Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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The professional associations agree
- Hilary Curtis (30 June 2007)
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Changing UK HIV Policy. Further delays are unethical.
- Martin F Brewster (3 July 2007)
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Re: Changing UK HIV Policy. Further delays are unethical.
- James E Parker (6 July 2007)
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Opt-out testing: is it the way forward?
- Jyoti Dhar, Schembri G, Bhuller K, Patel N (13 July 2007)
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HIV Infection -Further Support for opt out testing
- Charlotte-Eve S Sophia, Collins C Iwuji, Yvonne C Gilleece, Duncan R Churchill (13 July 2007)
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Expanding HIV testing: we need to know ‘what works’ in the UK
- Murad Ruf, Tim Chadborn, Senior Scientist; Brian Rice, Senior Scientist; Barry Evans, Consultant Epidemiologist; Valerie Delpech, Consultant Epidemiologist (14 September 2007)
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Missed opportunities: Undiagnosed HIV infection among patients attending a referral service for viral hepatitis
- Anna Maria Geretti, Sara Madge, Geoffrey Dusheiko, and Michael Jacobs (29 May 2008)
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Hilary Curtis, Freelance consultant 39 Esmond Road, London NW6 7HF
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Hamill et al cite the British HIV Association's (BHIVA) 2005 clinical guidelines but may be unaware of the 2007 report Standards for HIV Clinical Care published by BHIVA in partnership with the Royal College of Physicians, the British Association for Sexual Health and HIV and the British Infection Society (full text downloadable from http://www.bhiva.org/cms1191535.asp). The report recommends: All general practices and acute medicine services should provide direct HIV testing for diagnosis of patients with symptomatic disease that may be HIV-related. Such testing should routinely be considered for patients coming into contact with secondary care, and should be recommended for all patients with presenting conditions that are epidemiologically associated with HIV but frequently occur in HIV-uninfected individuals, in addition to those with recognised indicator diseases. In my opinion opt-out testing for HIV is an idea whose time has come and I commend Hamill's paper. Competing interests: I am paid by BHIVA to coordinate clinical audit and standards activities. |
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Martin F Brewster, Retired General Practitioner Wigtown, Scotland. DG8 9DZ
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Dear Editor,
This reinforces previous pronouncements in 2005, (BMJ and Lancet), 2 3 that "HIV testing should now not be accorded any special status" and "Gone is the equipoise requiring detailed consulting about the pros and cons of an HIV test. Knowledge of one's HIV status can be lifesaving". Such opinions, increasingly now a global perception, are seemingly ignored by the UK government and medical establishment, whereas in the USA, implementation of the necessary reform is well advanced.4
Clearly, all "exceptionalisms" attached to HIV infection management should be ended forthwith.
Against this background, the scientifically iniquitous history of exceptionalism deserves a brief summary.
Time-proven medical practices and tenets for the containment of communicable infection were ignored when, some twenty years ago, an unethical folly was imported into the UK from America and foisted on an unwilling medical profession. Prior to any general medical debate on HIV, the government health department had publicly and arbitrarily announced that it would not sanction unrestricted general or random screening for the virus. A legal opinion justifying this and other special HIV measures swayed the profession's leaders. The legal premise for this justification, namely, that HIV was always fatal and that there was no known treatment, had already become untrue by the time the judgement was obtained. Nonetheless, in defiance of intense opposition from the majority of doctors, 5 the profession's leaders gave in to the unprecedented new concepts, later christened as HIV exceptionalism and adopted world-wide by the United Nations AIDS Organisation.
Clinical judgement of physicians in day-to-day practice had been officially curtailed. Double blind trials and researches into early disease had been hamstrung. A disease management protocol had been dictated, not by scientific medical principles, but by medically ignorant politicians and lawyers supported by HIV human rights organisations, patients and other pressure circles. This, (exceptionalism ostensibly shielding human rights), has been tragic for such people and for the general public, some of whom through time have suffered from resulting delayed diagnosis and treatment, increased spread of disease, perpetuation of stigma, and accelerated or unnecessary deaths.
