HIV can occur in individuals who do not fall into any recognised risk group.The RCP guidance clarifies which patients should be tested, says Dr Chris Barclay


   

An estimated 53 000 adults in the UK were living with HIV infection at the end of 2003, but more than a quarter of this number were unaware of their HIV status.1 Today, the availability of highly active antiretroviral therapy (HAART) means that HIV is a treatable condition. It is therefore vital to make a diagnosis as early as possible, not only to ensure life-prolonging treatment for the individual, but also to reduce the risk of transmission of the infection.

The positive attitude implied by the phrase ‘living with HIV’ characterises the Royal College of Physicians’ recently published national guidelines on HIV testing.

The guidelines are intended to increase uptake of testing among patients attending general medical services in order to identify individuals with undiagnosed HIV. They also aim to standardise testing as the number of tests taking place outside genitourinary medicine (GUM) clinics increases.

So how valid are the guidelines, and should they change our practice?

Guideline development

The guideline development group was composed of ten members from appropriately diverse backgrounds, including a genitourinary specialist, a nurse, a virologist, a GP and a representative of the Terrence Higgins Trust.

Evidence on which to base the recommendations was gathered from two main sources. First, there was a thorough review of the literature, and second, because that literature was not comprehensive, expert opinions were sought. Evidence from the latter source is graded level IV, the lowest level (see Figure 1), and although it is less robust, it covers a considerable breadth of expert opinion.

The guidelines will be reviewed in three years, by which time perhaps there will be more clinical evidence.

The guidelines’ recommendations cover the situations in which HIV testing is appropriate, how to test for HIV, obtaining consent, giving results and, as an appendix, the insurance implications of undergoing an HIV test.

Figure 1: Levels of evidence and grades of recommendation

Changing attitudes

Until recently, HIV testing has been seen as a special service, provided in the main by GUM clinics. However, referral to a GUM clinic to be tested may increase the stigma associated with testing and deter patients from attending. More widely available testing will, it is hoped, reduce the stigma and encourage patients to undergo testing.

A positive HIV result, meanwhile, does not have the same stigma it once had. Since 1995, the uptake of HAART in the UK has reduced the number of AIDS-related deaths by two-thirds.1,2

The guidelines acknowledge that healthcare providers’ attitudes towards testing could present a barrier to successful implementation of the recommendations. One milestone, however, has been the introduction of routine HIV testing of women who attend for antenatal care. This has helped to change attitudes towards HIV testing not only among pregnant women, but also among GPs and midwives.

Nevertheless clinicians should be more ready to discuss HIV with patients, and it is important to do so in a sensitive manner.

Who should be tested?

In the UK, men who have sex with men are the group most at risk of HIV infection. Despite this, more than half of the newly diagnosed HIV infections in the UK in recent years have been in heterosexual individuals.

Of the heterosexually acquired HIV diagnoses made in the UK in 2003, three-quarters were in individuals who had been exposed to the infection in Africa.3

However, HIV occurs in individuals who may not be in any recognised risk group, and the guidelines stress the importance of testing not only in those who are at high risk, but also in any individual for whom knowledge of HIV status could affect clinical outcome.

Box 1 gives the guidelines’ recommendations for the situations in which HIV testing is appropriate.The list is not exhaustive and the guidelines encourage clinicians to exercise their clinical judgement over whom to offer a test.

Box 1: Who should be tested?
  • HIV testing should be offered wherever knowledge of the individual’s HIV status could improve or affect clinical outcome
  • Doctors should strongly recommend HIV testing whenever this enters the differential diagnosis.This would include any unusual manifestation of bacterial, fungal or viral disease, i.e.:
    • infection with tuberculosis
    • suspected Pneumocystis carinii pneumonia
    • suspected cerebral toxoplasmosis
    • oral/oesophageal candidiasis
    • hairy leucoplakia
    • persistent genital ulceration
    • presence of another blood-borne or sexually transmitted infection, e.g. syphilis or hepatitis B
    • suspected primary infection with a seroconversion illness (e.g. flu-like illness, suspected glandular fever with negative Epstein-Barr virus serology)
    • unusual tumours, i.e. cerebral lymphoma, non-Hodgkin’s lymphoma or Kaposi’s sarcoma
    • unexplained thrombocytopenia or lymphopenia
    • unusual skin problems such as severe seborrhoeic dermatitis, atypical
    • psoriasis or extensive molluscum; and, recurring herpes zoster or herpes zoster in a young person
    • persistent generalised lymphadenopathy or unexplained lymphoedema
    • neurological problems including peripheral neuropathy or focal signs due to a space-occupying intracerebral lesion
    • unexplained weight loss or diarrhoea, night sweats, or pyrexia of unknown origin
    • any other unexplained ill health or diagnostic problem
  • In addition, for problems that require immunosuppression, the exclusion of HIV should be considered prior to treatment

