Uptake of HIV screening in genitourinary medicine after change to “opt-out” consent
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7400.1174 (Published 29 May 2003) Cite this as: BMJ 2003;326:1174
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Dear Sir
Re: Increasing HIV Testing
We instituted routine offering of HIV tests in the Department of
Genitourinary Medicine at the Royal Hallamshire Hospital in 1999 and at
this time 32%(1) of patients (325 of 1004) accepted HIV testing.
Subsequently, in January 2000 a leaflet was produced to provide the
information normally given in pre-test discussion as written information
and this increased testing to 53% (210 of 397). Our data showed a
significant increase in the number of patients being offered a test as a
result of the introduction of the leaflet with 65% (654 of 1004) patients
being offered the test prior to introduction of the leaflet and 94% (371
of 397 p=<_0.001 being="being" offered="offered" a="a" test="test" after="after" its="its" introduction.="introduction." our="our" data="data" also="also" showed="showed" that="that" the="the" main="main" increase="increase" in="in" testing="testing" was="was" men="men" _60="_60" _139="_139" of="of" _233="_233" compared="compared" with="with" _43="_43" women="women" _71="_71" _164="_164" p="p"/> Reed(2) and Stanley(3) also found increases in uptake of HIV testing
by the introduction of a leaflet. However, both the above papers
introduced routine testing (an opt-out approach) and different methods of
providing information on the test at the same time. Our work introduced
the changes consecutively and thus differentiated between the effects of
them in increasing testing. The major factor increasing testing was in
fact the introduction of the leaflet rather than the normalisation of
testing.
Prior to introduction, our leaflet had been piloted to assess patient
response to it. Subsequently, during the time of the study, the patients
were asked more detailed information on the leaflet to assess that it was
providing the right balance of information and not causing undue anxiety.
Staff views were also assessed by means of a questionnaire to determine
the acceptability of giving information in this way.
Our data were originally presented at the MSSVD Spring meeting May
2001 and our work preceeded that in the above papers.
Our findings have been published in Sexually Transmitted
Infections(4) . They were initially submitted to the British Medical
Journal in March 2002 but were declined.
Authors
K E Rogstad, Consultant Physician in Genitourinary Medicine, Royal
Hallamshire Hospital, Glossop Road, Sheffield S10 2JF
Ruth Lowbury, Executive Director, Medical Foundation for AIDS &
Sexual Health, BMA House, Tavistock Square, London WC1H 9JR
Dr G R Kinghorn, Clinical Director, Directorate of Communicable
Diseases, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF
References
1. “Increasing the uptake of HIV testing in an STD Clinic by different
methods”.
Rogstad KE, Bramham L, Kinghorn G R
MSSVD Spring Meeting, Belfast 24th – 26th May 2001 – Abstract No 04
2. J Reed, S J Winceslaus
“New strategies for increasing the detection of HIV, analysis of routine
data”
BMJ 2003: 326; 1066-7
3. Stanley B, Fraser J, Cox N
“Uptake of HIV screening in Genitourinary Medicine after change to opt-out
consent”
BMJ 2003: 326; 1174
4. Rogstad KE, Bramham L, Lowbury R, Kinghorn GR
“Use of a leaflet to replace verbal pre-test discussion for HIV: effects
and acceptability”.
Sexually Transmitted Infections 2003;:79: 243-245
Competing interests:
None declared
Competing interests: No competing interests
Editor-The study of trying to influence the uptake of HIV screening
in genitourinary medicine1 comes at an opportune time. The paper mentions
targets from the Department of Health on the percentage of patients, who
should be tested for HIV infection. It is also a Royal College of
Physicians specialty specific standard for consultants in genitourinary
medicine that the percentage of new genitourinary medicine patients
offered HIV serology should rise from 80% currently to 100% by 2005.2 The
specialty must find an effective method of giving all new patients
adequate information about HIV testing.
I was surprised to read that the authors also included hepatitis B
and hepatitis C tests in their routine screening for sexually
transmissible infections. Hepatitis B is sexually transmissible but by
the time it is diagnosed in a genitourinary medicine clinic, it has
usually been a self-limiting illness. I am not aware of any study that
has found that all patients attending a genitourinary medicine clinic
should be tested for hepatitis B and it would seem from this study that
offering hepatitis B serology to 200 new patients identified no cases of
hepatitis B. The specialty’s UK national guideline on hepatitis B advises
that hepatitis B testing should be considered in sex workers, homosexual
men, injecting drug users (IDUs), HIV-infected patients, victims of sexual
assault, persons from countries outside of Western Europe, north America
and Australasia, those who have sustained a needle-stick injury and sexual
partners of those who have or are at high risk of having hepatitis B.3
Hepatitis C is inefficiently transmitted through sexual intercourse. The
UK national guideline recommends that genitourinary medicine clinics
should consider testing for hepatitis C in IDUs, persons who received
blood or blood products before 1990, those suffering an injury with a
needle that might be contaminated with blood from a person infected with
hepatitis C, sexual partners of persons with hepatitis C, sex workers, HIV
-infected homosexual men, tattoo recipients, alcoholics and ex-prisoners.3
A study in an urban sexually transmitted diseases clinic in San Diego,
California, found that identifying, by self-administered questionnaires,
and testing IDUs, recipients of a blood transfusion before 1992 and sex
partners of IDUs, identifies 70% of hepatitis C infections by testing 12%
of patients.4
Those working in genitourinary medicine are heard to express much woe
about the inadequate funding of the specialty. As money is tight, is
there not a need for the specialty to get the maximum value from every
pound that is spent and not to screen indiscriminately?
