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ANALYSIS: Cyrille Delpierre, Lise Cuzin, and France Lert Routine testing to reduce late HIV diagnosis in France BMJ 2007; 334: 1354-1356 [Full text]

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Issues to Consider in Exanding HIV Testing

Sofia Gruskin, Shahira Ahmed, and Laura Ferguson   (3 July 2007)

Policy shift to routine testing needs appropriate assessment

Stéphane Le Vu, Caroline Semaille, Françoise Cazein, Florence Lot, Josiane Pillonel and Jean-Claude Desenclos.   (20 July 2007)

Earlier Detection of HIV in Pneumococcaemia

Benjamin O Black, Tara Tricot, Mark Meltzer   (25 July 2007)

Issues to Consider in Exanding HIV Testing 3 July 2007
Sofia Gruskin, Associate Professor Harvard School of Public Health, 02115, Shahira Ahmed, and Laura Ferguson Send response to journal: Re: Issues to Consider in Exanding HIV Testing	Two articles in this week’s BMJ argue for the expansion of HIV testing in healthcare settings. M Hammill and colleagues believe the UK could do more to ensure people know their HIV status through use of a “ voluntary” opt-out approach to testing, while Delpierre and colleagues recommend expansion of HIV testing to all primary care settings in France (1, 2). Despite the strengths of voluntary counselling and testing, testing uptake in all countries has remained low drawing attention to the need highlighted by these two articles to explore new testing strategies. Knowing one’s status is important but, from both public health and human rights perspectives, there is an obligation to ensure that if testing is performed, information and access to prevention, care, treatment and support be not only a theory but a duly implemented practice. To facilitate appropriate monitoring of infection and timely initiation of antiretroviral therapy requires ensuring that people remain trusting of and connected to a wide range of HIV services. With adoption of new approaches to HIV testing increasing, national level monitoring and evaluation in France, the UK and elsewhere will be critical. A recent analysis of different testing strategies in the US found that the much touted CDC recommended “opt-out” testing policy may not be as effective as once thought (3, 4). Thus monitoring and evaluation must assess the process of HIV testing, and include assessment of the broader legal, social and policy environment, as well as the success in connecting people to health services over time. In particular, the impact that testing strategies will have on access to testing and treatment for vulnerable groups will need to be closely monitored. There is a danger that in some settings increased attention to testing could lead to specific targeting of these groups in health services but also in other settings such as prisons and detention centres, all with potentially negative longer term impacts. Situating changes in policy within lessons already learned can support successful implementation. In particular, in each case clarity as to the purpose of testing, the approach taken to testing, and the ways testing promotes continued engagement and access to health services in a timely and sustained manner will determine the value and effectiveness of any testing practice. This can shape which elements of the testing process are emphasised, and therefore how resources are best channelled to achieve the goal of universal access to comprehensive HIV prevention programmes, treatment, care and support for all those who need it. 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;334:1352-1354. 2. Delpierre C, Cuzin L, Lert F. Routine testing to reduce late HIV diagnosis in France. BMJ 2007;334:1354-1356. 3. Centers for Disease Control and Prevention. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR 2006 ;55:1. (http://www.cdc.gov/hiv/topics/testing/resources/reports/pdf/rr5514.pdf) 4. Holtgrave D. Costs and Consequences of the US Centers for Disease Control and Prevention’s Recommendations for Opt-Out HIV Testing. PLoS Medicine 2007:4(6) e194:1011-1018. Competing interests: None declared
Policy shift to routine testing needs appropriate assessment 20 July 2007
Stéphane Le Vu, Epidemiologist Institut de veille sanitaire, 94415, Saint-Maurice, France, Caroline Semaille, Françoise Cazein, Florence Lot, Josiane Pillonel and Jean-Claude Desenclos. Send response to journal: Re: Policy shift to routine testing needs appropriate assessment	Supporting a broader implementation of HIV testing is logical regarding the growing level of evidence of effectiveness and cost- effectiveness expressed in the USA [1;2]. We agree that concern of expanding the number of people tested should also be raised in France. However, the analysis of Delpierre et al. [3] requires critical examination with respect to the French epidemiological data. The main assumption on data that are used in the rationale of this article is the proportion of late testers. It is unclear how the authors chose the proportion of 40% (or 43% when calculating size of population) of late diagnosis among new HIV diagnoses in 2004. For the same period, the French Hospital Database on HIV reports 34% of late diagnosis [4]. In their previous articles to which they refer, Delpierre et al. found 31.5% of late testers in the corresponding period of 2004-2005 [5] and 33.1% in the ANRS-EN12-VESPA study [6]. The latter proportion depicts the situation of individuals