at a late stage and this statistic remains stubbornly high.

26. To what extent do you agree that general practitioners in primary care settings are ideally placed to offer HIV tests to their patients?
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Completely agree
Somewhat agree
Somewhat disagree
Completely disagree
Don’t know
Up to 75% of people diagnosed late will have seen their GP in the 1-3 years leading up to diagnosis often with signs and symptoms of HIV
References
Burns F et al. (2008). Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK. AIDS. 22(1):
Dorward J et al. (2012). Opportunities for earlier diagnosis of HIV in general practice. Sex Transm Infect. 2012;88:524
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27. What percentage of people diagnosed late with HIV will have presented to their GP in the 1-3 years leading up to their diagnosis?
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10%
20%
50%
75%
100%
Up to 75% of people diagnosed late will have seen their GP in the 1-3 years leading up to diagnosis often with signs and symptoms of HIV
References
Burns F et al. (2008). Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK. AIDS. 22(1):
Dorward J et al. (2012). Opportunities for earlier diagnosis of HIV in general practice. Sex Transm Infect. 2012;88:524
>

28. The unique role for primary care
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Up to 75% of people diagnosed late will have seen their GP in the 1-3 years leading up to diagnosis… often with signs and symptoms of HIV1,2
The majority of people with undiagnosed HIV commonly present to primary care1
References:
Burns F et al. (2008). Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK. AIDS. 22(1):
Dorward J et al. (2012). Opportunities for earlier diagnosis of HIV in general practice. Sex Transm Infect. 2012;88:524.
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29. *********************************************
Val’s story
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Val is a 50 year-old school teacher of UK origin and lives with her partner of eight years. She has been presenting with tiredness, feeling run down and night sweats for the past 8 months and seen various GPs at the surgery.
At her latest visit, you question her about the regularity of her periods and suspect she may be going through menopause. She says her periods are still regular and normal.

30. What is your differential diagnosis?
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31. *********************************************
Val’s story
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Six months later Val returns with shingles. She’s been off work for a number of days and still feels extremely tired and run down. You ask her about her work patterns and lifestyle and she says she’s been very busy at work and, as a result, is working long hours. You recommend her to take it easy and prescribe aciclovir to treat the shingles.
What else would you do?

32. *************************
Would you consider HIV?
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33. *********************************************
Val’s story
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Another 4 months later, Val returns. She’s had diarrhoea for 2 weeks and is growing frustrated as she’s taken a lot of sick days from work in the past six months. You ask her about any recent foreign travel, but she’s not been away.
You’re getting more concerned about her health. You order a test for her liver function and another full blood count and send off stool samples. You prescribe her anti-diarrhoeal medication to treat the diarrhoea

34. *************************
Will you consider adding an HIV test to the mix of tests you are ordering?
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35. *********************************************
Val’s story
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Test results reveal mild elevation of liver transaminases.
Since the tests, Val has had no response to the anti-diarrhoeal medication. She returns to the practice 3 weeks later looking very unwell and reveals she has lost 8kg in the last 2 months. You send a referral letter to your local GI department requesting further investigation. An appointment is arranged for 6 weeks time.
What do you think of this plan?
1 of 3
cont.
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36. *********************************************
Val’s story
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Another 3 weeks pass, Val has developed a persistent dry cough and marked breathlessness on exertion. Her partner grows increasingly concerned about her state and takes her to A&E on a Sunday when she is really struggling.
2 of 3
cont.
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37. *********************************************
Val’s story
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The doctor in A&E arranges an X-ray and she is admitted to the respiratory ward and diagnosed with pneumocystis pneumonia (PCP). An HIV test is also ordered.
She tests positive for HIV and her CD4 count is 100 cells/mm3.* She has late stage HIV.
*A normal CD4 count is between 500 – 1500 cells/mm3 1
References:
1. WebMD. (2016). HIV, AIDs, and the CD4 count. Available at: [Accessed: July 2016].
3 of 3

38. The many missed opportunities
With no apparent risk factors to suggest a significant probability of HIV infection, and with such an insidious onset, the diagnosis eluded many practitioners until Val was seriously ill
Remember, some people with HIV have no obvious risk factors for HIV infection