Another facet of exceptionalism was the ruling permitting unlinked anonymous HIV testing to get public health statistical information. Last week the BMJ featured the cases of two apparently healthy babies who presented at an older age with established HIV illness. The mothers' infection and later positive seroconversion had escaped detection after negative early pregnancy screening. 6 Abolition of exceptionalism would obviate such failure by restoration of named feedback. All neonates are HIV screened anonymously using blood from the Guthrie test taken for phenylketonuria, thyroid levels, etc.. As I understand it, although this screening cannot, and does not, detect the infant's HIV status, it reliably reflects the mother's HIV status at the time of delivery. Furthermore, despite information about this anonymous HIV screening appearing on midwives' pre-Guthrie test counselling protocols, few mothers realise the full implications of the information they are, or should be, given, namely, the drastic consequences of withholding positive result information from any unwitting infected. I have found that full understanding usually arouses incredulity and anger, reactions which have already been documented. 7
If reform does not take place soon, legal liability and negligent practice court action will become a reality. Cost of litigation, stigma and fear of press exposure, are probably stemming a tide of legal questioning among relatives unnecessarily bereaved by late HIV diagnosis. Such future trouble was predicted in 1999 - "what once was protection of individual rights may now represent negligent practice and missed opportunities for prevention" - I quote a paper referenced in the editorial. 8 It is indeed sad that 8 years of GMC and BMA inaction have passed since this particular contribution, which was, and still is, a well argued case for its title, "From Exceptionalism to Normalisation". Less well known is a High Court judgement 9 and its ruling that an infant's human rights to HIV testing outweigh the parental rights of choice. It can be only a matter of time before another court finds that the legal right to be born free of HIV infection outweighs all other considerations. The writing is on the wall. Doctors and politicians now failing to take note do so at their future peril. A further wait for cost-effectiveness evidence is unethical.
1. BMJ 2007;334:1352-1354
2. BMJ 2005;330:492-3 4. Medscape General Medicine 2007;9(1):58, and BMJ 2006;332:1169 5. BMJ 1987;294:1675-77, and BMJ 1988;297:356 6. A Jayasuriya, P S Allan, BMJ 2007;334:1287-1288 7. Paqita de Zulueta, Journal of Medical Ethics 2000;26:16-21 8. Kevin M De Cock and Anne M Johnson, BMJ 1998 316: 290-293. 9. BMJ 1999; 319: 658 forrie@brewsterweb.co.uk Competing interests: None declared |
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James E Parker, Retired Paediatrician 289 McCallum Rd Abbotsford B.C. Canada V2S 8A1
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The cogent arguments of Dr Martin F Brewster (Rapid responses 3 July 2007) are much appreciated. I find myself in complete agreement with him. It is high time that an exceptional designation to HIV diagnosis was replaced by normalisation as advised eight years ago (BMJ. 1998 316: 290-291). There are several 'grains of truth' in Brewster's communication not the least of which was the role played by local 'AIDS experts' who brought their philosophy to the United Nations AIDS organisatiion. Thank you Dr Brewster. I hope your communication receives the attention it deserves. James E Parker Competing interests: None declared |
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Jyoti Dhar, Consultant GU Physician Leicester Royal Infirmary LE15WW, Schembri G, Bhuller K, Patel N
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While we do not wholly agree with Hamill and colleagues1 about the advantages of opt out testing and its consideration in certain settings, we believe that the current testing policy in England fails to reach certain groups and communities and that there is an urgent need to expand the testing policies. The overall uptake of HIV tests by individuals attending GUM clinics has increased nationally and similar increases have been seen in Leicester.2 A recent study in our clinic, between the period 2000-2005, showed that 23,530 patients were offered an HIV test and 19045 (81%) accepted the test. Breakdown according to ethnicity indicated the majority of them to be White [14418 (76% )], followed by Black Africans [1660 (9%)] and finally Asians (which includes Indians, Pakistanis and Bangladeshis) [1335 (7%)].3 Leicester is the largest