In Brighton & Hove the proportion of new HIV diagnoses
which are made outside of sexual health and antenatal clinics has increased
from 25.7% in 2000 to 57.8% in 2012, driven by improvements in HIV testing in
primary care and community settings. Moreover, there has been a dramatic
improvement in the diagnosis of recent HIV infection.
Brighton & Hove is the area of the UK with the highest
HIV prevalence after London. The analysis was presented to the British Association of
Sexual Health and HIV (BASHH) conference in Bristol yesterday.
Since 2008, UK testing guidelines produced by sexual health
and HIV specialists have urged
healthcare workers of all specialities to consider HIV testing in a wide
range of situations and settings, including GP surgeries and most hospital
departments. In 2011, the National Institute for Health and Clinical Excellence
recommendations which endorse large parts of the 2008 guidelines.
However, health professionals from other specialities have
not always supported the guidelines and implementation has been patchy. Only a
few parts of the country are likely to have results as encouraging as Brighton
HIV clinicians there, led by Martin Fisher of Brighton &
Sussex University Hospitals NHS Trust, have placed a strong emphasis on
expanding HIV testing in recent years. There have been numerous educational
interventions for non-specialist clinicians, service innovations and research
General practitioners have been trained to recognise the
symptoms of primary HIV infection and are offered free HIV testing kits. Pilot
projects have attempted to make HIV testing universal for new patients admitted
to hospital and in primary care. A pilot has demonstrated the merit of
automatic prompts for HIV testing when a ‘clinical indicator disease’ is
recorded in the electronic patient record system.
Rapid testing has been in offered in community settings,
such as gay bars, a gay sauna and Terrence Higgins Trust premises. A walk-in sexual
health service has been opened next to Brighton station.
The data presented to the BASHH conference concern positive
test results (rather than all tests conducted) in Brighton & Hove between
2000 and 2012. During that time, 1359 people have been diagnosed, predominantly
men who have sex with men (72.9%) and people of white ethnicity (77.1%).
Nonetheless, 15% of diagnoses have been in women.
In 2000, three-quarters of diagnoses were made in the
‘traditional’ settings of sexual health clinics, antenatal clinics and blood
transfusion services. However, since 2010, a majority of diagnoses have been
made elsewhere – in 2012, 57.8% were made in ‘non-traditional’ settings.
Diagnoses made by general practitioners have increased from
2.7 to 21.2% (p<0.001). Those made in community settings have risen from 0
to 12.9% (p<0.001).
Hospital outpatient diagnoses have increased to a lesser extent, and
the proportion of diagnoses made in inpatient settings has actually
dropped slightly. However, actual numbers of diagnoses were not shown, so it is
possible that this is an artefact of increased diagnoses elsewhere.
Late diagnosis rates have gone down. In 2000, 52% of newly
diagnosed people had a CD4 cell count below 350/cells3, with this
dropping to 33% in 2012. The reduction in late diagnoses was most marked in the group of patients diagnosed through sexual health
The number of people diagnosed with recent infection
(infection within the past year) has increased from 24.3 to 45.2% (p=0.005),
as did the proportion testing with symptoms of seroconversion (16.7 to 55.3%,
p=0.011). These improvements have been driven by testing in general practice,
with GPs now being more aware of symptoms.
Clinicians also seem to be increasingly aware of the
possibility of HIV infection in older people. The proportion of people over the
age of 50 who are diagnosed outside of sexual health clinics has steadily
increased from around half in 2000 to almost all in the last two years.
The researchers say that the city’s multiple HIV
testing initiatives have been associated with changes in the settings of HIV
diagnoses. Moreover, sexual health clinicians need to work with and support
colleagues in primary care, secondary care and voluntary organisations in order to improve testing practices.