39. How to do it? Practical examples of how to offer an HIV test
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40. To what extent do you agree with the following statement: “Patients are happy to be offered a HIV test in primary care”?
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Completely agree
Somewhat agree
Somewhat disagree
Completely disagree
Don’t know
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41. How comfortable are you in offering a HIV test to your patients?
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Very comfortable
Comfortable
Not very comfortable
Not comfortable at all
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42. Empowering you to have confident conversations about HIV testing with your patients
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HIV testing is quick and easy to do and patients are happy to be offered a test in primary care, but how do you best manage the conversation?
Let’s get started with some practice…

43. Let’s revisit the story of Val…
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44. *********************************************
Val’s story
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Six months later Val returns with shingles. She’s been off work for a number of days and still feels extremely tired and run down. You ask her about her work patterns and lifestyle and she says she’s been very busy at work and, as a result, is working long hours.
How would you raise the test offer with Val?

45. Quick activity in threes
How to test in practice: Considering the conversation
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Quick activity in threes
How would you raise this conversation with Val? Spend 15 minutes testing this out; 2 role playing and 1 observer then rotate roles
What worked well – any top tips?
What did you find most difficult aspect?
Please ask the delegates to role play different patient scenarios. The most common scenario is easy acceptance of the offer of the test but it is worth role playing the more challenging conversation whereby the patient reacts badly to the offer of an HIV test.

46. *************************
Things to remember
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47. When offering the test just remember…
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Normalising HIV testing with patients helps address any worries or concerns they may have and reassures them that it is part of everyday medical practice of differential diagnosis
Offer the test as part of differential diagnosis – as you would with any other test – or if you are in a high prevalence area, offer the test to any patient who is undergoing blood tests for another reason and has not had an HIV test in the previous year
No need for sexual history taking or lengthy pre-test counselling
And… as with any other test, there is no need for written consent, verbal is sufficient

48. When offering the test just remember…
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It is important to communicate:
the benefits of HIV testing and being aware of your HIV status
that HIV testing is part of everyday medical practice
that HIV is treatable and now considered a long term condition
with early diagnosis and prompt treatment, people living with HIV can lead normal lives

49. Positive Diagnosis: What happens next?
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In this section, share experiences of giving a positive result and linkage to the Sexual health/HIV clinic.

50. Managing the positive diagnosis
GPs already have skills in giving bad news
*HIV is a manageable long term condition; with prompt diagnosis and treatment people with HIV can lead normal lives
*Consider referral arrangements: The patient will need to be referred to a specialist HIV clinic for assessment within two weeks of testing positive
*The HIV clinic will manage your patient’s treatment and will conduct partner tracing/
notification and can support you with any questions or concerns you might have.
Some tips:
GPs concerned about the impact of a positive HIV test on their patients should be aware of the following protections that exist:
The results of all medical tests, including those for HIV, are confidential, except where there is an overriding public interest in disclosure or where failure to disclose may result in injury or harm to others.
Updated ‘HIV and Life Insurance’ guidance from the Association of British Insurers (July 216) states that: HIV is treated by insurers like any other medical condition’ and the vast majority of life insurance contracts in the UK do not have exclusions for any medical conditions, including HIV, which are diagnosed after the Life Insurance cover has started.
HIV is covered by the Equality Act 2010 as a protected characteristic as all people diagnosed with HIV are considered ‘disabled’ regardless of their health status. As such, people with HIV have protection under law against discrimination in many aspects of employment, including the recruitment process.
Except in very restricted circumstances, an employer is prohibited from asking job applicants health or disability related questions until the person has been offered a job.
For people with HIV, the most commonly requested adjustments tend to be time off for clinic appointments, changes in hours worked and changes to start or finish times.

51. Referral pathway and support
*The best time to find out about local HIV treatment centres is before you have a patient who tests positive.
[Please add referral pathway and contact details for the local sexual health/HIV service together with details of local HIV support organisations]

52. **************************************
HIV testing is a simple intervention that can save lives.
With one simple blood test, we can save lives and improve patients’ health outcomes.
DON’T THINK TWICE, THINK TEST.
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#ChangeTheFaceOfHIV