1. NHS Tayside HIV Testing Guideline May 2013

2. The purpose of this presentation is to:
Provide an educational resource to support the implementation of the HIV testing guideline
Illustrate how the HIV testing guideline can be implemented
Explore common myths around HIV and HIV testing

3. Overview Why HIV testing is important:
Epidemiology of HIV in UK and Tayside
Consequences of undiagnosed infection
Healthcare Improvement Scotland Standards (2011)
Overcoming barriers to HIV testing
When to test for HIV
How to test for HIV

4. HIV was more common in the UK in the 1980’s and 1990’s than it is now
HIV has never been more common in the UK, or in Tayside, than it is today 1, 2

5. Number of people newly diagnosed and people living with diagnosed HIV infection: UK 1980-2011+
undiagnosed
Estimated total
96 000
HIV in the United Kingdom: 2012 overview,
HIV and STI Department, HPA, 5

6. 3462 living with diagnosed
HIV in Scotland (2011)

7. HIV in Tayside There have been 709 HIV diagnoses made
within Tayside since reporting began
There are almost 300 people currently living
with diagnosed HIV in Tayside in 2012
In 2011, 34 new diagnoses were made in Tayside. This is the greatest number of new diagnoses per year since reporting began
1999
2011
Data source: Health Protection Scotland

8. 1 in 20 MSM are living with HIV in the UK1
Men who have sex with men (MSM) are the risk group with the highest prevalence of HIV in the UK
1 in 20 MSM are living with HIV in the UK1
(1 in 11 in London)

9. Prevalent infection in the UK, 20111 n ~ 96 000
Prevalent infection in Scotland, 20112
n = 3478
Prevalent infection in Tayside, 20112
n = 258

10. New HIV diagnoses in the UK, 20111 n = 6280
New HIV diagnoses in Scotland, 20112
n = 362

11. Task: Can you match the risk group with the corresponding HIV prevalence?
2.2 in 1000 people
MSM
Black African men
Black African women
Pregnant women overall
People who inject drugs
1.2 in 1000 people
24 in 1000 people
50 in 1000 people
47 in 1000 people
The overall prevalence of HIV in the UK is 1.5 in 1000 people

12. HIV prevalence per risk group, UK 20111
MSM
Black African men
Black African women
Pregnant women overall
People who inject drugs
47 in 1000 people
25 in 1000 people
50 in 1000 people
2.2 in 1000 people
1.2 in 1000 people
The overall prevalence of HIV in the UK is 1.5 in 1000 people

13. Undiagnosed HIV infection1
Approximately 24% of all people infected by HIV
are unaware of their infection
PWID are least likely to be undiagnosed
Non-African born HTRS men are most likely to be undiagnosed
17% PWID
20% MSM
25% Black African women
30% Black African men
31% non-African born women
33% non-African born men
undiagnosed

14. Undiagnosed HIV and onward transmission3
Individuals with undiagnosed HIV:
 are 3 times more likely to pass on their infection than those with diagnosed infection
 are twice as likely to have condom-less sex
Individuals with diagnosed HIV:
 have access to treatment to reduce viral load (biggest predictor of transmission)
 have access to combination risk reduction interventions

15. Undiagnosed HIV accounts for >50% of all new infections
~25% Unaware of Infection
~75% Aware of Infection
Accounting for:
~54% of New Infections
~46% of New Infections
Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS Jun 26;20(10):

16. Late presenters
Most important predictor of morbidity and short-term mortality
Late
CD4 <350
Very late
CD4 <200
UK,
47%
26%
Scotland,
49%
Tayside, 2012/2013 2
62%
24%
BHIVA national audit 2006: 24% of all deaths in HIV-infected people were
reported as “diagnosed too late for effective treatment” 4

17. MSM least likely to present late
Heterosexual men most likely to present late

18. Cost of HIV3 Lifetime cost £280,000-360,000/patient
Annual cost £13,000/patient
Late diagnosis:
Costs are twice as high in the first year
Costs are 50% higher thereafter
In-patient costs are 15-fold higher for
late diagnoses