diagnosed between 1996 and 2003, period during which the epidemiology of HIV has changed. Although this study gives correlates of late testing, we argue that it may not give an accurate measurement of current testing activity. In addition, national case reporting shows that late diagnosis measured through the proportion of individuals diagnosed with HIV at AIDS stage has steadily decreased from 2003 (20%) to 2005 (15%) [7]. Moreover, a substantial proportion of late diagnoses may include individuals that acquired their infection abroad many years prior to their arrival and subsequent diagnosis in France [7]. In this population, testing is most often carried out soon after arrival and the late diagnosis and entry into care is therefore linked to a large extent to migration [6;8]. This should have been discussed by the authors when questioning the French testing framework capacity. We can especially wonder whether routine testing compared to targeted testing would have reduced late diagnosis significantly in this population. Nevertheless, we agree that French heterosexuals should be offered testing earlier. One out of five new HIV diagnoses occurs at AIDS stage in this population [7]. Whether is must be done through routine testing in primary care settings needs further analysis of its effectiveness. Public health research on HIV testing strategies should now take the debate further in assessing how the current testing policy in France should evolve towards routine testing. References [1] 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 Jan 10;352(6):570- 85. [2] Paltiel AD, Weinstein MC, Kimmel AD, Seage GR, Losina E, Zhang H, et al. Expanded screening for HIV in the United States--an analysis of cost-effectiveness. N Engl J Med 2005 Jan 10;352(6):586-95. [3] Delpierre C, Cuzin L, Lert F. Routine testing to reduce late HIV diagnosis in France. BMJ 2007 Jun 30;334(7608):1354-6. [4] Yéni P. Prise en charge médicale des personnes infectées par le VIH : Recommandations du groupe d'experts. Paris: Flammarion (Médecine- Sciences); 2006. [5] Delpierre C, Cuzin L, Lauwers-Cances Vr, Marchou B, Lang T. High -Risk groups for late diagnosis of HIV infection: a need for rethinking testing policy in the general population. AIDS Patient Care STDS 2006 Jan;20(12):838-47. [6] Delpierre C, Dray-Spira R, Cuzin L, Marchou B, Massip P, Lang T, et al. Correlates of late HIV diagnosis: implications for testing policy. Int J STD AIDS 2007 Jan;18(5):312-7. [7] Lutte contre le VIH/sida et les infections sexuellement transmissibles en France. 10 ans de surveillance, 1996-2005. Institut de veille sanitaire; 2007 Mar. [8] Calvez M, Semaille C, Fierro F, Laporte A. Les personnes originaires d'Afrique subsaharienne en accès tardif aux soins pour le VIH : données de l'enquête Retard, France, novembre 2003-août 2004. Bull Epidemiol Hebd 2006;31:227-9. Competing interests: None declared
Earlier Detection of HIV in Pneumococcaemia 25 July 2007
Benjamin O Black, Foundation Year 1 King George Hospital, IG3 8YB, Tara Tricot, Mark Meltzer Send response to journal: Re: Earlier Detection of HIV in Pneumococcaemia	Cyrille Delpierre and colleagues have stressed the need for early detection of HIV. Although France has good HIV testing rates, 40% of new diagnoses were in patients presenting with opportunistic infections (OI) or low CD4 counts (<200x106/l), particularly in patients perceived to be at lower risk of infection.1 It is known that HIV patients are up to 60 times more at risk of developing Invasive Pneumococcal Disease (IPD).2 This risk increases with CD4 counts < 500x106/l therefore often presenting earlier in the patient’s HIV history than other OIs.3 In King George Hospital, Ilford we conducted an audit to determine whether HIV testing was occurring in patients with Pneumococcaemia. Over a 33-month period 97 patients had IPD, of those 5 were known to be HIV positive. Of the 92 undiagnosed patients 9 (9.8%) were offered an HIV test, of which 4 (44%) tested positive. This shows that a minimum of 9.3% of our patient group was HIV positive. Within the 82 untested patients it is highly possible that a significant number of HIV diagnoses were missed. Retrospectively several of these patients also had biochemical or haemotological markers eg. raised globulins, suggestive of an increased probability of HIV infection. Results analysis also confirmed that doctors were being highly selective in offering HIV tests, almost exclusively offering them to patients of African origin and avoiding the older patient. As a response to these results the hospital is implementing an automatic reminder with results of Pneumococcaemia for doctors to consider HIV testing. As found by Cyrille Delpierre in France a large proportion of society is being overlooked; primarily the older, heterosexual man. It is likely the same stigma is attached across the channel. 1. Delpierre C. Routine testing to reduce late HIV diagnosis in France. BMJ 2007 ;334:1354-1356. (30 June.) 2. Queralt Jordano, Vicenc Falco, Benito Almirante, Ana Marý´a Planes, Oscar del Valle, Esteve Ribera, Oscar Len, Carles Pigaru and Albert Pahissa. Invasive Pneumococcal Disease in Patients Infected with HIV: Still a Threat in the Era of Highly Active Antiretroviral Therapy. Clinical Infectious Diseases 2004; 38:1623-1628. 3. The Pneumococcus. http://dom.ucsf.edu/housestaff/Chiefs_cover_sheets/pneumococcus.pdf Competing interests: None declared