Unlinked anonymous HIV screening programme in England and WalesBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6974.206 (Published 28 January 1995) Cite this as: BMJ 1995;310:206
- JE Banatvala
- Professor United Medical and Dental School of Guy's and St Thomas's Hospital (St Thomas's Campus), London SE1 7EH
Provides information on where to direct preventive efforts
The most recent report summarising the results of the unlinked anonymous monitoring of the prevalence of HIV infection in England and Wales illuminates many aspects of the current epidemiology of HIV-1 infection.1 2 These include the continuing transmission of HIV-1 among homosexual and bisexual men, including recently infected younger men who should have benefited from specifically targeted preventive measures; the fact that injecting drug users continue to share needles and syringes; the high prevalence among heterosexual men and women attending genitourinary medicine clinics; and the rising prevalence among pregnant women in London. Also particularly worrying is the high proportion of infected people who are unaware of their HIV status. Knowledge of positivity seems to be inversely proportional to perceived risk: thus among people attending genitourinary medicine clinics about 70% of homosexual and bisexual men and 35% of heterosexual men and women who were infected knew that they were, while less than 15% of pregnant women were aware of their infection.
The programme's success has depended on the integration of high quality epidemiological and laboratory studies; the development of tests to detect HIV-1 antibodies in saliva and in dried blood spots among injecting drug users and newborn babies was not only essential for studying these groups but also provided tests that were considerably cheaper than conventional, commercially available assays. Although some disincentives to testing remain, the balance has now shifted in its favour: lifespan may be somewhat extended and its quality much enhanced3 4; pregnant women may be offered termination of pregnancy or may benefit from recently described strategies that reduce transmission of HIV to their babies5; and further developments are likely. Those who counsel possibly infected patients must keep abreast of recent developments and appreciate that knowledge of positive HIV status will result in appropriate management, including guidance on avoiding transmission. Is our current approach consistent with good medical practice? Doctors must now take a lead in encouraging much more testing.
The risks of transmission of HIV-1 among homosexual and bisexual men and among injecting drug users are well established, and such groups may be readily, if not always effectively, targeted in attempts to reduce the risks of acquiring or transmitting infection. The risks of acquiring and transmitting HIV-1 heterosexually have been the subject of considerable discussion in the medical and lay press. Numbers of heterosexually acquired HIV infections detected through voluntary confidential testing have been increasing and in 1994 made up 28% of new reports to the Communicable Disease Surveillance Centre.6 People may, however, frequently conceal the fact that they have risk factors other than heterosexual intercourse.
An important limitation is that unlinked anonymous data cannot ascertain where infections were acquired. Increased precision is possible with locally based studies. For example, a recent linked survey of blood tests, carefully following up 25000 patients attending a London clinic between 1989 and 1994, showed that the prevalence of HIV-1 infection in heterosexual men and women increased from 0.2% to 0.9%. These infections were usually in foreign nationals and acquired in their country of origin, mostly in Africa (D Barlow et al, Xth international conference on AIDS, Yokohama, 1994); in 1994 it was worrying, though, that there was an increase in HIV-1 positive patients from the Caribbean (D Barlow, personal communication). Although this study suggests that substantial secondary spread among heterosexuals has, as yet, not occurred to any great extent in the population studied, careful monitoring to detect indigenous transmission is essential.
In 1991 the National Audit Office criticised the funding of preventive services and stated that resources needed to be targeted more closely at areas of greatest need; health departments needed to “improve their knowledge of their local population at risk and ensure that preventive resources and initiatives are directed at those groups.”7 The Department of Health has now addressed this issue, recommending that purchasers should provide resources for local prevention initiatives directed at those whose behaviour puts them at risk of acquiring HIV. The department has recommended that named HIV testing should be offered to all pregnant women in areas of relatively high prevalence.8 In Paris and Scandinavia over 95% of pregnant women are tested for HIV; research to identify reasons for the poor rates of uptake in Britain needs funding. The department's report also recommends that particular attention should be directed at families of African origin so that education and preventive measures can be sensitively provided. HIV is now spreading rapidly in other parts of the world, particularly Asia. Similar initiatives may be needed for other ethnic groups, and surveillance programmes must therefore be implemented to identify the spread in Britain from these ethnic groups.
It is encouraging that the Department of Health will continue to ring fence funding for preventive activity; hopefully this will include surveillance. To target accurately the ring fenced resources for prevention, the national programmes detailed in the Department of Health's report need to be complemented and enhanced by local initiatives that have HIV testing as an essential component. Purchasers must ensure that these are adequately funded.
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