Obtaining consent

The guidelines emphasise that the individual’s informed verbal consent should be obtained and that consent should be documented.

It is important to make sure that patients understand the benefits of undergoing an HIV test, for themselves, their partners and their families.

The guideline suggests some text for an information leaflet for patients (Figure 2), to support the pretest discussion.This should also cover:

  • a risk assessment, including date of last risk activity to determine the window period
  • how confidentiality will be preserved
  • insurance issues, if relevant
  • how the result will be given
  • HIV transmission and risk reduction, as necessary.

Those with a history of psychiatric problems, sexual or relationship problems and victims of rape or sexual assault will benefit from more extensive discussions.

Individuals who are likely to perform exposure-prone procedures as part of their job should be referred to an HIV specialist for expert advice.

Figure 2: Suggested text for a leaflet to use in a pre-test discussion

How to test for HIV

The guidelines recommend that patients should be tested for HIV when they first present. However, HIV antibodies do not appear in the blood until some weeks after infection, so the test should be repeated 12 weeks after any suspected contact with the virus. The infection can be transmitted during the ‘window period’, before sero-conversion, and patients should be informed of this.

During the window period the virus can be detected using the polymerase chain reaction, but falsepositive results occur and the test is not licensed for this indication, the guidelines caution.

When primary infection (including needle-stick injury) is suspected, expert advice should be sought from an HIV specialist, and the local laboratory laboratory should be consulted on which tests to perform.The Expert Advisory Group on AIDS produces guidance on post-exposure prophylaxis, which should be consulted in cases of needle-stick injury.4

In patients whose test result is positive, a further test to confirm the result should be carried out on a new blood sample. Similarly, all equivocal test results should be repeated, and these patients referred to a GUM clinic or HIV specialist.

Giving the test result

The guidelines emphasise the importance of discussing the arrangements for letting the patient know the result at the time of testing. If a positive result is likely or if the patient has particular problems, the result should be given face to face wherever possible.

Patients whose test result is positive or equivocal should be referred to a GUM clinic or HIV specialist, and the guideline emphasises the importance of developing clear pathways for referral. A post-test discussion in a GUM clinic should be offered to all patients who may need it.

Conclusion

This is a rigorously and thoughtfully developed guideline, which should enable GPs to consider HIV more readily and discuss it as a differential diagnosis in appropriate clinical situations. It should now be implemented across the NHS to help reduce the cases of undiagnosed HIV infection in the community.

The full concise guideline, HIV testing for patients attending general medical services – national guidelines is available from the Royal College of Physicians, price £6. For more information and details of how to order go to: www.rcplondon.ac.uk.The RCP series ‘Concise Guidance to Good Practice’ is being developed under the auspices of the college’s Clinical Effectiveness and Evaluation Unit. It will include guidance on issues that are not covered by the major guidelines producers but which are likely to be encountered across several medical specialties and in primary care. The guidelines are designed to allow clinicians to make rapid, informed decisions based on up-to-date systematically reviewed and accessible evidence. Where such evidence does not exist, consensus will be used to complete the clinical pathway.

References

  1. 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.
  2. Communicable Disease Surveillance Centre. HIV and AIDS in the UK. An update:November 2002. London: CDSC, 2002.
  3. Fenton KA, Chinouya M, Davidson O, Copas A. HIV testing and high risk sexual behaviour among London’s migrant African communities: a participatory research study. Sex Transm Infect 2002; 78(4): 241-5.
  4. Department of Health. HIV post-exposure prophylaxis: guidance from the UK Chief Medical Officer’s Expert Advisory Group on AIDS. London: DoH, 2004.

Guidelines in Practice, October 2005, Volume 8(10)
© 2005 MGP Ltd
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