1. For primary and secondary care settings
Increasing the uptake of HIV testing in black African communities in England and among men who have sex with men
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of two pieces of NICE public health guidance on increasing the uptake of HIV testing in black African communities in England and among men who have sex with men. The guidance has been written for directors of public health, and public health specialists and commissioners with a remit for sexual health, as well as commissioners and staff in primary and secondary care, local authorities and national organisations that produce or are responsible for providing information about HIV or HIV testing for black African communities or for men who have sex with men.
Two presentations have been produced to support these guidance topics, this one is for professionals in general practice and secondary care, and there is a second slide set for commissioners of specialised sexual health services. Both slide sets can be accessed from the NICE guidance website pages.
Both pieces of guidance and the corresponding quick reference guides are available from NICE. You may want to hand out copies of the quick reference guides at your presentation so that your audience can refer to them. See the end of the presentation for ordering details. It is also recommended that you download a copy of the clinical indications table within the UK National Guidelines for HIV Testing, from the British HIV Association for reference during slide 14 in this presentation.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. Some examples have been included of resources developed by external organisations that may help when putting the NICE guidance into practice. NICE is not responsible for the quality or accuracy of any information or advice provided by other organisations.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
For primary and secondary care settings
2011
NICE public health guidance 33 and 34

2. What this presentation covers
Background Scope Recommendations for primary and secondary care Clinical indications for testing Applying core skills Discussion Find out more
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background to the guidance and why it is important.
We will then present the recommendations for implementation in primary and secondary care settings.
We will then highlight some of the clinical indications for HIV testing, and detail examples of accredited resources to support healthcare professionals in applying their existing core skills to HIV testing.
Then we will open up the meeting with a list of questions to help prompt discussion on local issues for incorporating the guidance into practice.
Finally, we will end the presentation with further information about the support provided by NICE. The final slide is not part of the presentation – it is an opportunity for you to give feedback to NICE on this implementation tool.

3. Background
In 2009 an estimated 86,500 people in England were living with HIV
26% of HIV-positive men who have sex with men are unaware of their HIV status
More than 40% of new diagnoses among black Africans in the UK are late, which can lead to poorer outcomes
Late or non-diagnosis of HIV increases onward transmission of the virus
NOTES FOR PRESENTERS:
Key points to raise:
Lack of a diagnosis – or late diagnosis – can deprive people, including the partners of those infected of treatment and support.
30% of HIV-positive sub-Saharan Africans leave genitourinary clinics without a diagnosis.
Timely diagnosis (and subsequent treatment) should lead to the person having better health and a longer life expectancy, and a reduction in onward transmission to others.
In 2007 and in 2009 the Chief Medical Officer, Sir Liam Donaldson wrote urging all doctors and nurses in all healthcare settings to offer more HIV testing.
Findings from a recent Department of Health and Health Protection Agency pilot study of community HIV testing has found the routine offer and recommendation of HIV testing in primary care and hospital settings was feasible and acceptable to both staff and patients (reference below). Additional information:
Current UK guidelines (British HIV Association et al – see the quick reference guides) aim to normalise HIV testing, and increase testing in all healthcare settings to reduce the levels of undiagnosed HIV infection.
An HIV test should be accompanied by pre- and post-test discussions according to locally agreed procedures. Further information can be found in the UK national guidelines for HIV testing.
Health Protection Agency (2010) Time to test for HIV: Expanded healthcare and community HIV testing in England. Available from
An outline of the policy context for service delivery can be found within both full guidance documents.

4. Recommendations for primary and secondary care
Promoting testing for people from black African communities and for men who have sex with men
Offering and recommending HIV tests
Repeat testing
Referral pathways
Professional competencies
NOTES FOR PRESENTERS:
The NICE guidance contains lots of recommendations about promoting good health and preventing ill health. For this presentation we have divided the recommendations relevant for primary and secondary care settings into five areas and within these there are eight recommendations that we will consider in turn, these are:
Increasing testing among black African communities living in England – recommendations 4, 5, 6, 7;
Increasing testing among men who have sex with men – recommendations 2, 4, 6, 7.
It is important to emphasise that early HIV testing reduces cases of onward transmission of the virus, which will create savings in the longer term.
This slide set includes recommendations drawn from two pieces of guidance.  Where necessary the slide set will refer to recommendation numbers as presented in the quick reference guides along with an abbreviation in brackets to highlight which guidance it comes from.  We will use the abbreviation (MSM) when it comes for the quick reference guide related to men who have sex with men and we will use (BACE) for referring to the quick reference guide for referring to the guidance for black African communities in England. 

