November 2016 saw the publication of revised UK NICE Guidelines for HIV testing (last updated 2011) – only a few weeks before the appearance of the annual Public Health England Report: HIV in the UK/2016. The latter highlights the estimated level of still undiagnosed HIV in the UK (which, at 13,500/101,000, places us 3% short of the UNAIDS 90:90:90 target) and the proportion of late diagnoses (approx. two/five thousand). It also draws attention to the ‘diversity’ of the epidemic, and the relatively poor levels of diagnosis amongst the 16,500 infected non-black African heterosexuals (approx. 1/4, as opposed to 1/7 for MSM or 1/8.5 for black African heterosexuals).
In the light of these findings, we can appreciate the move in the NICE Guidelines, regarding opportunistic testing in primary and secondary care, towards an approach that, first, makes absolutely clear its basis in regional prevalence rather than any other factor, and, second, is more specific – and more demanding – about the occasions when testing is recommended. We find a new distinction of two levels of high local risk: high (0.2-0.5%) and extremely high (>0.5%). This determines whether testing should be offered on specified occasions, namely, in primary care, at registration and the performance of any blood test, and, in secondary care, at admission and performance of a blood test (‘high’ prevalence areas); or whether there should be universal opportunistic testing (‘extremely high’ prevalence areas). As compared with the 2011 guidelines, an insistence on local prevalence as the determining factor replaces the specification of multiple high-risk groups (e.g. MSM or black Africans).
The danger with routine HIV testing is well illustrated by a 2011 study of screening in 29 Paris emergency departments: Wilson d’Almeida & Cremieux/STIs/blogs. This trial seems to have spectacularly failed to pick up any HIV infections that would not have been detected even without the intervention. By contrast, what is proposed by the NICE Guidelines is routine testing in areas of extremely high prevalence. Of course, patients may still refuse testing (Dhairyawan & Orking/STIs) – and appear to do so all the more frequently where they belong to groups, like non-African heterosexuals, that the authors of the 2016 guidelines are so anxious to include (Mohammed & Hughes/STIs). Nevertheless, the 2014 HINTS study (HIv testing in Non-Traditional Settings) of the acceptability of routine HIV testing has demonstrated encouraging levels of uptake (c.65%) in UK Emergency Departments, Acute Care Units, Primary Care Centres, and dermatology outpatients (Rayment & Sullivan; see also Mohammed & Hughes/STIs). Conversely, there is evidence, where primary care is concerned, that practitioners may be capable of missing opportunities for testing even where their patients present with indicator conditions for HIV infection (Agusti & Casabona/STIs).
Responding to the new NICE guidelines, a GPs’ representative stresses the existing workload of GPs and the sensitivity of sexual health issues, but broadly welcomes the new emphasis.