Intended for healthcare professionals

News

London hospital says it will continue to offer HIV tests to all accident and emergency patients after trial

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3705 (Published 13 June 2011) Cite this as: BMJ 2011;342:d3705

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
indicator conditions.

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
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/HIVAndSTIs/...

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;
372:239-299.

4. Time to Test for HIV: Expanded Healthcare and Community HIV Testing in
England, Interim Report. Health Protection Agency (HPA). Published Dec
2010.

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
2008;47:352-357

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:

28 June 2011
Leena Sathia
Consultant in GUM/HIV
Sarah Duncan (StR in GUM, Garden Clinic, Slough)
Royal Free Hospital NHS Trust