culturally and ethnically diverse health district in the UK with 21% of its residents born outside Europe compared with 6% nationally. Asians and British Asians constitute 29.9% of the entire population (predominantly Indian, 25.7% vs 1.99% nationally). Despite 29.9% of Leicester being Asian, only 6.1% had utilised the local sexual health service during this period unlike Black Africans who are the second most common group attending even though they make up only 3.08% of Leicester’s population, providing evidence of some awareness of risk behaviour and potential exposure to HIV in this group. As monitoring data is derived from individuals using health services, it will exclude groups who have poor access to services and not necessarily accommodate diversity of populations. In the absence of this information it is difficult to analyse the link between sexual health and ethnicity. It is well recognised that nationally, Asians have lower levels of sexual ill health when compared to Whites and Africans. However, during the study period the number of newly diagnosed HIV cases in individuals of Asian origin has doubled and now represents 13% of the total, equivalent to 10 new cases in Asians in Leicester per year. Does one interpret this doubling as increased awareness? Further analysis of this cohort indicated that the majority of these cases were diagnosed incidentally, as 40% (36/91) required testing after presentation to hospital with late symptomatic disease, 14% (13/91) following partners diagnosis of infection, 7% (6/91) on antenatal screening and only 19% (17/91) were identified through routine screening.4 In GU attendees in Leicester, an HIV prevalence of 0.67% for individuals of Asian origin was documented compared to a 0.03% national prevalence. The corrected odds ratio for HIV infection is 0.94 for an Asian male born in India (95% CI, 0.25-3.55), compared to 0.96 (95%CI, 0.55-1.68) had the same individual been born in the UK. An individual of Black African origin born in the UK, is 3.5x (95% CI, 2.30-5.36) at risk of HIV infection compared to a UK born White Caucasian. This is less than for an individual born in Zimbabwe (OR 18.7, 95%CI, 11.98- 29.22).3One possible explanation for the continuing risk is sexual mixing within the same communities. However, this continuing risk emphasises the need for robust testing policies within various ethnic groups and needs to be explored further. Our study indicates that the current sexual health service is failing to meet the needs of this group and one could argue that opt out testing would be beneficial. However, the stigma, discrimination and the impact of disclosure has to be considered – questions that need to be answered in order to formulate appropriate interventions, as globally disclosure rates have always been lower in Asians and Black Africans (a third of women with HIV having reported sexual and physical abuse following disclosure). 69% of our Asian cohort was married and 72% of them needed treatment at diagnosis. Existent gaps at local levels regarding sexual health availability exist and these can present significant challenges to assess needs especially for communities and people who do not speak English. There is further evidence that this group not only have a poor understanding of the subject but also a low perception of risk.5 As small numbers of Asian individuals are attending sexual health services with significant problems, we recommend routine collection of age, gender and ethnicity for all providers of sexual health services as a minimum requirement. This will lead to the development of interventions to promote testing in a variety of health care settings to reduce missed diagnoses and HIV related stigma. However, we need to ensure that they are appropriate both to the setting and to the patients needs. References 1. Hamill M, Burgoine K, Farrell F,Hemelaar J, Patel G, Welchew DE, et al. Time to move towards opt-out testing for HIV in the UK. BMJ 2007 doi:10.1136/bmj.39218.404201.94. 2. The UK Collaborative Group for HIV and STI surveillance. A complex picture. HIV and other sexually transmitted infections in the UK;2006. London;Health Protection Agency, Centre for Infections,2006. www.hpa.org.uk/publications/2006/hiv_sti_2006/default.htm 3. Bhuller K, Schembri G, Dhar J. Who is having an HIV test in Leicester? Unpublished data. 4. Dhar J, Patel N. HIV in British Asians. Presented at HIV Congress March 2007, Goa, India. 5. Shukla R. Public Health Medicine, Leicestershire Health Authority. HIV and AIDS: An Assessment of the Educational needs of Asian People, March 1993. Competing interests: None declared |
