HIV testing is the gateway to accessing care – but can involve issues of stigma.  So improving accessibility to testing – by, amongst other things, overcoming the associated stigma – is a major concern for developed and underdeveloped countries alike, and has led to initiatives for testing in “non-traditional settings” (e.g. the UK based HINTS study: http://sti.bmj.com/content/88/8/601.abstract?sid=30e86f02-5f14-47ea-a52f-890e265e9295).  In many low-income countries, where need is particularly great, and medical infra-structure poor (e.g. many nations of sub-Saharan African), these “non-traditional settings” have included non-medical ones, including the home (see Obare & Kohler (2009): http://sti.bmj.com/content/85/2/139.abstract?sid=ec2937f2-fabf-4e25-bcf2-3d8d1c6fc021).

Yet, serious concerns have recently been raised about the implications of implementing such an approach in low-resource settings.  It is argued that the consequences of stigma may be very serious for those affected (Turan & Cohen: http://link.springer.com/article/10.1007/s10461-010-9798-5/fulltext.html) , and that, where there is a drive to implement testing by untrained and ill-qualified staff, considerations of acceptability can easily be over-ridden (e.g.  Human Rights Watch: http://www.hrw.org/sites/default/files/reports/lesotho1108.pdf).

So a recent meta-analysis of Sabathy & Ford in PLoS-Medicine seeking to cast a light on the acceptability of home-testing  in sub-Saharan Africa is very welcome (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001351).

21 studies reported in 19 papers are selected as meeting the criteria, and derive from six sub-Saharan African countries.  The overall results are a strong endorsement of the acceptability of home-based testing (HBT).  Of those offered the test 77% accepted and received a result; furthermore, among those testing positive between 40% and 79% turned out not to have tested previously.  There were two particularly encouraging findings.  First, in the eight studies that separated data on the basis of gender, 47% of those offered the test were men.  This is important, given the often very low rates of male attendance (as low as 9%) for facility-based testing.  Second, in the two studies that report CD4 counts,  only 68% and 69% respectively of those testing positive had a CD4 count >200.  The authors conclude that HBT may be a useful approach for earlier detection.

The study identifies as its key finding the potential of HBT to reach wide sections of the community who would not otherwise have sought testing.  It also indicates a number of directions for further research.  These include, most obviously, the feasibility and acceptability of repeat HBT for ongoing knowledge of HIV status.  On this the study of Obare & Kohler 2009 has produced some encouraging results (http://sti.bmj.com/content/85/2/139.abstract?sid=ec2937f2-fabf-4e25-bcf2-3d8d1c6fc021).  The option of self-testing with support from HBT staff is also something to be explored.  Finally, the whole issue of the cost-effectiveness of HBT relative to other interventions requires further research in order to guide policy-makers operating in resource-poor settings.

What sort of impact does HIV testing (Voluntary Testing and Counselling: VCT) have on an individual’s subsequent sexual behaviour?

A number of studies of VCT clients in sub-Saharan Africa, and published in STI journal, suggest a significant preventative effect.  A two-year cohort study of 401 clients of Kenyan government health centres (Arthur & Gilks, 2007) points to a significant reduction at 7.5 months both in the proportion of clients with multiple partners (from 16% to 6%) and in the numbers reporting symptoms of STIs (16% to 6%).  A more recent study of attendees at health-centre affiliated VCTs in two Zambian mining villages involving serial interviews (Sikasote & Murray, 2011) serve to consolidate pre-test decisions concerning sexual risk behaviour and reflect clients’ desire to “regain control of their lives”.

In the view of the support these studies lend to the preventative aspect of VCT, it is encouraging to note the comparable behavioural changes reported in a recent study of a very different client group of 1,038 cocaine and heroin users taking up base-line VCT at a US Emergency Department (Bernstein and Madico, 2012).  The study involved secondary analysis of data from a randomized control trial of a motivational intervention (ineffective, as it turned out), which included behaviour change at six and twelve months, notably: a sustained decrease in the proportion of unprotected sex acts (OR 0.7 at 6 months; 0.69 at 12 months), and a sustained drop off – from a high base-line, admittedly – in the number of sex acts (OR 3.1; 0.25).  Given the screening took place during visits to an ED, this effect cannot, as in the African cases, be attributed to a pre-test decision.

These recent findings seem to endorse once again, albeit in the relation to a very different client group, the preventative impact of VCT.  It is interesting, in this regard, that the Zambian study (Sikasote and Murray, 2011) raises the issue of VCT impact for those testing negative, and the importance of post-test support for this group.  They even recommend the de-linking of counselling from testing to encourage earlier attendance.

