Although the HIV testing guidelines developed by HIV and sexual health clinicians recommend that a wide range of non-HIV physicians should offer HIV testing, these recommendations are not supported or are contradicted by a significant number of clinical guidelines developed by other organisations, Martin Fisher told the British HIV Association conference in Bournemouth last week.
This is one reason why implementation of the 2008 testing guidelines outside of sexual health settings has been limited, as shown by a number of other presentations to the conference. A quarter of newly diagnosed people are thought to have had a ‘missed opportunity’ for an earlier diagnosis - they had previously seen a clinician who had neglected to offer an HIV test.
While there has been an increase in the number of diagnoses made outside of specialist settings, this has come from a low starting point. Four in five diagnoses are still made in either a sexual health or an antenatal clinic.
Guidelines and clinical indicator diseases
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 routinely recommended.
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.
GPs are making more diagnoses
Although three-quarters of new HIV diagnoses are still made in sexually transmitted infection clinics, the number testing positive elsewhere has increased in recent years. An HPA analysis of new diagnoses between 2006 and 2009 showed that the proportion of diagnoses made by GPs rose from 5.3 to 8.4%; those made in hospital medical admissions units and Accident & Emergency departments rose from 4.1 to 6.5%; and those made in hospital outpatient clinics went up from 1.7% to 2.9%.
Whereas 86% of men who have sex with men are diagnosed in STI clinics, the proportion is lower in other demographic groups. Almost one in five women are diagnosed in antenatal services.
One in three diagnoses of people from black and minority ethnic groups are made outside a sexual health clinic.
For people diagnosed over the age of 50, relatively large numbers (10.6%) test in a medical admissions unit or Accident & Emergency department. These are the settings where late diagnoses are most likely to be made - late diagnosis is less frequent in STI and antenatal clinics.
To continue to make progress, Martin Fisher recommended a combination of top-down and bottom-up approaches. HIV clinicians and advocates can lobby for top-down changes, such as late HIV diagnosis being a key quality indicator for the NHS, the implementation of NICE guidelines and the inclusion of HIV in the clinical guidelines of other specialist societies.
At a local level, clinicians should continue to engage with non-HIV physicians, informing them of the importance of late diagnosis and of testing recommendations, and through audit and discussion of missed opportunities.
But he pointed out that in the government’s proposed reforms of the NHS, it is not always clear where HIV testing sits. Local authorities will commission sexual health clinics to test, GP commissioning consortia will pay antenatal clinics for their activity and the NHS Commissioning Board is meant to promote opportunistic testing, but it is not clear which bodies - if any - will push forward an expansion of HIV testing.
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