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Charlotte-Eve S Sophia, Foundation year 1 doctor GUM/HIV Royal Sussex County Hospital, Collins C Iwuji, Yvonne C Gilleece, Duncan R Churchill
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Dear Sir, We welcome the well reasoned arguments presented for opt-out HIV testing by Hamill et al. 1. Current risk and symptom-based strategies are failing important patient groups. We recently managed an elderly patient whose case starkly highlighted these failings. A 71-year-old Caucasian man presented with a 2-month history of cloudy vision in his left eye. Examination revealed changes suggestive of cytomegalovirus (CMV) retinitis. A test for HIV-1 antibody was positive. His CD4+ lymphocyte count was 7 cells/mm3 (3%) and his plasma viral load 211, 403 copies/ml. In addition to his ocular symptoms, he had complained of a dry cough and breathlessness for 6 months, and had symptoms of peripheral sensory neuropathy for over 5 years. He had also suffered from a 15 year history of chronic diarrhoea and had been treated for oral and oesophageal candidiasis. He had been noted to have a normocytic anaemia and had been investigated for a polyclonal increase in gammaglobulins. He had never previously tested for HIV infection, although he had had unprotected anal sex with male partners 15 years previously. He was diagnosed with Pneumocystis jirovecii pneumonia (PCP), CMV retinitis and HIV-associated sensory neuropathy. He received a full course of therapy for PCP and CMV retinitis following which he was started on antiretrovirals. However, shortly before his planned discharge he became acutely hypoxic, hypotensive and pyrexial. Despite aggressive treatment, the patient died. Blood cultures later grew Klebsiella terrigena. In many ways this case was sadly unremarkable. The patient presented with advanced HIV disease, multiple opportunistic infections, and despite treatment, died. The case was particularly remarkable, however, because of the duration of his symptoms before the diagnosis of HIV infection was made. Despite 15years of symptoms probably due to HIV infection and multiple opportunities for HIV testing, both this man’s risk and diagnosis were not recognised. With hindsight, the possibility of HIV infection was not identified because he did not consider himself to be at risk, perhaps because his risk behaviour was in the distant past. Risk based testing is less effective if the patient is unaware of their risk2 . Many physicians remain reluctant to perform HIV antibody tests because of “HIV exceptionalism”3. We disagree with Dodds and Weatherburn’s editorial that opt-out testing would increase discrimination against those testing positive for HIV antibody4. In contrast, we believe that current risk based polices reinforce the stigma associated with HIV infection; more widespread testing would be a powerful tool for challenging stigma. In addition it would overcome any lack of familiarity with the ways that HIV can present and reluctance to discuss personal risk. In the USA, CDC guidelines advocate routine HIV testing for people aged 13-645. Had such a policy been in place in the UK when he first consulted a doctor with symptoms, his HIV infection would have been recognised, his prognosis would have been good and the outcome likely to be entirely different. Dr Charlotte-Eve Short
1. Hamill M, Burgoine K, Farrell F, Hemelaar J, Patel G, Welchew D, Jaffe H. Time to move towards opt-out testing for HIV in the UK. BMJ 2007; 334: 1352-1354. 2. Klein D, Hurley LB, Merrill D, Quesenberry CP; Consortium for HIV/AIDS Interregional Research. Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection. J Acquir Immune Defic Syndr. 2003; 32:143-152. 3. De Cock K, Johnson A. From exceptionalism to normalisation: a reappraisal of attitudes and practice around HIV testing. BMJ 1998; 316:290-293. 4. Dodds, C., Weatherburn P. Reducing the length of time between HIV infection and diagnosis. BMJ 2007; 334: 1329-1330. 5. Branson B, Hunter H, Lampe M, Janssen R, Taylor A, Lyss S, et al. CDC Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR 2006; 55; 1-17. Competing interests: None declared Editorial note
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Murad Ruf, Specialist Registrar in Public Health Centre for Infections, Health Protection Agency, Tim Chadborn, Senior Scientist; Brian Rice, Senior Scientist; Barry Evans, Consultant Epidemiologist; Valerie Delpech, Consultant Epidemiologist