5. Scope
Interventions to increase the uptake of HIV testing to reduce undiagnosed HIV infection among black African communities and among men who have sex with men living in England
NOTES FOR PRESENTERS:
Key points to raise:
Implementing this guidance may help in meeting local requirements outlined under the draft new Public Health England framework. Within this, ring-fenced budgets are expected to be granted to upper-tier and unitary authorities in local government for improving the health and wellbeing of local populations. The provision of some non-discretionary services such as sexual health services is referred to in the draft as being part of this expected ring-fenced budget.
Definitions: Men who have sex with men may be any age and, for the purposes of this guidance, may include those under the age of 16. They come from any cultural, ethnic or faith background and include those who:
identify as gay or bisexual
may identify themselves as heterosexual (and may be having sex with both men and women)
are involved in the commercial gay scene (such as bars and clubs)
use public sex environments (such as public toilets and cruising areas)
opportunistically have sex with men by other means, for example by using Internet sites where men meet for sex
may have physical or learning disabilities
may have a limited knowledge or understanding of English.
Black African communities includes anyone who identifies themselves as black African, whether they are migrants from Africa, African descendants or African nationals. Black African communities encompass diverse population groups including people:
from a range of cultural, ethnic and faith backgrounds
who may be heterosexual, bisexual or homosexual
who may have physical or learning disabilities
whose knowledge or understanding of English may be limited.

6. Promoting HIV testing in black African communities
Where local need is identified, develop tailored materials that:
Explain infection and transmission, the benefits of testing, treatment availability and dispel misconceptions
Emphasise early diagnosis as a route into treatment to avoid serious future illness
Detail how and where to access local testing services
NOTES FOR PRESENTERS:
This information should also be included in verbal messages conveyed to people from black African communities within primary care, for example in routine appointments or antenatal classes.
Evidence shows that the proactive offering and recommending of HIV testing can lead to much lower onward transmission of HIV.
Further information on assessing local needs can be found in the planning services – assessing local need recommendation, within the black African communities in England guidance.
Further points from recommendation 4 (BACE):
Detail of the full range of local HIV testing services should provided including rapid and anonymous testing.
HIV testing should be represented as a responsible act, for example when beginning a new relationship or changing sexual partner, or from the benefits of knowing one’s HIV status.
The needs of non-English-speaking black African communities should be addressed, for example through translated information.
Where satellite or community venues are to be used for HIV testing, use those that local black African communities frequent for example, prayer groups.
Work with black African community organisations to promote HIV testing.
Recommendation 4 can be found in full in the quick reference guide (BACE).

7. Promoting HIV testing among men who have sex with men
HIV health promotion at GP surgeries and other locations should use materials that:
Encourage sexually active men who have sex with men to test at least annually
Present testing as an empowering and responsible act
Present a positive test result as a route into treatment
Detail how and where to access local testing services
Provide information on point-of-care testing and the reduced ‘window period’ of 4th generation tests (if available)
NOTES FOR PRESENTERS: Key points to raise:
This information should also be included in verbal messages conveyed to men who have sex with men during routine interventions and consultations in primary care.
Interventions and resources should aim to reduce the stigma associated with HIV testing and living with HIV among health professionals, as well as among men who have sex with men. Further points from recommendation 2 (MSM):
Health promotion messages should aim to dispel myths about the need to disclose HIV status for insurance or legal purposes.
A positive test result should be presented as a way to avoid complications and future serious illness.
Promote HIV testing when delivering sexual health and HIV prevention interventions to men who have sex with men.
HIV promotions can be carried out in person (using printed publications such as leaflets, booklets and posters) or via electronic media.
Testing should be encouraged at key life stages such as the beginning of a new relationship or when changing sexual partner. Additional information: The window period is the time between infection and when antibodies to the virus are detectable by a test. Depending on the type of test it can take up to 3 months, although fourth generation testing can detect the virus much sooner.
British HIV Association recommend testing at least annually in men who have sex with men – see the relevant quick reference guide for the full reference. Recommendation 2 can be found in full in the quick reference guide (MSM).

