Effective pre-test discussion? A case note review Mel Ottewill & Dr Zoe Warwick SSHA Conference 2008

Context HIV +ve patients still dying - non-adherence - late presentation Current national targets to reduce late presentation Within GU clinics by end % offer of HIV test - 60% uptake - 50% reduction in number of HIV infected people who remain unaware of their infection after their visit Changes in testing policy towards opt-out - CDC - WHO - BASHH/BHIVA/BIS review

BHIVA Audit 2006: Scenario leading to death Mortality audit BHIVA audit and Standards Sub-Committee 2006; accessible at Top bars: reclassified during audit Bottom bars: as initially reported

Late Diagnosis (MSM)

Local context Patient stay & morbidity & mortality

Late Presenters in Brighton last 100 admissions Number of admissions Bed days on Inpatient Unit 23% 37%

Local context Patient stay & morbidity & mortality National targets –100% offered –71.8% tested at first visit –78.2% either tested or had tested within the last year

Effect of knowing HIV status on sexual behaviour Meta-analysis of 11 study analyses –6 HIV+ “aware” versus HIV+ “unaware” –5 pre- and post- HIV seroconversion –rates of unprotected anal or vaginal intercourse UPI 53% (CI 45-60%) lower in those aware versus unaware of HIV+ status –If only considering where partner HIV-, 68% (59-76%) Marks, JAIDS, 2005

HIV Testing in GUM % accepting an HIV test % of HIV+ remaining undiagnosed after GUM visit

Are we effectively targeting our HIV testing? Anonymous sero-prevalence study (2004) of MSM - HIV prevalence within MSM=13.7% - 33% undiagnosed. Breakdown by GU attendance: - 78% of HIV +ve men in the community had attended a GU clinic in the last year -23.8% of GU attendees were HIV +ve -of whom 28.2% were undiagnosed - 5.4% of non-GU attendees were HIV +ve -of whom 54.5% were undiagnosed Dodds et al STI 2007

2005 audit of CNC HIV testing HIV test was offered to 76% of patients and was performed in 48% Men having sex with men accounted for 14% of the total visitors to CNC The rate of testing in MSM and low risk group were 53% and 15% respectively.

One year later……. Clinic targeting of high risk groups for HIV testing (Jan-Jun 2006) % of gay men have an HIV test on first visit % of non-whites had a test on the first visit But belonging to a high risk group doesn’t necessarily mean you’re high risk

Objectives To establish: –if risk assessment was adequate –If the response was appropriate according to the level of risk To identify common themes in reasons given for declining a test To suggest changes in practice to improve uptake of testing

Methodology Search database for MSM, Black African & IVDUs attending as a new episode between Jan- June 2006 who did not have an HIV test Included patients diagnosed HIV +ve in 2006 who had previously visited the CNC and left without an HIV test Agree level of risk (high, not-high) Review notes against a data collection tool Statistical analysis – Chi-squared

Results 259 new episode attendances at CNC belonging to high risk gps who did not test for HIV at that visit We reviewed 100 MSM case notes, all endemic and all IVDU Risk category –9 endemic; 98 MSM (2 coded incorrectly); 0 IVDU Age range 20-67; median 38

Results 12/107 had an HIV test within previous 3 mths - 7 high risk 5/107 had a HIV + partner since last test –None had had UPAI ie none high risk

Risks in those never tested before (n=21)

Risk in non-testers 43/107 (40%) assessed as being high risk according to sexual behaviour (all MSM)

STIs in non-testers Of the 107 All STIs were in MSM –7 had an STI since last test (but not at this visit) 5 low risk –13 had STI at that visit (but not since last HIV test) 9 low risk –12 had STI at this visit and since last test 7 low risk

STIs in high risk patients

PTD in high risk non-testers Of those assessed as high risk (43) –4 saw a HA All had a risk assessment, extensive pre-test discussion & reason for declining test documented 2/3 subsequently tested negative; 1/3 no subsequent test; 1 subsequently tested positive –39 did not see HA 31/39 had no documentation of extensive PTD 4/28 subsequently tested negative, 3 tested positive 8/39 had documentation of extensive PTD 4/8 subsequently tested negative

Documented reasons for declining –Perceived low risk (1 x high; 15 x low) –Not psychologically ready (5 x high; 7 x low) –Both of above (1 x high; 1 x low) –Tested within last 3 months (3 x high; 7 x low) –Wants fast test (2 x high; 0 x low) –Other (5 x high) 17/39 High risk patients with reason for declining test documented

Reasons for declining HIV test (where documented n=47)

Patients subsequently testing HIV Positive

AgeRisk at AV (behaviour) EPTD / HA / reason Visits between last HIV test and AV 1 36Not high      4 prior visits Never tested 2 43High      1 visit Last test Not high      Nil prior visits Last test 2003 (U) 1 visit post AV 4 45High      5 prior visits Never tested 5 24High      2 visits Last test: 2002, 2005 (U) 6 31High      No visits since last test (1 month before) and AV 7 39Not high      2 visits Last test 2002 (U) 1 visit post AV

Time between AV and + test Risk at + testHAEPTD 13 weekHigh  25 weeks POCHigh  310 mnths THTNA*NA 48 mnthsNot Doc*  51 mnthHigh*  68 mnthHigh*  74 mnthHigh 

Should the presence of an STI define a MSM as high risk? 7 non-testers subsequently tested HIV + 4 were defined as high risk according to behaviour 2 were defined as “not high” but did have an STI at that visit or since last test 6/7 (86%) would have been targeted for EPTD

Of the 52 “not high risk” according to behaviour –17 subsequently tested –ve –4 subsequently tested positive –31 had no subsequent test

Defining risk according to behaviour only Of the 34 in whom we have a HIV test result –13 individuals of would have been given EPTD. 3 of these tested +ve (23%), 10 –ve (77%) –21 individuals would not have been targeted for EPTD 4 of these tested +ve (19%), 17 tested –ve (81%)

Defining risk according to behaviour and presence of STI Of the 34 in whom we have a test result –24 would have been given EPTD 6 of these tested +ve (25%), 18 –ve (75%) –10 individuals would not have been targeted for EPTD 1 of these tested +ve (10%), 9 –ve (90%)

HIV positivity rate according to risk definition (%) Behaviour onlyBehaviour and STI EPTD2325 No EPTD1910

Messages Individualised EPTD positively determines future testing. Anyone defined as high risk according to reported sexual behaviour and those with STI at this visit or since last test should be targeted for EPTD.

Implications for Practice Accurate risk assessment and documentation Target EPTD to all high risk individuals –HA involvement ?Offer HA discussion ?Make routine in care pathway Spend time performing individualised PTD think HIV test at EVERY visit Address common barriers to testing

Undiagnosed HIV in MSM “A tale of 3 cities” LondonManchesterBrighton Number HIV+12%9%14% Unaware HIV+44%36%33% Unaware HIV+ and not accessed GUM 70%78%54% HIV-: UAI with unknown status 21%26%24% Dodds et al, STIs 2007 (e-pub;1/5/07) 69% accessed GUM in past 12 months

Proportion of GUM clinic attendees 1 accepting an HIV VCT and proportion leaving the clinic unaware of their infection by world region of birth 1 Previously undiagnosed HIV includes those diagnosed at the clinic attendance and those remaining undiagnosed. Data source: Unlinked Anonymous prevalence monitoring, England, Wales and Northern Ireland Proportion leaving clinic unaware of HIV-infection Proportion accepting VCT Born outside UKUK-bornBorn outside UKUK-born