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We welcome the timely article by Hamill et al (1) and the accompanying editorial by Dodds et al (2) which reignite the discussion around HIV testing strategies in the UK. Continuing high proportions of undiagnosed HIV infections and late diagnoses clearly signify a preventable burden of ill health in the era of highly active anti- retroviral therapy (HAART). In their article, Hamill et al suggest that opt-out testing in a wide range of settings would both reduce undiagnosed HIV and HIV-related stigma and should therefore be ‘seriously considered’ in the UK (largely referring to 2006 CDC guidelines(3)). In contrast the editorial by Dodds et al argue that this approach could increase stigma and discrimination against people living with HIV and instead propose intensifying the targeted approach directed at individuals at greatest risk of HIV infection. There have been significant successes in increasing uptake of HIV tests in UK genito-urinary medicine (GUM) and antenatal (ANC) clinics over recent years, and as a result the large majority of new HIV diagnoses are from these settings. However we agree with Dodds and Weatherburn that there is a continued need and room for improvement, particularly in GUM clinics – where only half have a clear opt-out HIV testing policy (4). Several national level bodies, including the British Association for Sexual Heath and HIV (BASHH), the Expert Advisory Group on AIDS (EAGA) are considering recommending routine HIV testing (with opt-out) in GUM clinics. These are supported by the recent call for routine opt-out testing in GUM clinics by the National Aids Trust (NAT)(5). It is doubtful, however, that sole reliance on GUM and ANC services will be sufficient to further reduce undiagnosed HIV at a population level. Community based surveys indicate that large proportions of population groups at greatest risk have never attended a GUM clinic (38% of MSM and 59% of individuals from Black African communities) (6,7). Further, the HPA estimates that a quarter of undiagnosed infections in adults are in ‘low risk’ groups. Lastly, there is an increasing body of evidence on ‘missed opportunities’ for earlier HIV diagnosis in several UK healthcare settings (8,9,10). The need to expand HIV testing into healthcare settings outside of GUM and ANC is highlighted in the recent urgent communication by the Chief Medical Officer(11). While roll-out of HIV testing into wider healthcare settings may provide opportunities, we should be cautious in uncritically adopting CDC guidelines in this country. Firstly, there are significant differences in the HIV epidemiology and health care systems between the US and the UK. In the UK, a large percentage of HIV infections are acquired abroad and access to the numerous GUM services is universal, free and confidential. Secondly, the CDC recommendations are based on US effectiveness and economic information, which may not be directly transferable to the UK. Thirdly, key to the CDC guidelines is the recommendation of, essentially, an initial large scale catch up intervention, to be scaled down quickly in settings where prevalence is found to be low, rather than an ongoing universal screening programme. This is of particular relevance to the UK, where in the face of resource constraints and lower HIV prevalence rates, prioritisation of HIV testing in different healthcare settings poses particular challenges. Lastly, while the US guidelines consider general consent to medical care sufficient to encompass consent to HIV testing, this may require legislative changes in the UK and is unlikely to be acceptable to clinicians and patients in all UK settings. Both articles raise the issue of discrimination against people with HIV by non-HIV specialists in primary care and acute settings as arguments, either for, or against HIV testing in wider healthcare settings. These social issues, together with political and economic aspects are central to the decision whether to use targeted or universal testing, and opt-in or opt-out approaches. HIV related stigma is a perceived major barrier to both offer and uptake of HIV testing in wider healthcare settings in the UK (12,13). Tackling these issues through education of health professionals and communities will be key if expanding HIV testing into a wider range of settings in the UK is to be successful. The availability of effective treatments, which increasingly transform early diagnosed HIV infection from a fatal disease into a manageable complex chronic medical condition, makes a strong medical case for a paradigm change in HIV testing(14). Any change to national policy on HIV testing should be informed by ‘what works’ within the UK. At present there is a limited body of UK evidence on the feasibility, acceptability, effectiveness and