8. Black African communities: offering an HIV test
Routinely offer and recommend an HIV test to those:
From a country of high HIV prevalence
Who report sexual contact abroad or in the UK with someone from a country of high HIV prevalence
Who have symptoms that may indicate HIV or where HIV is part of the differential diagnosis
With a sexually transmitted infection
Who are sexual partners of men and women known to be HIV positive
Men who have disclosed sexual contact with other men
Female sexual contacts of men who have sex with men
Patients reporting a history of injecting drug use
NOTES FOR PRESENTERS:
Key points to raise:
Recommendations on this and the following slide apply to those working in primary and secondary care, including accident and emergency departments, antenatal services, general practice, genitourinary medicine, outpatient departments, sexual health clinics and other healthcare settings.
Regardless of local prevalence health professionals in primary and secondary care should routinely offer and recommend an HIV test to people in the categories set out on this slide.
Further points from recommendation 6 (BACE):
People who also may be at risk of exposure to HIV include those who have a new sexual partner or may have previously tested negative during the ‘window period’.
The routine offer and recommending of HIV testing should be made to all patients attending: genitourinary medicine or sexual health clinics; antenatal services; termination of pregnancy services; drug dependency programmes; tuberculosis, hepatitis B, hepatitis C and lymphoma services.
Recommending HIV testing as part of new patient registrations and admissions should be conducted in line with the British HIV Association guidelines.
Additional information:
The window period is the time between infection and when antibodies to the virus are detectable by a test. Depending on the type of test it can take up to 3 months, although fourth generation testing can detect the virus much sooner.
Recommendation 6 can be found in full in the quick reference guide (BACE).

9. Black African communities: HIV testing in primary and secondary care
In areas with high prevalence of diagnosed HIV – where diagnosed cases are over 2 in 1000 of the population - offer and recommend an HIV test:
when registering and admitting new patients (primary care and general medical admissions)
to anyone who has a blood test
NOTES FOR PRESENTERS:
Key points to raise:
These recommendations should be applied to both men and women who are attending a healthcare appointment or intervention.
Further points from recommendation 6 (BACE):
The HIV test should be offered in line with British HIV Association guidelines.
Regardless of the reason for the blood test, an HIV test should be recommended.
Additional information:
For an up-to-date list of high prevalence countries see:
Recommendation 6 can be found in full in the quick reference guide (BACE).

10. Men who have sex with men: HIV testing in primary care
Offer and recommend HIV testing to all men who:
Register with a practice in an area with a large community of men who have sex with men
Register with a practice in an area with a high HIV prevalence
Disclose that they have sex with other men
Are known to have sex with men and have not had a HIV test in the previous year
Are known to have sex with men and disclose they have changed sexual partner or high risk sexual practices
Have symptoms that may either indicate HIV, or that HIV is part of the differential diagnosis
Are diagnosed with, or request screening for, a sexually transmitted infection
Live in a high prevalence area and are undergoing blood tests for another reason
NOTES FOR PRESENTERS:
Key points to raise:
An area with a high HIV prevalence is defined here as more than 2 diagnosed cases per 1000 people.
This recommendation applies to practice managers, GPs, practice nurses clinical staff in community clinics, health centres and walk-in centres and commissioners.
Recommendation 4 can be found in full in the quick reference guide (MSM).
Ensure annual HIV testing is part of integrated healthcare offered to men who are known to have sex with men

11. Men who have sex with men HIV testing in secondary care
Offer and recommend HIV testing during hospital admittance for men who:
are admitted in areas with a high prevalence of HIV
disclose that they have sex with men
have symptoms that may indicate HIV, or HIV is part of the differential diagnosis
NOTES FOR PRESENTERS:
Key points to raise:
High prevalence is defined for this guidance as more than 2 diagnosed cases per 1000 people.
Further points from recommendation 4 (MSM):
Secondary and emergency care providers should also offer testing to men who are not diagnosed with HIV when admitted to hospital and are:
- within a practice in an area with a large community of men who have sex with men, or
- registered with a practice in an area with a high HIV prevalence (more than 2 diagnosed cases per 1000 people), or
- are known to have sex with men and have not had a HIV test in the previous year, or
- are known to have sex with men and disclose that they have changed sexual partner or disclose high risk sexual practices.
Ideally, test providers should offer both fourth generation serological testing and point-of-care testing.
Additional information:
Further information on indications that may be part of the differential diagnosis can be found on slide 14. A full list of these conditions can also be found in the UK national guidelines for HIV testing, British HIV Association (2008). Full reference is available in the quick reference guides.
Recommendation 4 can be found in full in the quick reference guide (MSM).

