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EDITORIALS: Catherine Dodds and Peter Weatherburn Reducing the length of time between HIV infection and diagnosis BMJ 2007; 334: 1329-1330 [Full text]

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Reducing the length of time between HIV infection and diagnosis

Adrian J Palfreeman, Martin Fisher, Consultant Physician The Royal Sussex County Hospital Brighton   (4 July 2007)

Reducing the length of time between HIV infection and diagnosis 4 July 2007
Adrian J Palfreeman, consultant physician University hospitals Leicester NHS Trust LE1 5WW, Martin Fisher, Consultant Physician The Royal Sussex County Hospital Brighton Send response to journal: Re: Reducing the length of time between HIV infection and diagnosis	Dear Sir Despite the best efforts of Genitourinary Medicine physicians and HIV specialists in encouraging HIV testing in populations at risk, the proportion of patients undiagnosed with HIV has remained at above 30% for at least the last 4 years.[1] Subsequent late diagnosis of HIV, often when the individual or their partner presents with AIDS or severe immuno- suppression is associated with a significant increase in mortality, impaired response to anti-HIV therapy, and increased risk of onward transmission. Multiple studies have demonstrated that such “late presenters” have often attended their general practitioners or secondary care services and the diagnosis has been missed. Such late diagnoses now accounts for the largest proportion of HIV-related deaths in the UK.[2] The reasons for not testing are often that specialised counselling was thought to be needed before testing or that the diagnosis was not considered, indeed it is often the case that patients assume they have already had an HIV test done amongst the battery of investigations already performed. The 2006 UK guidance on HIV testing[3] was influenced by the GMC guidance on testing for serious communicable diseases which dates from before effective treatment was available for HIV infection. This guidance recommended that as an HIV diagnosis had “serious social and financial, as well as medical, implications. In such cases you must make sure that the patient is given appropriate information about the implications of the test, and appropriate time to consider and discuss them “[4] This GMC Guidance was subsequently withdrawn in October 2006 and the UK guidance on HIV testing is currently being revised by the British HIV Association, British Association for Sexual Health and HIV, and the Department of Health Expert Advisory Group on AIDS. The argument that opt-out HIV testing in non specialist settings will lead to increased discrimination has not been borne out by the experience of ante-natal testing. Furthermore, it is only since the introduction of opt-out testing that diagnosis rates have risen to >80% 1 The current guidance on good medical practice states that “The investigations or treatment you provide or arrange must be based on the assessment you and the patient make of their needs and priorities” and furthermore, “You must not unfairly discriminate against patients by allowing your personal views to affect adversely your professional relationship with them or the treatment you provide or arrange”.[5] We recognise that HIV remains a stigmatising diagnosis however It is our view that fear of potential prejudice should not stand in the way of delivering appropriate clinical care, and that targeting HIV testing is more likely to maintain stigma than create it. The UK has for many years been at the forefront of HIV prevention and diagnosis, noteably with the existence of confidential sexually transmitted disease clinics, introduction of needle-exchange programmes, and recommendation of routine antenatal testing. We agree with Hamill et al [6] that now is the time for the UK to catch up with the US, France and others and to shift towards normalisation of HIV testing in clinical practice. Adrian Palfreeman Martin Fisher 1. www.hpa.org.uk/publications/2006/hiv_sti_2006 2 www.bhiva.org/cms1192339.asp 3. www.gmc- uk.org/guidance/current/library/serious_communicable_diseases.asp 4 www.bashh.org/guidelines/2006/hiv_testing_june06.pdf 5. www.gmc-uk.org/guidance/good_medical_practice 6. Time to move towards opt-out testing for HIV in the UK M Hamill, K Burgoine, F Farrell, J Hemelaar, G Patel, D E Welchew, and H W Jaffe BMJ 2007 334: 1352-1354 Competing interests: Both authors are on the British Association for Sexual Health and HIV special interest group, and Martin Fisher is on the executive commitee of the British HIV Association