NICE supports expansion of HIV testing at GP's and in hospital settings

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In its first ever guidance related to HIV, the health watchdog NICE recommends today that health services not concerned with sexual health take a greater role in offering HIV tests to black African people and to men who have sex with men.

NICE also encourages outreach testing projects for gay men in venues such as saunas and cruising grounds, using rapid point-of-care tests.

The National Institute for Health and Clinical Excellence (NICE) issues recommendations to the NHS about the most effective and cost-effective treatments and public health interventions to provide. In some cases, NHS bodies are legally required to fund medicines and treatments which are recommended by NICE.

Glossary

referral

A healthcare professional’s recommendation that a person sees another medical specialist or service.

stigma

Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

window period

In HIV testing, the period of time after infection and before seroconversion during which markers of infection are still absent or too scarce to be detectable. All tests have a window period, the length of which depends on the marker of infection (HIV RNA, p24 antigen or HIV antibodies) and the specific test used. During the window period, a person can have a negative result on an HIV test despite having HIV.

safer sex

Sex in which the risk of HIV and STI transmission is reduced or is minimal. Describing this as ‘safer’ rather than ‘safe’ sex reflects the fact that some safer sex practices do not completely eliminate transmission risks. In the past, ‘safer sex’ primarily referred to the use of condoms during penetrative sex, as well as being sexual in non-penetrative ways. Modern definitions should also include the use of PrEP and the HIV-positive partner having an undetectable viral load. However, some people do continue to use the term as a synonym for condom use.

antenatal

The period of time from conception up to birth.

Guidelines on HIV testing have been previously issued by organisations representing specialist clinicians such as the British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASHH). Their most recent guidelines recommended that HIV testing should be offered to patients in a wide range of healthcare settings, including GP surgeries and most hospital departments.

Implementation of that part of the guidelines has generally been limited, although 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.

But with NICE today endorsing large parts of the BHIVA / BASHH guidelines, there may be more hope that non-specialist clinicians will take further steps to promote HIV testing.

NICE have produced public health guidance on increasing the uptake of HIV testing in two related documents. One concerns interventions for men who have sex with men, the other work with black African communities.

The document concerning black African communities repeats a number of the key recommendations in the BHIVA / BASHH guidelines. In all healthcare settings (including general practice, outpatient and emergency departments), an HIV test should be routinely offered and recommended to all patients who come from high prevalence countries, patients who have had sexual contact abroad and patients who have symptoms that may be related to HIV.

In addition, everybody attending a sexual health, antenatal, termination of pregnancy, drug dependency, tuberculosis, hepatitis B, hepatitis C or lymphoma services should be offered an HIV test.

At health services in areas of relatively high HIV prevalence, healthcare workers ‘should consider’ recommending HIV testing when registering and admitting new patients. In addition, an HIV test should be offered and recommended to all patients who are having another blood test anyway.

Areas of high HIV prevalence are those in which more than two in 1000 have diagnosed HIV. This is the case in most parts of London as well as in places such as Brighton & Hove, Manchester, Blackpool, Salford, Bournemouth and Eastbourne that have historically had high HIV prevalence. Areas which have experienced more recent increases in HIV prevalence such as Luton, Watford, Harlow, Southend-on-Sea, Reading, Slough and Crawley are also included, with around a fifth of the English population living in areas touched by these recommendations.

The wording of the document on testing men who have sex with men is somewhat different, but the implications are similar. In all healthcare settings, male patients who are known to be gay or bisexual should be offered and recommended an HIV test. General practitioners should repeat the offer on an annual basis.

At health services in areas of high HIV prevalence, all male patients (whether they are known to have sex with men or not) should be offered and recommended a test.

For both population groups, NICE recommends that directors of public health and commissioners develop a local strategy for increasing testing rates. The strategy should lead to more health professionals offering HIV testing and more individuals accepting the offer. The strategy should be developed in consultation with local voluntary organisations and community members and should pay particular attention to groups who are less likely to access services.

Community engagement and involvement is seen as particularly important in relation to black African communities. NICE recommends that community members should be recruited and trained to act as champions and role models. Programmes need to address misconceptions about HIV testing and treatment, promote the benefits of early diagnosis and tackle HIV-related stigma.

Health promotion interventions promoting testing to men who have sex with men should be encountered in venues, such as saunas or websites, which facilitate sex between men.

Moreover, the guidance supports outreach testing programmes in high-prevalence areas and also in venues where high-risk sexual behaviour between men occurs. This could include saunas and cruising areas. NICE appears to be more enthusiastic than BHIVA / BASHH about such projects, although they do note that testing will not be appropriate in all such venues. In such settings, rapid tests (using mouth swabs or fingerprick blood samples) should be provided by trained staff, in a secluded or private area.

All testing services (including community testing) need to have clear referral pathways to confirmatory HIV testing, HIV treatment services and support groups. Moreover people who test negative may need referral to counselling and safer sex interventions, as well as repeat testing (for example, if a risk has been taken during a test’s window period). Men who have sex with men are recommended to test annually, or more frequently if their sexual behaviour suggests that they may be at higher risk.

Dr Clare Gerada, chair of the Royal College of General Practitioners commented: “It is important that all health professionals do everything possible to encourage HIV testing amongst high risk groups. The RCGP welcomes the new NICE guidelines and we are sure that GPs will help patients come forward for testing."

Deborah Jack, Chief Executive of NAT (National AIDS Trust) said: "It is crucial that HIV testing becomes ‘normalised’ in our society, not just among gay men and African communities, but also amongst health professionals. Many people with HIV attend NHS services for years without being offered an HIV test and this neglect needs to be addressed and stopped." She called for late HIV diagnosis to be used a key outcome indicator in public health monitoring and for the new government body, Public Health England, to ensure that NICE's recommendations are "consistently implemented across the whole of the NHS and public health system".