G. Arthur, C. Gilks et al., “Sexual behaviour change in clients of health centre-based voluntary HIV counselling and testing services in Kenya”, Sexually Transmitted Infections 2007: 83;7

[Abstract][Full text][PDF]

Janet Sikasote, Scott A. Murray et al., “Voluntary counselling and testing for HIV in a Zambian mining community: serial interviews with people testing negative”, Sexually Transmitted Infections 2011:87;5

[Abstract][Full text][PDF]

Edward Bernstein, Guillermo Madico et al., “Long-term Follow-up After Voluntary Human Immunodeficiency Virus/Sexually Transmitted Infection Counseling, Point-of-service Testing, and Referral to Substance Abuse Treatment From the Emergency Department, Academic Emergency Medicine, Volume 19, Issue 4, April 2012

http://onlinelibrary.wiley.com/doi/10.1111/acem.2012.19.issue-4/issuetoc;jsessionid=7D68FDAA3B7B33CFC869B379642BA484.d03t02

A large, recently published French study, based in metropolitan Paris, places a question mark over the value of non-targeted HIV screening as a strategy to lower the number of undiagnosed infections and improve early detection.

Late diagnosis of HIV remains a common problem both in France – where, despite accessible testing, one-third of diagnoses are in conjunction with CD4 counts less than 200/μL – and in other countries.  National health authorities have therefore promoted untargeted testing in the US, the UK and France.    However, the strategy remains controversial.  The authors of this study claim that it is the first large-scale study to have assessed its effectiveness.

The testing was conducted in 29 Paris Emergency Departments (ED) – an ideal setting for assessing the impact of untargeted testing, given that 25% of French population visit an ED at least once a year, including low-income, uninsured and other subgroups that might not be reached in other health care settings.  Of the 20,962 eligible patients who visited the EDs during the periods when screening was operative (i.e. during the 6-week period randomly assigned to each participant ED), a total of 12,754, or 63% of those eligible, consented to the test.

The number of HIV cases newly diagnosed (18 or 0.14%) as a result of the study, though small, fell within the authors’ expectations.  The significant finding relates to the characteristics of those newly diagnosed.  With one exception, they all belonged to high risk groups – sub-Saharan African or men having sex with men (MSM).  8 were being seen for HIV related symptoms, 7 of them with advanced-stage disease.  Of the 18 newly diagnosed, 6 did not return for a follow-up visit despite repeated calls, 4 were hospitalized immediately, 8 returned for the follow-up.  Among the 12 patients successfully linked to care, only 4 had CD4 counts greater than 350μ/L.

Certainly, this intervention does not appear to have reached infected persons not belonging to high-risk groups.  The authors point out that an ED-based screening strategy limited to men aged 18-45 and African-born persons would have identified all new HIV infections for 50% fewer HIV tests!   Questionnaires administered to consenting patients demonstrate characteristics that seem broadly representative of the Paris population, and findings of a complementary study of covariates of HIV refusal in 7 EDs suggest that refusal-associated factors did not unduly bias the results of the study.  The authors conclude that their observations do not support the implementation of non-targeted screening in the ED setting.  Given this study group appears highly representative of the general population, the authors are also very sceptical of the likely value of untargeted screening in other healthcare settings – at least in France.

The applicability of these findings to other countries cannot be assumed.  But the study certainly highlights the need for additional country-specific studies of the effectiveness of the strategy of untargeted HIV testing.

Kayigan Wilson d’Almeida, Anne-Claude Crémieux et al., “Modest Public Health Impact of Nontargeted Human Immunodeficiency Virus Screening in 29 Emergency Departments”, Archives of Internal Medicine, published online 24^th October 2011

http://archinte.ama-assn.org/cgi/content/full/archinternmed.2011.535

For national strategies supportive of untargeted HIV testing, see the following:

In the US:  http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm;  in the UK http://www.hpa.org.uk/Publications/InfectiousDiseases/HIVAndSTIs/1011TimetotestHIVtesting/; in France http://www.sante.gouv.fr/plan-national-de-lutte-contre-le-vih-sida-et-les-ist-2010-2014.html.

The economic case for investment in the prevention of vertical (mother to child) transmission of HIV and syphilis is easily made – even in low resource settings.  Yet the virtual elimination of maternal HIV transmission remains a goal still to be achieved in many regions, while syphilis in pregnant mothers is often unaddressed with tragic consequences in terms of peri-natal mortality.

