Intended for healthcare professionals


Guidelines call for HIV testing to be “normalised”

BMJ 2008; 337 doi: (Published 24 September 2008) Cite this as: BMJ 2008;337:a1796
  1. Jacqui Wise
  1. 1London

    All healthcare professionals should view HIV testing as a normal part of the diagnostic process and a duty of care, says guidance published and disseminated by the Department of Health.

    A booklet on HIV testing, produced by the Medical Foundation for AIDS and Sexual Health, challenges the commonly held assumption that pre-test counselling must be lengthy and should only be carried out by specially trained counsellors.

    More testing may help to diagnose the many people with HIV who are unaware that they are infected, the guidance says.

    The booklet has been released alongside the new UK National Guidelines for HIV Testing 2008 produced by the British Association for Sexual Health and HIV, the British HIV Association, and the British Infection Society.

    “Over the past 25 years HIV has been seen as a condition that needs special skills when offering testing but this is not the case,” says Rachel Baggaley, author of the booklet. “We need to take away the mystique and recognise that HIV is an infection like any other.”

    The booklet says that there is no need for special counselling skills beyond that required for normal clinical practice. It says the term “pre-test discussion” is more appropriate than “pre-test counselling,” which implies the need for in-depth counselling. With a well informed, reasonably low risk person the discussion may take just a minute or two. It says that “normalising” HIV testing will help to reduce stigma and increase uptake.

    The move follows a letter sent out in 2007 by the United Kingdom’s four chief medical officers to all doctors, which set out good practice to improve the detection and diagnosis of HIV in non-HIV specialist settings and to remind doctors of the need to consider offering an HIV test where clinically indicated.

    Lisa Power, head of policy at the Terence Higgins Trust, welcomed the booklet’s guidance, “We have long abandoned the need for intensive counselling. Any doctor or nurse should be able to give advice and offer a leaflet and a telephone number if the patient wants to talk further. It is not rocket science.” She added, “Doctors are often embarrassed to mention an HIV test, but they should stop being scared about it.”

    It is estimated that more than 73 000 people in the United Kingdom have HIV, but almost a third of these are undiagnosed. A delayed diagnosis accounts for at least 35% of deaths related to HIV and increases the chances of onward transmission. Ian Williams, chairman of the British HIV Association, said, “HIV is a treatable condition, and late diagnosis is associated with increased mortality and morbidity.”

    A recent audit carried out by the British HIV Association showed that in about 25% of cases diagnosis occurred too late for optimal treatment ( Late diagnosis is defined as having a CD4 cell count of less than 200.

    If late diagnosis is defined as having a CD4 count of less than 350, which is the threshold currently recommended for starting antiretroviral therapy, this figure rises to 57%. “The majority of these individuals were already in the healthcare system, and a differential diagnosis of HIV had not even been considered,” added Ed Ong, an infectious disease consultant at Newcastle General Hospital and an author of the guidelines.

    In the United States the Centers for Disease Control and Prevention have recommended that screening for HIV infection should be performed routinely for all patients aged 13-64 years in all healthcare settings.

    Routine screening of the whole population is not recommended in the UK because the overall HIV prevalence is lower, at 0.1%. However, the guidelines recommend offering routine HIV testing to all patients in an area where diagnosed HIV prevalence in the local population exceeds 0.2%.

    People with undiagnosed HIV may potentially be seen in any hospital outpatient clinic or ward, and offering HIV testing should be considered during any clinical contact. The guidelines set out where HIV testing should be made routine, such as sexual health clinics, antenatal services, termination of pregnancy services, and drug dependency programmes.

    In addition testing should be offered to people who belong to a group at higher risk of HIV infection—such as anyone diagnosed with a sexually transmitted infection, all men who have sex with men, and all people from countries with high HIV prevalence.

    Ms Power said, “Every patient with tuberculosis and hepatitis C should definitely be offered a HIV test, and this is still not happening. If a patient is HIV positive they are tested for tuberculosis and hepatitis C but not vice versa.”


    Cite this as: BMJ 2008;337:a1796


    • The booklet HIV for Non-HIV Specialists: Diagnosing the Undiagnosed is at

    • The UK National Guidelines for HIV Testing 2008 are at