19. Cost effectiveness of HIV testing3
American studies
HIV testing is cost-effective when one individual diagnosed/1000 tests done
(not accounting for reduced costs for the prevention of onward transmission)
UK cost effectiveness studies limited
1% shift of patients
diagnosed early
Up to £265k saving/year
Implementation of NICE
HIV testing guidelines
3500 new infections
prevented
£18 million treatment
costs saved/year

20. Summary so far
HIV has become increasingly common nationally and locally
Risk factors change and vary nationally and locally
Earlier diagnosis results in
Reduced morbidity and mortality
Reduced onward transmission
Cost savings

21. Barriers to HIV testing
Awareness
I’m not trained
Fear of + result
Perception of
patient’s risk
Perception of risk
Stigma of testing
Fear of causing
offence
Embarrassment
Awareness
“I’d rather not know”
Time
pressures

22. HIV testing pilots5 DH funded HIV testing pilots in England
Expanded HIV testing
Emergency Department x 1
Acute medical admissions x 3
Dermatology OPD x 1
Primary care x 3
Community x 4
Acceptability to patients
59-75% uptake in primary care
62-91% uptake in hospital settings
Patient questionnaires
GP new registrations
85% happy to have HIV test

23. HIV testing pilots5 All fears assuaged after roll-out
Offer of testing variable 21-62%
Evidence of targeted testing
AMU Brighton
39.7% offered HIV test
91% uptake
Parallel seroprevalence study
6 new diagnoses
*4 of these remain undiagnosed*
Staff acceptability questionnaires
Initial concerns
Need for training
?How to answer difficult questions
Time pressures to gain informed consent
All fears assuaged after roll-out

24. HIS Standards for HIV, 20116
The NHS Board develops and promotes a written HIV testing policy
Identification of asymptomatic infection (6.1)
Identification of symptomatic infection (7.1)
A critical case review is performed for all late presenters (7.2)
Recognition of symptomatic HIV is included in local medical CPD programmes

25. NHST HIV Testing Guideline
Consultation period August-December 2012
Endorsed by
Area Clinical Forum
Clinical Quality Forum
Improvement and Quality Committee
Launched 13th May 2013

27. Who can undertake an HIV test
“It should be within the competence of any doctor, nurse and midwife to obtain consent for and conduct an HIV test” 7
(There are other non-clinical staff in non-clinical settings who are trained to provide HIV testing within Tayside)

28. Who should be tested for HIV?

29. Who should be tested for HIV?7
Universal testing in high prevalence areas
Opt-out testing in certain clinical settings
Screening of high risk groups
Testing in the presence of “clinical indicators”

30. Who should be tested for HIV?
Universal testing in high prevalence areas
Opt-out testing in certain clinical settings
Screening of high risk groups
Testing on clinical grounds

31. Universal testing*
In high prevalence areas in the UK (local prevalence >0.2%) HIV testing is recommended to
all general medical admissions
all new patients registering at general practice
Tayside’s prevalence is <0.2%
HPA - Colindale
* The individual has the option to decline a test

32. Who should be tested for HIV?
Universal testing in high prevalence areas
Opt-out testing in certain clinical settings
Screening of high risk groups
Testing on clinical grounds

33. Opt-out HIV testing*
Opt-out testing means that HIV testing would be considered part of the routine care for people attending certain services
The test should be recommended to every individual regardless of the perceived individual risk
This is a screening intervention for public health benefit
* The individual has the option to decline a test

34. Opt-out HIV testing*
Which services do you think should offer opt-out HIV testing to ALL individuals accessing their service?
Termination of
pregnancy services
Antenatal services
There is a
higher
prevalence of
HIV in
individuals
accessing
these services
than in the
background
population
The risks
associated
with
undiagnosed
HIV in these
settings are
unacceptably
high
GUM clinics
Assisted conception
services
Drug dependency
services
* The individual has the option to decline a test

35. Who should be tested for HIV?
Universal testing in high prevalence areas
Opt-out testing in certain clinical settings
Screening of high risk groups
Testing on clinical grounds

36. Screening of high risk groups*
People with identifiable risk factors should be routinely offered and recommended to have an HIV test
An HIV test should be recommended regardless of their clinical presentation
* The individual has the option to decline a test