The final resolution of these problems will no doubt require a multi-dimensional and holistic approach of the kind recommended by the UNAIDS report.  Yet a recently trialled technology, designed by biomedical engineers from Columbia University, may ease the way to that solution:  it promises to deliver a point-of-care HIV/syphilis test that replicates all the steps of ELISA (enzyme-linked immunosorbent assay), with a sensitivity and specificity to match traditional benchtop assays – but at low cost, with minimal equipment, and requiring no user interpretation (all important considerations in low resource settings).

A recent paper in Nature Medicine describes the technology – the “mChip” assay (mobile microfluidic chip for immunoassay on protein markers), and reports the encouraging results of three trials undertaken in Rwanda.

The device consists in a microfluidic cassette (5.4 cm x 8.5 cm) costing $0.10.  A metal spacer, displacing 6 ml of air in a syringe, is used to draw into the cassette a fluid plug consisting in 14 reagents separated by air spacers.  The procedure produces a signal that can be detected using low cost optics such as light emitting diodes and photodetectors (costing $0.50 and $6.00 respectively).  The test requires less than 1μl of unprocessed whole blood and is complete in 15 minutes.

When tested in Muhima Hospital Kigali on 70 specimens of known HIV status the device demonstrated an overall sensitivity of 100% and a specificity of 96%.  It was also evaluated on 101 archived specimens from couples receiving HIV voluntary counselling, and showed similar levels of sensitivity (100%) and specificity (94%).  Thirdly, the ability of the device to perform a combined HIV-syphilis test was investigated at Project Ubuzima, using 67 serum and plasma samples collected for a separate research study on female sex workers in Kigali.  The duplex test showed sensitivities of 100% and 94% and specificities of 95% and 76% for HIV and syphilis respectively.

A paper covered in a previous blog (Screening for syphilis in pregnancy: evidence for the effectiveness of doing something) reviews the disastrous failure in many low resource contexts to test and treat syphilis in pregnancy.  For all the priority rightly given to the prevention of HIV, the inclusion of syphilis in the duplex test seems a commendable element.

Curtis D Chin et al., “Microfluidics-based diagnostics of infectious diseases in the developing world”, Nature Medicine 17, 1015-1019, 31^st July 2011

http://www.nature.com/nm/journal/v17/n8/full/nm.2408.html

At the same time as the release of depressing figures by the UK Health Protection Agency (HPA) showing a doubling of the annual rate of fresh HIV diagnoses in the UK, the National Institute for Health and Clinical Excellence (NICE) has just issued two sets of recommendations on HIV prevention.
Annual figures for new diagnoses of UK-acquired HIV have risen steadily from 1,950 in 2001 to 3,780 in 2010. Three fifths of these diagnoses are “late” diagnoses (i.e. after the point treatment should have begun). The HPA places a figure of £32 million annually on the failure to prevent the 3,780 cases diagnosed this year.
Two documents have been issued by NICE containing detailed recommendations regarding the most at risk groups – respectively, men who have sex with men (MSM), and UK black Africans. The aim of both documents is to recommend a more proactive approach to HIV testing. The strategy builds on current UK guidelines (British HIV Association et al. 2008) advocating the “normalization” of HIV tests, and specifically recommending that in certain areas – e.g. where more than 2 in 1000 people have been diagnosed with HIV – tests be offered to everyone.
Specific guidance in the MSM document is directed to those capable of playing a role in different capacities. Specialist sexual health services should offer testing to all who attend. Primary and secondary care providers should recommend testing at registration or admission, not only to individuals at high risk, but to everyone in areas where there is high prevalence (more than 2 in 1000), or a large community of men having sex with men. Health care promoters are specifically urged to promote testing in their promotional literature. Finally, planning services should work in partnership with relevant local organizations to gather data, assess local need and develop a strategy in respect to both of these at risk groups.
The recommendations for black Africans, though complementary and covering some of the same ground, are differently structured and more complex. The failure of the two documents to dovetail is no doubt an unfortunate result of the differing needs of the respective groups. The latter document builds on current UK guidelines (British HIV Association 2008) recommending that HIV testing be offered to men and women from countries of high prevalence as well as the guidelines mentioned above. The different emphasis in the latter document, and the preponderance of recommendations addressed to directors and commissioners of public health, may reflect the smaller role of specialist sexual health services, on the one hand, and the real possibility (and challenge) of community engagement, on the other, with responsibility falling on public health commissioners to ensure that that the needs of high risk communities are met through the provision of primary and secondary health care services within their sphere of operation.
Recommendations to “collect information about current HIV diagnoses” may pose a challenge to public health services lacking the necessary epidemiological expertise.

