HIV testing and management of newly diagnosed HIVBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4275 (Published 08 July 2014) Cite this as: BMJ 2014;349:g4275
All rapid responses
The clinical review on HIV testing and management is welcome and timely. Since the publication of guidelines on testing in 2008, implementation has been patchy. We recently conducted a systematic review of implementation of these guidelines in the UK; the overall estimate of test coverage was only 27.2% (95% CI 22.4% to 32%) in eligible populations outside of antenatal and sexual health clinics. (1) The data showed that test offer was much lower than patient acceptance, indicating that it is provider behaviours that need to change.
We have recently completed a mixed methods study of people newly diagnosed with HIV in a London trust where around 40% of patients are diagnosed late, i.e. with a CD4 count of less than 350mm/cm3. Information from 58 recently diagnosed patients, including 25 in-depth interviews, highlights some of the barriers to early diagnosis that lie with health care professionals. (NHS Research Ethics Committee 12/LO/0779).
Preliminary analysis shows that two thirds of the patients had consulted a healthcare provider, mostly in primary care, in the 12 months prior to diagnosis. Many had symptoms that could be attributed to HIV, and some felt they had described relevant risks, but testing had not been initiated. Even where clinicians appeared to suspect HIV, some were reluctant to offer testing, preferring to send the patient to sexual health clinics. “When I was there she (practice nurse) said she doesn’t have the knowledge to diagnose what I had … She said there’s a clinic over here. I didn’t know what type of clinic, mind... It wasn’t a place where I really wanted to go, to be truthful with you. I’ve come to the clinic myself because it seems I’ve got nowhere else to go.”
To improve outcomes for people with HIV and reduce onward transmission there is an urgent need to normalise testing and implement existing guidelines. Alongside education for physicians and other health care professionals we need awareness campaigns to help people recognise risk and seek testing.
Competing interests: No competing interests
We welcome the thorough overview of HIV testing and initial management by Rayment et al for clinicians in primary care and acute hospital settings.1
The review provides non-HIV specialists with clear clinical indications for testing and recommends that screening be considered for “all men and women registering in general practice” and “all general medical admissions” in areas (including all of London) where prevalence is >2/1000, describing the clear benefits to patients of early diagnosis and treatment.
However, the review does not comment specifically on advice for clinicians working in mental health settings, such as psychiatric outpatient departments, acute psychiatric wards and crisis resolution and home treatment teams. We regret this omission, particularly in view of the current campaigns within the National Health Service to tackle health inequalities for patients in this group, moving towards "Parity of Esteem".2,3
International evidence indicates that mental health populations have higher rates of undiagnosed HIV infection, with patients reporting higher rates of sexual risk behaviours and lower rates of condom use.4
We suspect that psychiatric trainees (to whom physical examination and baseline blood testing of mental health patients is usually delegated) lack knowledge and confidence to offer HIV testing routinely, even though “any doctor, nurse, midwife, or other trained healthcare provider can offer an HIV test”.1
When questioned, a group of West London Mental Health Trust psychiatric trainees reported to us the belief that explicit pre-test counselling is still required (beyond that which would be provided for other blood tests), and feared that it would be inappropriate to offer testing to patients with impaired capacity to consent, despite them testing routinely for other potentially stigmatising illnesses (eg syphilis) in the patients' best interests.
Previous work has shown the acceptability and necessity of testing in this patient cohort.5
The anecdotal views of trainees are reflected in data from our Trust pathology supplier in one borough (Ealing); these indicate that between July 2013 and July 2014, for patients in Local Services, whilst 455 screening tests for syphilis were requested (28 positive), only 14 screening tests for HIV (0 reactive) were ordered.
However, elsewhere in the same organisation, where a programme is in place to offer screening to patients in our long-stay forensic wards and Broadmoor Hospital, nearly all of 300 inpatients have been offered HIV testing by the Liaison Physician (GP) and physical health service, with take-up rates of 63%.
As we aim to ensure parity of care for patients with mental illness, we would advocate: that clinicians in mental health settings follow the same guidelines for HIV testing as our colleagues in primary and secondary acute care, including universal screening where recommended; and that the benefits of early diagnosis and instigation of antiretroviral therapy are considered as reasons testing may be all patients’ best interests. We would also highlight this example of the benefit of a dedicated Liaison Physician in the delivery of integrated physical health care for patients in mental health settings.
Dr Christopher Hilton, Consultant Liaison Psychiatrist, WLMHT
Dr Alan Cohen, Director of Primary Care, WLMHT
Dr Frank Geoghegan, Consultant Chemical Pathologist, Ealing Hospital NHS Trust
1 BMJ 2014;349:g4275
2 Whole-person care: from rhetoric to reality Achieving parity between mental and physical health 2013 RCPsych
3 Closing the gap: priorities for essential change in mental health 2014 DOH
4 Clin Psychol Rev 2005; 25: 433-57
5 BJPsych (2013) 202: 307-308
Competing interests: CH has received honoraria for speaking on the subject of HIV and Mental Health from Janssen and is a personal friend of the authors of the paper.