cost- effectiveness of different HIV testing strategies outside of GUM and ANC settings. Hammill et al suggest a need for further unlinked anonymous sero -prevalence surveys in high prevalence areas and high prevalence settings. While this might support local buy-in, this approach will be costly and may further delay piloting of actual HIV testing interventions in wider UK settings. Selection of suitable settings could be guided by estimates using local target population characteristics, published and grey literature, and routinely available surveillance data. An example is the successful implementation of routine diagnostic HIV testing in London Tuberculosis clinics, given increasing rates of Tuberculosis and HIV co- infection in London (15,16). Primary care and community based settings are likely to provide significant opportunities for early detection of asymptomatic infection, but at present it is unclear what approaches or criteria should be used, whether at area, healthcare setting, or individual level. Possible pilots could include targeted testing of new entrants to the UK at registration with primary care, or testing of sexual partners of women diagnosed through antenatal screening. Expanding HIV testing outside GUM settings has been recommended in the 2001 National Strategy for Sexual Health and HIV and in several national documents since, yet to date there has been no specific guidance on how to implement these recommendations. While there is consensus among key stakeholders on the need to increase HIV testing to reduce late diagnoses and undiagnosed HIV, there is less agreement on the way forward. Improving knowledge on ‘what works’ and how we will address the social impacts in the UK context will allow us to develop evidence informed HIV testing strategies and to make a more convincing case to non-HIV specialist clinicians and decision makers. References 1.Hamill M, Burgoine K, Farrell F, et al. Time to move towards opt-out testing for HIV in the UK. BMJ. 2007 Jun 30;334(7608):1352-4 2.Dodds C, Weatherburn P., Reducing the length of time between HIV infection and diagnosis. BMJ. 2007 Jun 30;334(7608):1329-30. 3.Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55(RR- 14):1-17 4.National BASHH/HPA study of HIV testing in men who have sex with men (MSM) attending genitourinary (GUM) clinics in the UK, H L Munro, C M. Lowndes, D Daniels et al, Sextransinf, in press 5.http://www.nat.org.uk/page/5569 (accessed 18.08.2007) 6.Consuming passions: findings from the United Kingdom Gay Men’s Sex Survey 2005. http://www.sigmaresearch.org.uk/data06/All_England_2006.pdf 7.Mayisha II study,http://www.ahpn.org/downloads/publications/Mayisha_II.pdf 8.BHIVA national clinical audit of diagnoses. http://www.bhiva.org/files/file1001369.ppt 9.Burns F, Johnson A, Nazroo J, et al. COULD PRIMARY CARE BE DOING MORE? HIV Med 2006; 7(Suppl. 1):8 (abstract no. O29) 10.Sudarshi D, Pao D, Homer G, et al. MISSED OPPORTUNITIES FOR DIAGNOSING ACUTE SEROCONVERSION ILLNESS HIV Med 2006; 7(Suppl. 1):8 (abstract no. O31) 11.Improving the detection and diagnosis of HIV in non-HIV specialities including primary care, Chief Medical Officer, Urgent communication 13.09.2007, www.dh.gov.uk 12.Burns FM, Imrie JY, Nazroo J et al. Why the(y) wait? Key informant understandings of factors contributing to late presentation and poor utilization of HIV health and social care services by African migrants in Britain. AIDS Care. 2007 Jan;19(1):102-8 13.Tackling HIV stigma and discrimination - Department of Health implementation plan, May 2007. www.dh.gov.uk 14. Bayer R, Fairchild AL., Changing the paradigm for HIV testing--the end of exceptionalism. N Engl J Med. 2006 Aug 17;355(7):647-9 15.Collett AS, Sanefuji R, Togun E et al. P072 Which patients with tuberculosis accept an HIV test? [Abstract]. Thorax December 2006;62 Supplement 2:ii80 2006 16.Ridge M, 2006 Audit of HIV testing for new TB patients in South East London, South East London Health Protection Unit (unpublished) Competing interests: None declared |
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Anna Maria Geretti, Consultant and Senior Lecturer in Virology Royal Free Hospital and RF&UC Medical School, Pond Street, London NW3 2QG, Sara Madge, Geoffrey Dusheiko, and Michael Jacobs