National Institute for Health and Clinical Excellence, “Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among men who have sex with men”, PH34, March 2011

National Institute for Health and Clinical Excellence, “Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among black Africans in England”, PH33, March 2011

http://www.nice.org.uk/

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 1^st 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

Please see letter below from Surinder Singh in response to the article

Richard Ma
Time to improve HIV testing and recording of HIV diagnosis in UK primary care
Sex Transm Infect 2009; 85: 486

http://sti.bmj.com/cgi/content/extract/85/7/486

Richard Ma makes some excellent points in his editorial (1). I would like to ‘correct’ a misperception but add to the current debate about HIV-testing and subsequent care within UK general practice. Ma states that it was the use of highly active antiretroviral therapy (HAART) which precipitated the debates around shared care of patients with HIV infection. Unfortunately this is not true. For those old enough to remember, the serious debate began when patients with HIV and AIDS were denied local services and traditional primary care, particularly when entering the terminal stages of their illness (2). It was also apparent that patients living in one part of the country but receiving care in London were having problems accessing general practitioner (GP)-type services (3). It is true that HAART seemed to focus the mind – it became fairly obvious that prescribing could be one of the facets of care which could be examined in the “shared-care” process. However, in the present context let’s examine some of the dynamics in shared care. Primary care is undoubtedly becoming more involved in the care of patients with HIV/AIDS though it has been argued that general practice could still do more (4), for example in trying to uncover the unidentified 21000 people with HIV infection in the UK (5). Yet up to now the problem has been that patients have liked the highly successful hospital model, a model that has either implicity or in some cases explicity “taken over” GP care. In truth this gold standard model is not sustainable and this is the reason why general practice has to be more involved. The barriers to full primary care involvement have been outlined before (1,3,4) but patient fears about disclosure, confidentiality and stigma are still present. Things change in general practice as they do in Medicine; early in the UK it would necessarily take an hour to ‘counsel’a patient about an HIV test, now we can do the test in the privacy of our consulting room and give the result to the patient 2 minutes later (we are about to embark on point-of-care testing in our practice). The real questions are these: (a) How can we expect a more pressured primary (6) to take up the challenge of increasing testing when the priorities within general practice seem to increase all the time (6). Furthermore it is appropriate to be mindful of the often complex needs of the various heterogenous groups which are affected by HIV infection (gay men, African men, women and children, drug-users)? As the recent research paper states “further work is needed on the mechanisms required to deliver increased HIV testing in primary care”(7). (b) Next and increasingly important especially if more cases of HIV infection are uncovered in GP, what is the optimal location for a systematic approach to HIV/AIDS – the chronic condition? In other words what system or systems will be responsible for regular patient monitoring of CD counts & viral loads, surveillance of cervical smears and perhaps immunisations as well as offering basic prevention activities, for example smoking cessation advice in those already at higher risk of ischaemic heart disease? References:

1. Ma, R. (Editorial) Time to improve HIV testing and recording of HIV diagnosis in UK primary care: Sex Transm Infect 2009;85:486 doi:10.1136/sti.2009.038091

2. Smits,A., Mansfield,S., Singh,S. (1990). Facilitating care of patients with HIV infection by hospital and primary care teams. British Medical Journal 300, 241-243. ISSN: 0959-8146 3. Mansfield,S., Singh,S. (1993). Who should fill the care gap in HIV disease? Lancet 342(8873), 726-728. ISSN: 0140-6736

4. Singh,S., Dunford,A., Carter,Y.H. (2001). Routine care of people with HIV infection and AIDS: should interested general practitioners take the lead? British Journal of General Practice 51(466), 399-403. ISSN: 0960 -1643

5. Health Protection Agency. HIV in the United Kingdom: 2009 Report. 2009, London, Health Protection Agency also available athttp://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1227515298354 (accessed 7.1.2010)

6. Oakeshott, P; Aghaizu A; Prime, K; Hay P. Promoting long acting reversible contraception & HIV-testing: more work for harassed GPs. BJGP (2009) Vo 59 (569) 895-6 7. Evans HER, Mercer CH,Rait G et al. Trends in HIV testing and recording of HIV status in the UK primary care setting: a retrospective cohort study 1995-2005. Sex Transm Infect 2009;85:520-6.

Conflict of Interest:

None declared