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Specialists produce evidence to show HIV testing in UK hospitals is a ‘lottery’

17 May, 10 | by John Evans-Jones, STI Blogmaster

By Harriet Smith at Munro and Forster, on behalf of the British Association for Sexual Health and HIV ( BASHH):

Three new research studies unveiled at the Second Joint Conference of the British Association for Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA), in Manchester today, revealed that people with HIV infection are still routinely going undiagnosed by healthcare professionals, despite presenting to hospitals in high prevalence HIV areas with HIV-related conditions.

Dr Keith Radcliffe, President of BASHH, has told delegates at the conference (20-23 April) that the lottery of HIV testing guidelines in hospital settings means that over a third of people with an HIV infection are still diagnosed late, causing avoidable morbidity, mortality and onward transmission.

The rate of new HIV infections, especially amongst heterosexuals, has been steadily rising in the past few years, and forty-three English Local Authorities now have a prevalence of diagnosed HIV greater than 2 per 1,000 population. Prevention of 3,550 HIV infections would reduce future HIV-related costs by more than £1.1 billion1. Two separate studies to be presented at the Conference revealed the extent of the lottery:

·       An investigation of HIV testing patterns in a large inner city hospital with high local prevalence found that 41% of HIV positive patients had been in contact with a health professional, for an HIV related reason, in the last two years but had failed to be offered a test2.

·       A six month study of acute general medical admissions found that only one third of undiagnosed HIV positive patients were correctly targeted by clinicians for testing. Implementation of the routine offer of an HIV test would have identified the remaining two thirds which were correspondingly missed3.

One reason for which widespread HIV testing remains low is that often Health Care Professionals feel uncomfortable offering tests to patients as part of a routine diagnosis. A third study being presented to the Conference investigated the feasibility and acceptability, to both patients and staff, of routinely offering HIV tests in an Emergency Department (ED) over a three month period.

·       95% of respondents considered the offer of a test of an HIV test acceptable

·       Post-study focus groups demonstrated a high level of satisfaction amongst staff that the delivery of testing was feasible and acceptable to the majority

·       61% of patients offered an HIV test, accepted it

·       The test acceptance rate was not influenced by ethnicity or sexual orientation, assuaging concerns that higher risks groups may be less likely to accept an HIV test in such settings4.

Dr Keith Radcliffe, said:

“These excellent research studies clearly demonstrate that HIV testing in high prevalence areas remains a ‘lottery’, despite national guidelines which recommend routinely offering an HIV test to adults in high prevalence areas.

These studies add to the overwhelming body of evidence that demonstrates the urgent need to move away from targeted testing, to a system of routine testing in high prevalence areas. It is in the interest of everyone, for local health authorities, and healthcare professionals to take a real stance on this issue”

Dr Ian Williams, Chair of the British HIV Association said:

“It is clear from these and other studies that  opportunities for earlier diagnosis of HIV infection are being missed. Late diagnosis is associated with higher risk of death and severe illness. It is important that more widespread testing is available in both health care and community settings and that there is an acceptance by all clinicians to offer a HIV test routinely when indicated”

Professor Ian Gilmore, President of the Royal College of Physicians:

“Someone in their early twenties promptly diagnosed with HIV can today, with the current treatments available, look forward to a relatively normal life, whereas delayed diagnosis and treatment increase the rate of illness, premature death and the unknowing spread of the disease. Changing patterns of HIV transmission further underscore the need to raise awareness amongst physicians and make the test a standard first-line investigation in many secondary care settings.”

Dr Ewen Stewart, Chair of the Royal College of General Practitioners Sex, Drugs & HIV Group said:

“This is not only an important issue for hospitals but also for general practice as these patients are presenting in primary care as well as in hospitals.  We would encourage people to offer more HIV testing in general practice to try to bring down the numbers of new cases of HIV.”

References:

1.      Health Protection Agency (HPA) “HIV in the United Kingdom: 2009” (November 2009)

Report available at http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1259151891866

2.      PJ Read, D Armstrong-James, CYW Tong and J Fox, ‘Community and hospital HIV testing in the highest HIV prevalence area in the UK; missed opportunities for earlier diagnoses identified’ Guys and St Thomas’ NHS Foundation Trust, London UK (April 2010) The study set out to discern missed opportunities for HIV testing, by studying HIV testing patterns in a large inner city hospital with high local HIV prevalence.  All HIV tests performed in 2008 were analysed and stratified for location of request, and HIV positive results underwent case note study review to establish circumstances surrounding the test and to identify previous presentation, HIV indicator diseases and missed opportunities for HIV testing. Results: 90% of hospital tests were carried out as part of routine screening. Of the remaining 10% which were carried out outside of routine screening, 1.3% were HIV positive (51/3408) 41% of HIV diagnoses had attended the Trust with HIV indicator diseases within the preceding 24 months, but not tested for HIV.  The Authors conclude that local implementation of HIV testing guidelines would have detected over one third of late presenters earlier, and prevented subsequesnt hospital admission. 