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In line with international initiatives1,2, the Chief Medical Officer recently called upon doctors in the UK to increase uptake of HIV testing and improve recognition of undiagnosed HIV infection nationwide3. One strategy is the adoption of routine, voluntary opt-out HIV testing in health care settings where undiagnosed patients may present. Patients would be informed that HIV testing is part of routine care and given the option to opt out, without the traditional extensive pre-test counseling4,5. Available evidence indicates that patient acceptance may not be an important barrier6. Anecdotally however, many clinicians remain uncertain of the cost-benefit ratio of routine testing in settings with low HIV prevalence, partly based on the assumption that clinical judgment is sufficient to identify patients at risk of HIV infection. We show here that half of HIV-infected patients attending a viral hepatitis referral unit remain undiagnosed. Surveillance data estimate that 69,400 adults were living with HIV in the UK at the end of 20067. Despite the wide availability of voluntary counselling and testing services, high rates of screening in genito- urinary clinics, and adoption of routine opt-out testing in antenatal services, a third of HIV-infected persons remain unaware of their infection7,8 . Undiagnosed persons are unable to access effective treatment and, compared with those who know they are infected, are 3.5 times more likely to transmit HIV to others4. Many are also known to repeatedly seek medical care for a variety of minor and major ailments, but are not identified as HIV-infected until much later in their disease course4. Of adults newly diagnosed with HIV in the UK in 2006, 33% had a CD4 count below the recommended threshold for starting antiretroviral therapy (<200 cells/mm3) and 8% presented with an AIDS-defining condition, including life-threatening disease7,9. Given the average period of 10 years between initial infection and development of AIDS and the availability of effective antiretroviral therapy, this morbidity and mortality can be avoided through earlier diagnosis. HIV, hepatitis C and hepatitis B have routes of transmission in common. It is estimated that approximately 30% of HIV-infected individuals worldwide are also infected with hepatitis C, and 10% have chronic hepatitis B. It is important clinically to establish HIV/hepatitis C or hepatitis B co-infection. Co-infected patients show more aggressive liver disease than persons without HIV, with accelerated progression of fibrosis, earlier onset of cirrhosis and hepatocellular carcinoma, and reduced responses to antiviral therapy against hepatitis C10,11. In addition, several antivirals available against hepatitis B, including lamivudine, emtricitabine, tenofovir and entecavir, have activity against HIV and can induce HIV drug resistance if used as monotherapy or dual therapy in persons with undiagnosed HIV infection12. UK and international guidelines for HIV management recommend routine testing for co-infection with hepatitis B and hepatitis C13. In contrast, major international practice guidelines for management of chronic viral hepatitis do not recommend routine HIV testing but rather suggest testing individuals judged to be at risk14. In order to define the likely yield of routine HIV testing in persons with known or suspected chronic viral hepatitis in the UK, we determined the prevalence of undiagnosed HIV infection among patients referred to a specialist hepatitis clinic. We were able to compare this strategy with current standard practice of clinician-directed HIV testing. We conducted a retrospective, anonymous HIV seroprevalence study among all adults referred to a tertiary hepatology clinic for assessment of known or suspected hepatitis B or hepatitis C infection. The samples were collected between January 2005 and December 2006, at a time when standard clinical practice was selective, clinician-driven testing of patients deemed to be at risk of HIV infection. By the end of December 2006, 268 patients (148, 55% males) with a median age of 41 years (range 17 to 71) had attended the referral unit, including 150 (56%) with chronic hepatitis C, 90 (34%) with chronic hepatitis B, 7 (3%) with both hepatitis B and hepatitis C, and 20 (7%) with abnormal liver function tests in the absence of hepatitis B or hepatitis C infection. With approval from the local Ethics Committee, stored serum samples collected for routine hepatitis B and hepatitis C testing were matched to demographic (age, gender, ethnicity, and risk group for acquisition of blood borne viruses) and clinical (reason for referral, HIV status where known) details, anonymised, and retrospectively screened by a third generation HIV antibody assay followed by confirmatory testing of reactive samples. Overall 4/268 (1.5%; 95% confidence interval 0.04-2.82%) persons tested HIV-1 antibody positive, comprising one woman and three males aged 33-53 years. One patient was known to be HIV