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NICE Guidance & Research: HIV testing in settings other than specialist clinics

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Mark Platt
Posts: 290
NICE Guidance & Research: HIV testing in settings other than specialist clinics
Posted on: March 11 2015, 10:40 am

Overview: An estimated 107,800 people in the UK were living with HIV in 2013 (Public Health England 2014). People diagnosed with HIV late – that is, those who have a CD4 count of more than 350 cells/mm3 within 3 months of diagnosis – have a 10-fold increased risk of death in the year after diagnosis compared with those diagnosed promptly. Almost half (42%) of people diagnosed with HIV in 2013 were diagnosed late.

HIV is routinely diagnosed in genitourinary medicine, sexual health and antenatal clinics. In 2013, 71% of people who attended a genitourinary medicine or sexual health clinic in England and 98% of pregnant women who underwent antenatal screening were tested for HIV (Public Health England 2014). In 2007 the UK’s Chief Medical Officers and Chief Nursing Officers recommended extending HIV testing all healthcare settings to reduce the number of people with undiagnosed HIV infection and late diagnosis.

Current advice: The UK National Guidelines for HIV Testing, produced by the British HIV Association in 2008, recommend that universal HIV testing should be offered in the following settings:
•   Genitourinary medicine and sexual health clinics.
•   Antenatal services.
•   Termination of pregnancy services.
•   Drug dependency programmes.
•   Healthcare services for those diagnosed with tuberculosis, hepatitis B, hepatitis C and lymphoma.

An HIV test should be considered for all men and women registering in general practice and for all general medical admissions in settings where diagnosed HIV prevalence in the local population exceeds 2 cases per 1000 population.

HIV testing should also be routinely offered and recommended to people diagnosed with sexually transmitted infections or with illnesses for which HIV is considered in differential diagnosis. In addition, testing should be offered to sexual partners of people who are HIV positive; all male and female sexual contacts of men who have sex with men; people with a history of injecting drug use; and all men and women from a country of high HIV prevalence (>1%) or who have had sexual contact with people from such a country.

NICE has published public health guidance on increasing the uptake of HIV testing among men who have sex with men and among black Africans in England. These 2 pieces of guidance likewise recommend offering HIV testing in primary and secondary care, as well as in genitourinary medicine and specialist sexual health services. NICE is currently preparing guidance on increasing the uptake of HIV testing among people at higher risk of exposure (expected publication date September 2016).

The NICE Pathway on HIV testing and prevention brings together all related NICE guidance and associated products on this area in a set of interactive topic-based diagrams.

New evidence: Elmahdi et al. (2014) conducted a systematic review and meta-analysis of HIV testing in at-risk populations in settings other than genitourinary medicine, sexual health and antenatal clinics in the UK. The authors searched for quantitative studies from after the 2008 UK National Guidelines for HIV Testing were published. The 2 patient groups covered were people diagnosed with a disease indicative of HIV infection, such as tuberculosis or Kaposi’s sarcoma, and people who should have been routinely screened for HIV according to the 2008 guidelines.

A total of 30 studies measuring HIV testing in recommended settings were identified (n=109,290), 14 of which were cross-sectional studies or retrospective audits from hospital settings. In a random effects meta-analysis, the proportion of people eligible for HIV testing who were offered and accepted an HIV test was estimated as 27.2% (95% confidence interval [CI] 22.4 to 32.0%). Among those tested, 0.5% (95% CI 0.3 to 0.7%) were positive for HIV infection.

Less than one-quarter (22.4%, 95% CI 13.9 to 30.9%) of people diagnosed with a disease indicative of HIV infection received an HIV test (10 studies, n=3947). Almost one-third (29.5%, 95% CI 23.6 to 35.4%) of people attending settings where screening should have routinely been offered had an HIV test (20 studies, n=105,343).

Among studies reporting the number of tests offered (14 studies, n=62,725), less than half of eligible people were offered an HIV test (40.4%, 95% CI 24.3 to 56.7%). However, almost three-quarters of people who were offered a test decided to take it (71.5%, 95% CI 56.0 to 86.9%; 14 studies, n=62,725).

The authors suggest that the low proportion of eligible people who received an HIV test in settings other than specialist clinics indicates that adherence to the UK National Guidelines for HIV Testing is poor. This analysis was limited by the varying quality of the included studies and the wide variety of populations, settings, duration and methods in the included studies (heterogeneity [I2] was 100% for some analyses). As such, the authors conclude that caution should be used in interpreting the summary statistics as a true level of overall test coverage.

Commentary: “The evidence presented by Elmahdi et al. (2014) reinforces the difficulties of expanding HIV testing to general medical services. There are clear benefits to both the individual and to society of diagnosing HIV as early as possible, yet nearly half of new HIV diagnoses (47%) in 2013 were diagnosed late.

“Expanding HIV testing in general medical services is one part of a public health strategy to reduce these unacceptably high rates of late diagnosis. However, progress is slow, despite recommendations in national HIV testing guidelines. Worryingly, Elmahdi et al. (2014) found low coverage of HIV testing even in individuals with clinical indicator diseases, where there is both a clinical and public health imperative to offer an HIV test. The rate of HIV diagnosis in this group was 2.7% (95% CI 1.1 to 4.4%), equivalent to that seen among the highest risk individuals being tested in sexual health clinics.

“The excess costs of treating a late HIV diagnosis, both in the short and long term, continue to inflate the HIV treatment budget. Data presented here indicate that routine HIV testing in services and for clinically-indicated diseases is a cost-effective intervention, with the positive rates surpassing the 0.1% threshold. Thus, despite the clinical, financial and moral arguments for more widespread HIV testing, there remains a long way to go before it becomes embedded as routine practice.” – Dr Anthony Nardone, Head of Sexual Health Promotion, HIV and STIs Department, Public Health England

Study sponsorship: This study was not funded.

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