In 2008, guidelines developed by the British HIV Association
(BHIVA), the British Association for Sexual Health and HIV (BASHH) and the
British Infection Society (BIS) 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. More recently, the more influential National
Institute for Health and Clinical Excellence (NICE) has issued recommendations
which endorse large parts of the 2008 guidelines.
Furthermore, a series of pilot projects have established
that widespread HIV testing is feasible, acceptable to patients and effective
in identifying a substantial number of people with undiagnosed HIV. The most
important barriers to implementation have not been with patients, but the needs
and concerns of doctors and nurses.
One key aspect of the 2008 testing guidelines was that there
are a number of health conditions which may be caused by HIV infection itself,
be more common in people with weakened immune systems or, for behavioural
reasons, be more common in HIV-positive people than in the general population. If
a patient in any healthcare setting has one of these ‘clinical indicator diseases’,
BHIVA recommends HIV testing.
But what do other clinical guidelines say? Martin Fisher,
lead author of the BHIVA guidelines, presented the results of a survey of
guidelines prepared by non-HIV specialist societies and other bodies which
describe the management of 13 clinical indicator diseases. In only four of the guideline
documents is HIV testing considered or recommended.
For example, whereas BHIVA recommend an HIV test for some
women with abnormal cervical screening results (CIN grade 2 or above, VIN), recommendations
from the National Screening Committee and the Royal College of Obstetricians
and Gynaecologists specifically discourage the offer of an HIV test.
Fisher said it was “staggering” that in the guideline on
pulmonary tuberculosis developed by NICE and BTS (British Thoracic Society),
HIV testing should only be considered on a case by case basis. In the BTS
guideline on bacterial pneumonia, the management of the condition in people
with diagnosed HIV is excluded from the document’s scope, but the possibility
of the condition being caused by undiagnosed HIV is not mentioned.
Of the guidelines examined, only in the documents on central
nervous system TB, central nervous system lymphoma and anal cancer is testing
Perhaps as a result, a BHIVA audit of people accessing HIV
care for the first time found that a quarter of new patients had had a missed
opportunity for HIV testing before they were actually diagnosed. (In other
words, they had presented to a clinician with a clinical indicator disease, but
no test had been offered). Moreover, for 14% of new patients, their missed
opportunity had occurred after the publication of BHIVA’s testing guidelines
and in a situation where the guidelines specifically recommended HIV testing.
An analysis of the health conditions people had presented
with and the settings where they did so suggests that the greatest scope for
reducing late diagnosis lies in improving the testing practices of GPs,
gastroenterologists and haemotologists, especially when they see patients with
chronic diarrhoea, weight loss, blood dyscrasias or symptoms that could be
associated with seroconversion to HIV.
In relation to GPs, an audit of general practice showed that
in only 16% of cases where a patient had a clinical indicator disease was HIV
testing done or considered.
The audit was of one large practice with eleven GPs and
12,000 patients. The practice is in central Birmingham, where HIV prevalence is high
enough for the guidelines to recommend that all
new patients at primary care should be offered an HIV test.
148 patients (amounting to 3% of consultations) had an
indicator disease which should prompt HIV testing (regardless of local
prevalence). To give some examples, testing was recommended to only two of ten patients
with tuberculosis (an AIDS defining condition); one of eight patients with
unexplained weight loss; ten of 40 patients with a sexually transmitted
infection; and none of 35 patients with bacterial pneumonia.
Sometimes an indicator disease had originally been diagnosed
in secondary care, and GPs were particularly unlikely to suggest HIV testing
when this was the case. The researchers note that when conditions are diagnosed
outside primary care, it is unclear who has responsibility for ensuring that
testing is carried out.