In hospital, the offer of an HIV test needs to be genuinely universal if it is to be effective, one of the pilot projects concluded. Although all new patients were meant to be offered the test, it became clear that clinicians targeted the offer to certain people. Within the project, two of 1413 patients were diagnosed with HIV (0.14%). But an anonymised testing programme, run in the same setting at the same time, found that a further six individuals had HIV infection that remained undiagnosed.
The project took place at the Royal Sussex County Hospital in Brighton, for all patients aged 16 to 79 admitted to acute general medicine. Doctors were asked to offer an HIV test to all patients not known to be HIV-positive.
In fact clinicians offered the test to less than half the patients, but the vast majority of patients accepted the offer. Of 3913 patients admitted, 1553 were offered the test (40%) and 1413 accepted the offer (91%).
In 92% of cases where the clinician did not offer testing, they did not record a reason for not doing so. While younger patients and those with a clinical indicator disease were more likely to be offered a test, there was once again great variability between doctors in the number of HIV tests offered. Doctors at more junior grades offered more tests, but there was also great variability between clinical teams, suggesting to the researchers the importance of clinical leadership.
The two individuals diagnosed HIV-positive as part of the programme were both black African and presented with clinical indicator diseases (one male, one female).
Looking at the extra six individuals identified by the anonymised programme but who remained undiagnosed, all were men and five were white British (the ethnicity of the sixth man was unrecorded). Their age ranged from 34 to 68, with three being over the age of 60 - doctors were significantly less likely to offer testing to those in this age group. In all cases, their sexuality was unrecorded (in fact the sexuality of 98.5% of all patients was not recorded and presumably not discussed, highlighting one challenge in attempting to target testing rather than offer it universally).
Had all eight cases of undiagnosed HIV been identified, the positivity rate would have been 0.2%.
The researchers suggest that in order to genuinely achieve routine opt-out testing, clincians’ barriers to HIV testing need to be better understood and tackled. But they point out that similar challenges were overcome in the implementation of opt-out antenatal testing, and suggest that there are lessons to be learnt from this experience.
Following the study, the hospital’s trust in Brighton has built HIV testing in to Commissioning for Quality and Innovation (CQUIN) payment framework. This provides financial incentives for the hospital to offer the test to at least 60% of newly admitted patients and for at least 90% of them to accept the offer.
While the pilot project at the acute medical unit in Leicester had a high overall positivity rate (1%), the proportion of eligible patients tested was low and varied month by month. At the beginning of the pilot 22% of patients were tested but this dropped at one point to 6%. There was considerable variation from one doctor to another.
In London, the HINTS project evaluated offering testing in three hospital settings - the emergency department at the Chelsea & Westminster (positivity rate 0.2%), the acute care unit at Homerton (1%) and the outpatient dermatology clinic at King's College (none).
Of those who were offered a test, two-thirds took up the offer. Those who declined to do so most commonly cited having tested recently, not being at risk and having other health concerns at the time as their reasons.
Staff surveys conducted before the project began showed that more than three-quarters of staff agreed with the principle of HIV testing being offered routinely to everyone and with this occurring in their own hospital department. Nonetheless, only 42% of acute care unit staff and 57% of emergency department staff agreed that they would feel comfortable offering tests themselves.
Staff concerns included needing additional training, there not being sufficient privacy, not having enough time and being unable to answer all the patients’ questions. However, at the end of the pilot, focus groups showed that many of these fears had been allayed, especially the latter two.
Commenting on these studies, Andy Ustianowski of North Manchester General Hospital noted that making ongoing testing sustainable could be challenging. It needs to become embedded in routine practice but it remains unclear what will facilitate this. Mentioning HIV screening in general patient information leaflets and on admission forms, making testing a performance indicator and providing resources for staff training may all help. He also suggested that HIV specialists should jointly develop procedures with their colleagues in other specialities and avoid attempting to impose systems from outside.