37. Screening of high risk groups*
Which of these groups should be routinely
offered an HIV test?
Female partners
of bisexual men
Adults from
endemic areas
People who
inject drugs
Heterosexual
men
Men who have
sex with men
Partners of people
living with HIV
Children from
endemic areas
Healthcare
workers
Anyone with multiple
sexual partners
Sexual partners
from endemic areas
People in prison
History of iatrogenic
exposure in
an endemic area
* The individual has the option to decline a test

38. Screening of high risk groups*
Which of these groups should be routinely
offered an HIV test?   
Female partners
of bisexual men 
Adults from
endemic areas
People who
inject drugs
Heterosexual
men  
Men who have
sex with men
Partners of people
living with HIV  
Children from
endemic areas
Healthcare
workers  
Anyone with multiple
sexual partners 
Sexual partners
from endemic areas 
People in prison
History of iatrogenic
exposure in
an endemic area
* The individual has the option to decline a test

39. Screening of high risk groups
High prevalence
areas are:
Sub-Saharan Africa
Caribbean
Thailand
Regular screening
should be
recommended
based on on-going
risk
HIV testing should
be recommended for
children born to HIV+
or untested mothers
from endemic areas
Adults from
endemic areas
Men who have
sex with men
The prevalence
of HIV in these
risk groups is
higher than the
background
population
Regular screening
should be
recommended
based on on-going
risk
Female partners
of bisexual men
Children from
endemic areas
People who
inject drugs
Sexual partners
from endemic areas
Partners of people
living with HIV
History of iatrogenic
exposure in
an endemic area

40. Screening of high risk groups
This is not a discriminatory risk factor
Anyone with multiple
sexual partners
People in prison
A custodial sentence is a good opportunity
to test people with particular risk factors
for blood borne viruses but is not a risk group itself
There is no evidence that this group has a
higher prevalence of HIV
Healthcare
workers
This is not a discriminatory risk factor
Heterosexual
men

41. Who should be tested for HIV?
Universal testing in high prevalence areas
Opt-out testing in certain clinical settings
Screening of high risk groups
Testing on clinical grounds

42. Testing on clinical grounds7
When HIV falls within the differential diagnoses and HIV test should be performed regardless of risk factors (a risk assessment is not necessary)

43. More than 50% of people living with HIV are asymptomatic until they present with symptoms of advanced immunosuppression
Approximately 80% of people who acquire HIV experience symptoms of primary HIV infection (seroconversion illness) which usually presents within 2-4 weeks of infection

44. Primary HIV Infection
HIV may present with the following transient symptoms:
Myalgia
Headache/aseptic meningitis
Lymphadenopathy
Fever
Pharyngitis
Maculopapular rash
Recommendations:
Adults presenting with a “glandular fever-like” illness, where the EBV IgM is negative should be offered an HIV test
Adults presenting with aseptic meningitis should be tested for HIV

45. Symptomatic HIV HIV is a multi-system disease Opportunistic Infections
AIDs-related cancers
Other clinical indicators

46. These are “AIDs-defining “conditions and represent HIV-associated immunosuppression until proven otherwise
These conditions are more common in people with HIV and testing is recommended
These conditions are epidemiologically linked to HIV and testing is recommended
The UK National HIV testing guideline recommends HIV testing in these presentations

47. These are “AIDs-defining “conditions and represent HIV-associated immunosuppression until proven otherwise
These conditions are more common in people with HIV and testing is recommended
These conditions are epidemiologically linked to HIV and testing is recommended
The UK National HIV testing guideline recommends HIV testing in these presentations

48. Testing on clinical grounds
If you would like further information about specific systems or specific clinical indicators please contact the BBV MCN team We are happy to provide tailored teaching within your department or clinical area

49. Pre-test counselling is considered best practice
The perception that specific training for pre-test counselling is required is a barrier to HIV testing. It also contributes to the stigma around HIV and HIV testing. It is recommended that the same level of counselling and consent is required as for any other serious medical condition