Peter Watson
consultant in genitourinary medicine
Bronglais General Hospital, Aberystwyth, SY23 1ER
peter.watson@ceredigion-tr.wales.nhs.uk
1 Stanley B, Fraser J, Cox NH. Uptake of HIV screening in
genitourinary medicine after change to “opt-out” consent. BMJ
2003;326:1174. (31 May.)
2 http://www.agum.org.uk/filingcab/spec_stand_gu1201.doc (accessed 4 June
2003).
3 http://www.agum.org.uk/ceg2002/viralhepatitides0802.htm (accessed 4
June 2003).
4 Gunn RA, Murray PJ, Brennan CH, Callahan DB, Alter MJ, Margolis HS.
Evaluation of screening criteria to identify persons with hepatitis C
virus infection among sexually transmitted disease clinic clients. Sex
Transm Dis 2003;30:340-4.
Competing interests:
None declared
Competing interests: No competing interests
HIV Screening in Brighton, a different approach!
EDITOR - We are aware through the unlinked anonymous sero -survey
that 50% of HIV infection among GUM clinic attendees remains undiagnosed
1. We agree with Stanley et al 2 that increasing HIV testing uptake within
this patient group is important, and this is supported by the national
strategy for sexual health and HIV (NSSHH) which aims to increase the test
uptake to 40% by 2004 and 60% by 2007 3.
In April 2001, prior to the publication of the NSSHH, we changed
clinic policy in the Brighton GUM clinic such that all new patients were
routinely offered an HIV test. Simultaneously we introduced a new case-
note proforma in which the HIV testing section was more prominent and
details of previous test, risk group and risk factors were recorded.
Clinic doctors were encouraged to routinely offer the test, after an
appropriate risk assessment and pre-test discussion, with particular
attention to those from high risk groups.
Between April and July 2001 there were 1888 new episodes (patients
not attending in the previous 3 months) or first patient visits, of which
we analysed 400 cases chosen randomly. Just under one quarter (22%) of
attendees belonged to a high risk group, of which men having sex with men
(MSM) predominated (14%). Overall 76% of patients were offered HIV testing
with an uptake rate of 48%. In MSM disclosing significant risk and
patients from areas of HIV endemicity, testing rates rose to 53% and 63%
respectively. Testing rates varied by individual clinician, with three
doctors who did the bulk of the clinics having testing rates of 71%, 77%
and 37% respectively amongst high-risk groups. The total number of
patients seen by them was comparable. In this time period we identified 12
new HIV positive cases (10 MSM, 1 known positive partner, 1 unprotected
sex in endemic area).
With appropriate staff training and proforma modification we found we
achieved the NSSHH targets by introducing HIV testing as routine. The wide
variation between individual clinicians suggests that tester
characteristics are crucial, as previously shown by Jones et al 4, and
with additional education uptake rates may be further improved. Whilst we
agree an opt-out policy may effectively increase the absolute number of
people testing for HIV, such an approach does not always consider the
relative risk for each tester. In Brighton we were concerned that without
targeting high-risk groups, patients with significant exposure may avoid
testing. Hence the NSSHH targets could be achieved without reducing the
rate of undiagnosed HIV infection. It is of interest that all of the cases
diagnosed had a specific risk factor which were identified prior to
testing, which further supports the policy of targeted intervention.
Barriers to HIV testing in those at high risk of HIV infection need
to be better understood and different strategies for reducing undiagnosed
infection need to be evaluated. We would recommend a combination of an opt
-out testing policy which respects the principles of informed consent,
greater input targeted to those at higher risk and appropriate education
of individual clinicians.
Usha Natarajan,SPR Genito Urinary Medicine,Brighton and Sussex
University Hospitals Trust,Brighton
Martin Fisher, Consultant in Genito Urinary Medicine,Brighton and
Sussex University Hospitals Trust,Brighton.
Gillian Dean,Consultant in Genito Urinary Medicine,Brighton and Sussex
University Hospitals Trust,Brighton.
1.Unlinked Anonymous Surveys Steering Group prevalence of HIV and
hepatitis infections in the United Kingdom 2000. London: Department of
Health 2001
2. Stanley B, Fraser J, Cox NH. Uptake of HIV screening in
genitourinary medicine after change to opt-out” consent. BMJ 2003;
326:1174-
3. The National Strategy for Sexual Health and HIV .Department of
Health, London,2001.www.doh.gov.uk/nhs/strategy.htm
4. Jones S, Sadler T, Low N, Blott M, Welch J. Does uptake of
antenatal HIV testing depend on the individual midwife: Cross sectional
study. BMJ 1998; 316: 272-273
Competing interests:
None declared
Competing interests: No competing interests