12. Repeat testing for men who have sex with men
Recommend:
annual testing to all
more frequent testing for those at high risk of exposure
repeat testing after the ‘window period’ for those who tested negative, but have possibly been exposed to the virus
NOTES FOR PRESENTERS:
Key points to raise:
The window period is the time between infection and when antibodies to the virus are detectable by a test. Depending on the type of test it can take up to 3 months, although fourth generation testing can detect the virus much sooner.
High risk exposure to the HIV virus may be for example, through multiple sexual partners or unsafe sexual practices.
Recommendation 6 can be found in full in the quick reference guide (MSM).

13. HIV referral pathways
For everyone: provide information on behavioural or health promotion interventions
Positive test: seen by an HIV specialist, preferably within 48 hours; given information about diagnosis and local support
Negative test: encourage repeat testing if at risk
Test declined: ensure they know how to access testing services
NOTES FOR PRESENTERS:
Further points from recommendations 7 (BACE and MSM):
For people who test positive an appointment with an HIV specialist should take place at the earliest opportunity, and certainly within 2 weeks of receiving the result.
Behavioural or health promotion interventions can be provided from both voluntary and statutory services.
Such interventions may include advice on safer sex, training in negotiating skills and providing condoms.
Some men who have sex with men (including under-16s) may need additional psychological support and should be referred to counselling services that are totally accepting of their sexuality.
Behavioural or health promotion interventions should be provided for those with positive and negative HIV test results, if appropriate.
Repeat testing should be advised, for example for those who have new or multiple partners.
Recommendations on HIV referral pathways (for both the BACE and MSM guidance) can be found in full in the corresponding quick reference guide.

14. Clinical indications for HIV testing
Patients may present with non-specific symptoms such as malaise and weight loss, or symptoms from a range of clinical areas, including:
• thoracic medicine
• gastroenterology
• oncology
• dermatology
• haematology
• emergency medicine A full list of clinical indications for HIV testing can be found in the UK National Guidelines for HIV Testing, British HIV Association
NOTES FOR PRESENTERS:
Key points to raise:
A ‘dear colleague’ letter from the Chief Medical Officer (CMO) has highlighted that a significant number of people who are diagnosed late with HIV have already been in contact with healthcare professionals in the preceding year exhibiting symptoms likely to be related to HIV.
• Examples of potential clinical indications where HIV testing should be considered include: - oral candidiasis, severe gastroenteritis - lymphoma - shingles, severe fungal dermatoses - Idiopathic Thrombocytopenic Purpura - and meningitis.
Please note, the above list is only indicative, a full list of the clinical indications for HIV testing can be found in the BHIVA UK National Guidelines for HIV testing. It is recommended that presenters download a copy of the clinical indications table from the BHIVA guideline for reference during this presentation.
Further information on diagnosing HIV for non-HIV healthcare professionals, including case studies and learning points can be found in the MedFASH resource that is referenced on slide 16.
References for the CMO’s Dear colleague letters: Chief Medical Officer (2007) Improving the detection and diagnosis of HIV in non-HIV specialties including primary care. Public Health Link, 13 September Gateway no: Chief Medical Officer (2009) Tackling undiagnosed HIV infection (letter to the Presidents of medical Royal Colleges and Faculties) 21 September 2009.