50. What does a patient need to know?
That they are being tested for HIV What the benefits of testing are How and when they can expect to receive results That results will not be given to a third party Written information can be made available
Available in 6 languages

51. Consent Informed verbal consent is required
Document consent in medical case record
Refusal of HIV test should be documented
HIV testing can be undertaken for an incapacitated patient if testing is in their best interest*
Additional specialist support can be made available on request
*See section 4.5 of the testing guideline

52. Confidentiality
The same level of confidentiality applies to HIV test results as to any other medical test results Results should never be disclosed to any third party without the patients expressed consent HIV tests undertaken at a GUM clinic can be done anonymously

53. Practicalities Results available to clinician within 48 hours
Results available to clinician within 48 hours
Same-day testing can be arranged by discussion with virologist (bleep 4449)

54. HIV tests can become positive as early as 2 weeks after infection
4th generation HIV tests detect both antibody and p24 antigen and can detect infection very early. A negative test 6 weeks after an exposure is very reassuring but we still recommend a test at 3 months to exclude HIV8

55. Communicating results
The method of communicating results should be agreed with the patient prior to testing Services who undertake routine opt-out HIV testing should agree a local policy for managing positive results Face to face communication is recommended where the result is likely to be positive See Section 6.2 of NHST testing guideline

56. Positive results
Make sure you clarify what the pathway is for onward referral before you give the results to the patient
Follow good clinical practice as with the communication of any bad news
A confirmatory test will be carried out on the same sample and a second sample should be sent
See section 6.4 of the testing guideline

58. HIS standards6
All HIV positive results should be communicated to the patient within 7 days
All newly diagnosed patients should be seen by an HIV specialist within 14 days of receiving a positive result

59. Negative results Reassure patient
Re-test 3 months after high risk exposure if necessary
If risk factors have been identified offer risk reduction information
(These are available on BBV MCN website)

60. Having an HIV test may affect your
insurance premiums
This was the case prior to The most recent statement from the Association of British Insurers states that it is standard practice to ask about positive HIV tests. The results of negative tests should not be asked, need not be disclosed, and if it is, will not affect the terms of any policy9

61. Frequently asked questions
The answers to common FAQs are contained within
the NHT HIV testing guideline (section 7)
the “Having an HIV test” patient leaflet

62. If I use the guideline properly I should expect to
(final)
If I use the guideline properly I should expect to
have a high “hit rate” for positive HIV tests
HIV testing is cost-effective when the prevalence in those being tested is >0.2%. Don’t be discouraged by negative results. The more tests you do the more likely you are to find those 2 in 1000. 62

63. Take Home Messages Expanded HIV testing will:
Reduce morbidity/mortality
Reduce onward transmissions
Result in cost savings
Significant barriers to HIV testing still exist
HIV testing is acceptable to patients
Education and support is available to help you to implement these guidelines

64. Excellent BMJ Learning module

65. Workforce development lead for HIV
Dr Morgan Evans
Consultant ID
Clinical lead for HIV
Dr Sarah Allstaff
Consultant GUM/HIV
Workforce development lead for HIV
Contacts
Mrs Donna Thain
Manager SH+BBV MCN
Jackie Caterer
ID Unit Secretary
Telephone:
Ext: 36456
HIV nurse specialists
Telephone:
Ext: 36554

66. References
1 Health Protection Agency (2011). HIV in the United Kingdom 2012 Report. Available at
2 Health Protection Scotland (2012). HIV infection and AIDS: quarterly report to 31 December 2012 (ANSWER). Available at
3 Health Protection Agency (April 2012). Evidence and resources to commission expanded HIV testing in priority medical services in high prevalence areas, April Available at
4 British HIV Association (2006). National Mortality Audit. Available at
5 Health Protection Agency (September 2011). Time to test for HIV: Expanded healthcare and community HIV testing in England
6 Healthcare Improvement Scotland (2011). HIV Services Standards. Available at
7 British HIV Association/BASHH/BIS (2008) UK National guidelines for HIV testing. Available at
8 British Association of Sexual Health and HIV (2010). Statement on HIV window period. Available at
9 nam guidance: New UK Guidelines on HIV testing and Insurance Issued. Available at