London hospital says it will continue to offer HIV tests to all accident and emergency patients after trialBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3705 (Published 13 June 2011) Cite this as: BMJ 2011;342:d3705
All rapid responses
Caroline White (13 June 2011)1 reports routine offering of HIV tests
at one London accident and emergency department , soon to be followed by
one other, and at a medical unit in Manchester, in a bid to curb onward
transmission of infection through detection of undiagnosed cases. Das et
al (27 November 2010)2 discussed primary HIV infection as an "easily
missed" condition, and described a 19 year old male who was hospitalised
with an acute illness, initially not recognised to be primary HIV
infection. We have seen a very similar case whose
HIV infection was diagnosed only when the patient attended to donate blood three
weeks after discharge from hospital after being investigated for a "viral
illness". Our recent experience suggests that opportunistic offers of HIV
testing should be more widespread, based on our experience with three
individuals in an older age group, where the opportunity to diagnose early
HIV infection was missed, despite them all presenting to medical care with
what we believe was their primary HIV infection illness .
All three individuals were repeat blood donors over the age of 64,
two male and one female, with established HIV infection. All three had
seroconverted since their last attendance to give blood. In each case,
careful history-taking undertaken by the donor care teams at the time of
notification of the positive test results revealed an illness compatible
with symptoms of HIV seroconversion for which the donor had previously
sought medical attention. In no case was the illness recognised, or HIV
Two of the donors had been seen by their General Practitioners, while the third had been admitted to hospital and underwent lymph node biopsy. The final diagnosis for two was "a viral infection" while the third was treated with antibiotics for a gastro-intestinal infection. Two of the three donors reported to us a new sexual partner shortly before the onset of the illness: in one case no sexual history had been taken, despite a previous history of sexually transmitted infection acquired abroad, while in the second a history was taken but HIV testing was not suggested. The third donor had a clearly identifiable life style risk but no history had been taken.
Despite coming to medical attention at the time of their illness of
seroconversion, none of our donors was recognised to have a primary HIV
infection illness. It is likely that their HIV infection would have gone
unnoticed for years until they became symptomatic again with disease
progression had they not been blood donors. One of them had reached the
previous retirement age for blood donors, but following removal of the
upper age limit (70 years) was able to continue blood donation and thus
benefit from early diagnosis of HIV infection. The donor who had declared
a lifestyle risk would not have been eligible to donate blood again unless
the donor's partner was willing to be tested for evidence of HIV infection. The partner tested positive - as a result both donor and partner were diagnosed as being infected.
These three older individuals (and the young patient) donated blood in
different parts of England, but all of them lived outside London, two of
them in rural areas. There may be less awareness of HIV infection outside
London and other large conurbations. The two oldest donors of our series
had given multiple blood donations prior to their seroconversion illness
(77 and 92 donations) and might therefore have been seen as "low risk" as
they had been tested many times in the past. They may also have perceived
themselves to be low risk.
The high rates of late diagnosis of HIV infection in adults over the
age of 50 has recently been described3 and these three donors, aged over
64, lend support to the concern that risk of HIV infection, and more
specifically, HIV seroconversion illness, is not being recognised or, more
importantly, even being considered in this age group. Lifestyle risks
should be explored more readily and a high index of suspicion maintained
in all cases of "non-specific viral infection"
1. London hospital says it will continue to offer HIV tests to all
accident and emergency patients after trial. White C. BMJ 2011: 342:d3705
2. Easily missed? Primary HIV infection. Das G, Baglioni P and
Okosieme O. BMJ 2010. 341: 1159 - 1160.
3. HIV transmission and high rates of late diagnosis among adults
aged 50 years and over. Smith Ruth D, Delpech Valerie C, Brown Alison E
and Rice Brian D. AIDS 2010. 24: 2109 - 2115.
Competing interests: No competing interests
Re:London hospital says it will continue to offer HIV tests to all accident and emergency patients after trial
Caroline White's article highlights initiatives to increase HIV
testing in A&E settings in high prevalence areas (where diagnosed HIV
prevalence >2 per 1000).
These initiatives are commendable and innovative; a welcome step
forward towards normalising HIV testing. Traditionally most HIV testing
has been offered in GUM and antenatal clinic settings.
The UK National HIV testing guidelines(1) support the need for a more
comprehensive approach to testing for HIV. They advocate HIV screening of
medical admissions and new primary care registrants in high prevalence
areas, and diagnostic testing of patients presenting with clinical
Slough has a diagnosed HIV prevalence of 3.45 per 1000(2). In Oct
2010 we launched the S.H.A.R.P project (Screening for HIV as Routine
Practice), a local initiative to increase HIV screening & diagnostic
testing across primary and secondary care. We aimed to identify more new
HIV diagnoses in non-GUM healthcare settings, through targeted education
of local clinicians.
