Opportunities for earlier HIV testing missed for Africans in the UK

Africans in the United Kingdom are utilising GP and out-patient care, but many still have their HIV infection diagnosed late, according to a study published in the January 2^nd edition of AIDS. The study also showed that many patients perceived themselves to be at a low risk of HIV, and the investigators suggest that primary care and non-HIV clinicians should proactively promote HIV testing to Africans in the UK.

It is well established that Africans with HIV infection in the UK access HIV services at a later stage of HIV disease than other groups. The extent to which opportunities for earlier diagnosis are missed in primary care and non-HIV-related hospital care is not known.

Reducing late diagnosis of HIV amongst Africans in the UK could have benefits at both an individual and community level, enabling individuals to access antiretroviral therapy in a timely manner and reducing the pool of infectious HIV. Research in gay men suggests that earlier diagnosis can reduce short-term mortality by 56% - 84% and longer-term mortality by 32%.

Approximately 50% of Africans diagnosed with HIV in the UK have a CD4 cell count below 200 cells/mm³ and individuals diagnosed late are approximately eight to ten times more likely to die within a year of their diagnosis than those not diagnosed late.

Investigators therefore sought to identify opportunities for earlier HIV diagnosis within primary care and hospital settings in the UK and to see what factors were related to missed opportunities for earlier diagnosis amongst Africans.

The study population consisted of 263 African patients recently diagnosed with HIV at 15 HIV treatment centres across London between 2004 and 2006. These individuals completed questionnaires that enquired about their utilization of health services before their HIV diagnosis, their previous HIV testing history and their perceptions of personal HIV risk.

Approximately 50% of individuals (131/263) were diagnosed with HIV when their CD4 cell was below 200 cells/mm³. The median age was 34 years, 63% were women and 71% came from a country with an adult HIV prevalence above 15%.

Use of primary care was high with 85% registered with a GP. In the year before diagnosis with HIV, 76% had visited their GP, 38% had received care from a hospital as an out-patient and 15% had received in-patient care.

Of the patients who had visited a GP, only 17% said that their GP had mentioned HIV testing. A previous negative HIV test was reported by 78 patients (37%) and 33% of these individuals had had an HIV test in the UK.

There was no significant difference in utilization of primary or hospital care between patients diagnosed late and those who with higher CD4 cell counts at diagnosis. But the investigators did note that patients who had had a previous HIV test were less likely to be diagnosed late (OR, 0.55; 95% CI, 0.31 – 0.96).

Although 90% of individuals said they trusted the staff at their HIV clinic, only 40% said they trusted staff at their GP surgery. The main concerns surrounded confidentiality (54%), the behaviour or attitudes or receptionists (53%), discrimination (33%), and lack of knowledge. Only 36% of patients had disclosed their HIV status to their GP.

When the patients were asked to identify the reasons for not having an HIV test earlier, 70% said that they had not considered the possibility that they might have HIV. Furthermore, two-thirds had been surprised by their positive test result. A total of 59% of individuals said that they would have had an HIV test earlier if someone had suggested that they had an HIV risk.

“Our data suggests that rather than having poor access to health care, Africans report higher rates of primary and secondary care attendance and HIV testing than the general population,” comment the investigators, adding “that Africans continue to present to HIV services with advances disease despite accessing health services prior to diagnosis suggests HIV is often missed as a differential diagnosis, or that clinicians are reluctant to address HIV or are doing so ineffectively.”

The investigators believe their study has five key messages:

• Late diagnosis increases HIV-related illness and death and hinders HIV prevention.
• Africans access HIV care later than non-Africans; opportunities for prevention and earlier diagnosis of HIV are being missed in primary and secondary care.
• There are high levels of HIV testing in Africans.
• Africans are accessing healthcare before their HIV diagnosis, but clinicians are failing to use these visits as an effective opportunity for testing or prevention.
• Primary care is particularly well accessed, but HIV testing is not being raised.