Increased uptake of HIV testing should reduce transmission and facilitate early treatment, says Dr Jez Thompson
The Royal College of Physicians has published the third set of evidence-based guidelines in its Concise Guidance to Good Practice series which covers issues not already addressed by other guidelines. This time, the focus is on HIV testing in generic environments such as primary care.1
The guidelines aim to standardise testing procedures and to reduce the number of individuals infected with HIV who are unaware of their diagnosis 2 by encouraging more widespread testing. This strategy will not only help to reduce HIV transmission, but will also afford early access to treatment for infected individuals.
The document acknowledges a major shift in attitude towards HIV testing now that treatment is available which can prolong the life expectancy of infected individuals.3 It also recognises the role that primary care can play in facilitating access to testing and reducing the stigma associated with it.
The guidelines do not advocate actively targeting at-risk groups for HIV testing in primary care, but concentrate advice on two areas: when to offer an HIV test and how to go about testing.
GPs should offer an HIV test wherever knowledge of a patient’s HIV status could affect clinical outcome. Conditions that should trigger the offer of a test include:
- Unusual bacterial, fungal or viral disease including tuberculosis, Pneumocystis carinii pneumonia, oral/oesophageal candidiasis and genital ulceration
- Another blood borne or sexually transmitted infection
- Unusual tumours, for example Kaposi’s sarcoma
- Unexplained thrombocytopenia or lymphopenia
- Unusual skin problems including extensive molluscum contagiosum, severe seborrhoeic dermatitis or recurrent herpes zoster
- Neurological problems, including peripheral neuropathy
- Unexplained weight loss, diarrhoea, night sweats or pyrexia of unknown origin.
There is good practical advice on testing. For example, on the need to test on presentation and 12 weeks after any suspected contact with the virus, on taking expert advice in complex areas such as needle stick injury, and on the need for a confirmatory test on a new sample of blood in all cases that test positive.
The guidelines emphasise the need for documented, informed consent before testing. A draft patient leaflet is included, but a full pre-test discussion is recommended and should cover:
- The benefits of testing
- The date of last risk activity
- How confidentiality will be preserved
- Insurance implications (full details are given in an appendix)
- How the result will be given, which ideally should be face to face
- HIV transmission and risk reduction
- Occupational issues, if appropriate.
All those who test positive should be referred for specialist management, and a post-test discussion should be offered if required.
The guidelines are both timely and welcome. Their development has been rigorous and collaborative, involving a wide range of healthcare professionals as well as service users. They should give GPs confidence in deciding whom to offer HIV testing, and how to carry it out effectively and sensitively.
- Royal College of Physicians. Concise Guidance to Good Practice No. 3. HIV testing for patients attending general medical services. London: 2005, RCP.
- Department of Health. The national strategy for sexual health and HIV implementation action plan. London: DoH, 2002.
- The UK Collaborative Group for HIV and STI surveillance. Focus on prevention. HIV and other sexually transmitted infections in the United Kingdom in 2003. London: Health Protection Agency Centre for Infections, 2004.