15. Professional competencies
Ensure staff feel able to routinely offer and recommend an HIV test. They should:
provide information on testing, discuss why it is recommended and emphasise confidentiality
be able to discuss symptoms, and the implications of a positive or a negative test
be familiar with referral pathways
recognise symptoms that may signify primary HIV infection or co-existing illnesses
NOTES FOR PRESENTERS:
Key points to raise:
The competencies required to effectively offer and recommend an HIV test are within the range required for many health professionals.
All frontline healthcare staff, including non-clinical staff, should be trained in diversity issues and be able to challenge the stigma of, and dispel the myths surrounding HIV and HIV testing.
Healthcare staff should also be able to -
provide information and explain why testing is important to those who may decline an HIV test
direct those who are concerned about confidentiality to a genitourinary medicine clinic, where people do not have to give their real name
provide appropriate information to those who have tested negative, including details of where to get free condoms or training in negotiation skills
challenge the stigma of, and dispel any myths surrounding, HIV and HIV testing and be sensitive to the individual needs of people.
Further point from the NICE guidance:
Familiarity with referral pathways is necessary to ensure people who test positive receive prompt support.
Further points from recommendation 5 (BACE):
Ensure HIV testing services can offer rapid tests to people who are reluctant to wait for results (or can refer people to a service that provides rapid tests).
If people are unwilling to have a blood test, they should be offered less invasive options (such as a saliva test), or should be referred elsewhere for such a test.
Recommendations 4 (MSM) and 5 (BACE) can be found in full in the corresponding quick reference guide.

16. Applying core skills: HIV testing
Offering and recommending a HIV test should be within the existing competencies of health professionals. Resources that may help when applying these core skills to HIV testing include: Tackling HIV Testing: increasing detection and diagnosis (MedFASH) HIV in primary care (MedFASH)
HIV for non-HIV specialists; diagnosing the undiagnosed (MedFASH)
NOTES FOR PRESENTERS: Key points to raise:
A lack of specific training should not be a barrier to carrying out HIV tests, for example, many health professionals should already be already be able to take blood and carry out a range of other tests and be trained in giving bad news.
Resource 1 - Tackling HIV Testing: increasing detection and diagnosis, MedFASH (2009) A comprehensive resource pack with practical tools to support educational sessions with non-HIV staff and template resources to support the roll out of this work across general healthcare settings. This includes templates for recording local HIV specialists’ contact details and noting referral pathways; protocols for performing HIV tests and providing results; and an aide-memoire summarising key points to cover in a pre-test discussion. The pack can be downloaded from: Resource 2 - HIV in primary care (MedFASH) (2005) A practical guide written by GPs that provides information for primary health care professionals on the clinical diagnosis of HIV (including photos), outlines the opportunities for offering an HIV test and advice on the principles of offering a test and giving test results. It can be downloaded via Resource 3 - HIV for non-HIV specialists; diagnosing the undiagnosed (MedFASH) (2008) A practical guide for secondary care it contains advice on how to offer an HIV test, conducting pre and post test discussions, obtaining informed consent, and managing situations where an HIV test has been refused. The tool also provides information on potential cultural barriers to testing and includes case studies and learning points throughout. It can be downloaded from the MedFASH website and from
Additional resources British HIV Association (BHIVA) E-Learning module is accredited by the Royal College of Practitioners and is awarded 3 CPD points. It is based on the BHIVA guidelines for the treatment of HIV-1-infected adults with antiretroviral therapy 2008.
Resources for pharmacists can be found via the HIV Pharmacy Association

17. Discussion
What information do we have on HIV prevalence in our region?
How do our local protocols deal with offering and recommending HIV testing in general healthcare settings?
What steps need to be taken to incorporate HIV testing into new patient registrations?
What may help to improve the process of offering HIV testing for elective surgery patients in high prevalence areas?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.

18. Find out more
Visit and for:
the guidance
the quick reference guides
costing report and template
slide set for commissioning
self assessment tools
BMJ Learning module
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The guidance documents, including all the recommendations in full plus considerations and evidence statements.
A quick reference guide for each piece of guidance, which includes the recommendations.
For a printed copy of one of the quick reference guides, phone NICE publications on or and quote reference number N2486 (PH33) (Black African communities in England) or reference number N2487 (PH 34). (Men who have sex with men).
NICE has developed tools to help organisations implement both pieces of guidance, which can be found on the NICE website.
Costing tools – a costing report gives the background to the national savings and costs associated implementing both pieces of guidance, and a costing template allows you to estimate the local costs and savings involved.
Slide set for commissioning of sexual health services – to raise awareness of the whole set of recommendations within both pieces of guidance.
Self assessment tools – for monitoring local practice. One self assessment tool has been developed for each of the two guidance topics.
BMJ Learning module - available from May 2011, this resource has been developed for healthcare professionals from primary and secondary care who are not specialists in HIV medicine. The module is free to access, though registration is required.

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