3.      N Perry, L Heald, J Cassell, M Hankins, S Barden, M Cubbon, J Quin, D Richardson, and M Fisher, “HIV testing in acute general medical admissions must be universally offered to reduce undiagnosed HIV” Brighton and Essex University Hospitals NHS Trust, Brighton, UK and Brighton and Sussex Medical School, Brighton (April 2010).  About the study: The study set out to assess the offering rate of HIV tests in areas with high rates of HIV. Study: Individuals not known to be HIV positive eligible to be offered HIV test as routine investigation in AGM (Acute General Medicine).  A parallel anonymous seroprevalence study was undertaken to assess effectiveness of pilot in correctly identifying undiagnosed HIV in hospital: Results: The six month study of acute general medical admissions found that only one third of undiagnosed HIV positive patients were correctly targeted by clinicians for testing. Implementation of the routine offer of an HIV test would have identified the remaining two thirds which were correspondingly missed.  Conclusion: The rate of offering a test during the pilot was low and varied between medical teams.  Although recommended as routine, clinicians appeared to be targeting testing, yet failing to identify majority of undiagnosed infections.

4.      M Rayment, A Thornton, S Gidwani, C Rae, K Phekoo, J Holland, M Atkins, A Nardone, D Asboe, M Tenant-Flowers, J Anderson, P Roberts, and A Sullivan “HIV testing in the emergency department – reporting one arm of the HIV testing in Non-Traditional Settings (HINTS) study” Chelsea and Westminster Hospitals NHS Foundation Trust, Health Protection Agency, NIHR CLAHRC, North West Londond, Feedback South Londond, Kings College Hospitals Foundation Trust, London, Centre for the Study of Sexual Health and HIV, Homerton University Hospital NHS Foundation Trust, London UK (April 2010) About the study: Where National guidelines recommend the routine offer of an HIV test to adults in general healthcare settings when the local diagnosed HIV prevalence exceeds 0.2%, the aim of the study was to assess the feasibility and acceptability to patients and staff of routinely offering HIV tests in an Emergency Department (ED). Method: All patients attending the ED during study hours over a three month period were offered a saliva HIV test. Subsets of patients completed a questionnaire collecting behavioral and attitudinal data, or participated in focus groups or interviews. Results: Of 3459 patients offered an HIV test, 2123 accepted. (61%) Patients were more likely to accept if they were younger or if they were offered a test by clinical rather than non-clinical staff. There was no association observed between ethnicity and test. 95% of respondents to the survey considered the offer of an HIV test in the ED acceptable. The most common reason for declining a test was due to having been recently tested (46%) and self perception of low risk (41%) Reported sexual orientation was not associated with test uptake. Whilst pre study clinical staff had expressed anxieties about the feasibility of delivering the service and its acceptability to patients, post study focus groups showed that there was high levels of satisfaction amongst staff that the delivery of testing was feasible and acceptable to patients. Conclusion: HIV testing in an emergency setting is acceptable to patients and staff and operationally feasible. 

5.      National guidelines for HIV testing, jointly produced by the British Association for Sexual Health and HIV (BASHH), the British HIV Association (BHIVA) and the British Infection Society (BIS) were launched in 2008 and published in the Journal of Clinical Medicine on the 1st October 2009.

6.      BASHH is the lead professional representative body for those managing STIs and HIV in the UK. It seeks to innovate and deliver excellent tailored education and training to healthcare professionals, trainers and trainees in the UK and to determine, monitor and maintain standards of governance in the provision of sexual health and HIV care.  Please click here to download the new UK National Guidelines for HIV Testing 2008 from the BASHH website http://www.bashh.org/

7.      ‘The British HIV association is the leading UK professional association representing professionals in HIV care. It acts as a national advisory body to professions and other organisations advising on all aspects of HIV care. Please click to download the new UK  national guidelines for HIV testing 2008 from the BHIVA website www.bhiva.org

8.      The British Infection Society is the specialist society for Infectious Disease physicians.  Please click here to download the new UK National Guidelines for HIV Testing 2008 from the BIS website www.britishinfectionsociety.org

9.      The Second Joint Conference of the British HIV Association (BHIVA) with the British Association for Sexual Health and HIV (BASHH) is being held at the Manchester Central Convention Complex from 20 to 23 April 2010.  The conference programme includes a number of high-quality plenary sessions presenting the very latest research across a number of fields, including a focus on the ongoing work in the UK. Specialists have been invited to present on topics in HIV medicine, opportunistic infection, HIV co-infection, genito-urinary medicine and sexual health.

PRESS CONTACT DETAILS:

For further information, please contact Harriet Smith, on behalf of BASHH at Munro and Forster, harriet.smith@munroforster.com or 020 7815 3905

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