positive from routine antenatal testing prior to referral to the hepatology clinic. During the sample collection period, only 12 HIV tests were done at the request of the treating clinician, which identified one further HIV seropositive patient. Thus, 2/268 (0.75%) patients had undiagnosed HIV infection. Both were white males with hepatitis C, acquired through injecting drug use in one case and via an undetermined route in the other. Overall HIV seroprevalence was 1.5% in this cohort, which significantly exceeds the estimated prevalence rates of 0.2% in the general adult population and 0.09% in the antenatal population in the UK7. The prevalence of undiagnosed HIV infection was 0.75%, well above the 0.1% threshold that according to US guidelines should trigger routine opt-out testing as a cost-effective intervention1,15-17. In fact, modeling suggests that testing would be cost-effective even in health care settings with prevalences as low as 0.05% when the effects on reducing subsequent HIV transmission are taken into account16. In the UK, routine opt-out HIV testing is well established in antenatal clinics, with a high acceptance rate7, and has also been shown to increase testing among genitor-urinary clinic attendees18. In our clinic cohort 89 HIV screening tests would have been required to identify each undiagnosed infection, at a testing cost to the NHS of less than £1400. The recent editorial in this journal concluded that to inform HIV testing strategies in the UK, data on the likely yield from a changed testing policy are required5. Our results clearly indicate that even within a specialized service with a high level of awareness of blood-borne virus infections, clinical judgment is not sufficient to ensure that all persons at risk of HIV infection are identified. Not offering this group of patients an HIV test has important consequences for their health and carries also wider public health implications. While we recognise that no cost-effectiveness data are currently available for the UK, we believe that a pragmatic and likely cost-effective strategy is to adopt routine, opt-out HIV testing in all patients with known or suspected chronic viral hepatitis. References 1. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55(RR- 14):1-17. 2. UN General Assembly. Scaling up HIV prevention, treatment and support: note by the secretary general. Geneva: United Nations, 2006. http://data.unaids.org/pub/InformationNote/2006/20060324_HLM_GA_A60737_en.pdf. 3. Chief Medical Officer, Professor Sir Liam Donaldson, Department of Health. Improving the detection and diagnosis of HIV in non HIV specialities including primary care. CEM/CMO/2007/19;13 September 2007. 4. Branson B. Current HIV epidemiology and revised recommendations for HIV testing in health-care settings. J Med Virol 2007;79 Suppl 1:S6- 10. 5. Hamill M, Burgoine K, Farrell F, Hemelaar J, Patel G, Welchew DE, Jaffe HW. Time to move towards opt-out testing for HIV in the UK. BMJ 2007;334:1352-1354. 6. Haukoos JS, Hopkins E, Byyny BL. Patient acceptance of rapid HIV testing practices in an urban emergency department: Assessment of the 2006 CDC recommendations for HIV screening in health care settings. Ann Emerg Med 2008;51:303-309. 7. UK Collaborative Group for HIV and STI Surveillance. Testing Times - HIV and other Sexually Transmitted Infections in the United Kingdom: 2007. London: Health Protection Agency, Centre for Infections, 2007. 8. Rogstad KE, Palfreeman A, Rooney G, Hart G, Lowbury R, Mortimer P, et al. United Kingdom national guidelines on HIV testing 2006. www.bashh.org/guidelines/2006/hiv_testing_june06.pdf. 9. British HIV Association. 2005-6 Full results of mortality audit. http://www.bhiva.org/cms1192339.asp 10. Vallet-Pichard A, Pol S. Natural history and predictors of severity of chronic hepatitis C virus (HCV) and human immunodeficiency virus (HIV) co-infection. J Hepatol 2006;44(1 Suppl):S28-34. 11. 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Sanders GD, Bayoumi AM, Sundaram V, Bilir SP, Neukermans CP, Rydzak CE, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005;352:570–585. 17. Walensky RP, Weinstein MC, Kimmel AD, Seage GR, Losina E, Sax PE, et al. Routine human immunodeficiency virus testing: An economic evaluation of current guidelines. Am J Med 2005;118:292–300. 18. Shagufta Z, Mahto M. Uptake of HIV testing in a genitourinary medicine clinic following opt-out screening method and uptake rate by individual clinicians. Int J STD AIDS 2007;18:650-1. Competing interests: I am an elected member of the British HIV Association Executive Committee |
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