Educational tools were developed, focusing on the National HIV
Testing Guideline & clinical indicator conditions. SHARP training was
conducted over a 6 month period in a variety of formats, ranging from
individual /small group training sessions to academic half days.
Prior to the launch of educational sessions, local clinicians were
surveyed. Of 74 respondents, 70% had been deterred from requesting an HIV
test due to 'clinician barriers.' Examples of clinician barriers include
"I do not have enough time to perform a pre-test discussion," or "The
patient does not report any obvious risk factors for HIV, so the test is
likely to be negative," or "if I suggest an HIV test the patient may
perceive I am making a judgement about their lifestyle." This survey
demonstrates that some non-GUM clinicians are deterred from requesting HIV
tests for reasons that are no longer relevant: The prognosis of HIV has
dramatically changed since the advent of antiretroviral therapy. HIV is
now a manageable chronic condition. When diagnosed early, and given access
to appropriate treatment, life expectancy approaches that of the general
population.(3) The need for in-depth pre-test discussion is long gone;
informed consent for testing is all that is required. The National
Guidelines are clear that routine screening for HIV in high prevalence
areas is essential, and cost effective. HIV risk assessment is
unnecessary in these settings.
We provided SHARP training sessions to 129 local clinicians (68 in
primary care, 61 secondary care). Unlike the initiatives described in
Caroline White's article, which used 3rd generation salivary HIV POCT, the
SHARP project advocated the use of 4th generation serological HIV tests in
patients already undergoing phlebotomy for any other reason. Whilst
serological test results are not immediately available, the increased turn
-around time is offset by superior specificity and a reduction in the
window period observed with 4th generation serological tests. In the 6
months following the launch of SHARP training, 9 new HIV diagnoses were
made in primary & secondary care (376 tests performed), giving a
diagnosed HIV prevalence of 24 per 1000. Two further new diagnoses were
made through contact tracing. This compares to 2 new HIV diagnoses (274
tests) in the 6 months preceding the launch of the SHARP project.
DH funded pilots have demonstrated high rates of patient
acceptability & uptake of HIV tests offered in non-traditional
settings(4). The barriers to normalising HIV testing are not coming from
patients or the public. A shift in clinician's attitudes to HIV testing is
necessary to eliminate missed opportunities for diagnosing the 26% of
people living with HIV who are unaware of their status(5). Early
diagnosis results in improved outcomes for the individual(3), for public
health(6), and for the NHS purse(7).
We welcome the encouraging results found both at Chelsea and
Westminster and in the SHARP project in Slough as a way to highlight our
collective professional responsibility to reduce late HIV diagnoses
through normalising HIV testing.
1. British HIV Association (BHIVA), British Associations of Sexual
Health and HIV (BASHH), and the British Infection Society (BIS).UK
National Guidelines for HIV Testing 2008.
2. 2009 Data from the Health Protection Agency (HPA), UK. Available at
3. Antiretroviral therapy cohort collaboration. Life expectancy of
individuals on combination antiretroviral therapy in high-income
countries: a collaborative analysis of 14 cohort studies. Lancet. 2008;
4. Time to Test for HIV: Expanded Healthcare and Community HIV Testing in
England, Interim Report. Health Protection Agency (HPA). Published Dec
5. Health Protection Agency (HPA). HIV in the United Kingdom: 2010 report.
Published Nov 2010
6. Pinkerton SD et al. Infections prevented by increasing HIV serostatus
awareness in the United States, 2001 to 2004. J Acquire Immune Defic Syndr
7. Health Protection Agency (HPA). HIV in the United Kingdom: 2009 report.
Published Nov 2009
Dr Leena Sathia - Consultant GUM /HIV Medicine(1)
Ms. Malorie M-R Bader - S.H.A.R.P Project Coordinator(2)
Dr Koenraad Van Den Abbeele - Consultant Physician Acute Medical Unit(3)
Dr Mike McIntyre - Consultant Microbiologist(3)
Ms. Julia Trott - Advanced Nurse Practitioner in Serology(3)
Dr Stephen Dawson - Clinical Lead, Consultant GUM/HIV Medicine(2)
1. Marlborough Clinic, Royal Free Hospital, London, UK (formerly from Garden Clinic)
2. Garden Clinic, Berkshire East Sexual Health Services, Slough, Berkshire, UK
3. Heatherwood & Wexham NHS Foundation Trust, Slough, Berkshire, UK
Competing interests: The S.H.A.R.P project was supported by a grant from Gilead Sciences UK & Ireland Fellowship. The authors submit this rapid response on behalf of the S.H.A.R.P Project Team, comprising:
- Offering and recommending the test "to anyone who has a blood test (regardless of the reason)".
- Considering offering and recommending the test to all medical admissions and all patients registering in general practice.
Competing interests: No competing interests