I How To TEST FOR HIV IN PRIMARY CARE

How To
TEST FOR HIV IN PRIMARY CARE
Key points
UK guidelines recommend
testing all adults registering in
general practice where HIV
prevalence is >2 in 1,000
G Any
doctor, nurse, midwife or
trained healthcare worker can
obtain consent for and conduct
an HIV test
G
Practices must establish clear
care pathways for early referral
of patients with positive tests to
the local specialist HIV team
G
Normalising HIV testing should
reduce undiagnosed infection
and ensure appropriate
treatment and care to people
living with HIV
HIV testing first became available in 1985, and for many
years had ‘exceptional’ status, with extensive pre-test
counselling. Practice has changed since the availability
of highly active antiretroviral treatment (HAART), which
almost overnight transformed the prognosis of HIV to
that of a chronic illness with a good life expectancy.
Lengthy pre-test counselling is no longer
recommended or required, and the main purpose of the
consultation is to obtain consent to the test. But,
according to the Health Protection Agency, 22,000 of
the 83,000 people living with HIV do not know that
they are infected. And almost a third of new patients
are identified after a diagnosis of acquired immune
deficiency syndrome (AIDS) or a CD4 <200, well after
they should have started treatment.
WHOM TO TEST
Late diagnosis significantly disadvantages patients. A
national audit found that a quarter of deaths in HIVpositive adults in 2006 were directly attributable to
diagnosis of HIV too late for effective treatment.
Conversely, early diagnosis reduces the risk of onward
transmission. Active treatment reduces infectiousness,
and enables people to behave in a less risky manner.
Many patients who are diagnosed late have been in
recent contact with healthcare services. In 2007 the
Chief Medical Officer for England wrote to all doctors,
highlighting missed opportunities to establish earlier
diagnosis and encourage wider HIV testing. This was
followed in 2008 by new UK guidance recommending
that HIV testing should be ‘normalised’ in all healthcare
settings in the UK.
AJ Photo/Hop American/Science Photo Library
Dr Eric Monteiro
Clinical Director, Department of
Genitourinary Medicine, Centre for
Sexual Health, Leeds Teaching
Hospitals NHS Trust
G
I
f current pilot schemes are successful,
routine testing for human
immunodeficiency virus (HIV) is likely
to be extended to general practice
surgeries across the country. The authors
discuss the rationale for this plan, and
advise on the practicalities of testing in
primary care.
CO
PY
RI
RE GH
PR T
O SH
DU ER
CT BO
IO RN
N E
PR G
O IBB
HI S
BI LI
TE M
D IT
ED
Dr Nicola Armstrong
Locum Consultant Genitourinary
Medicine, Trinity Centre for Infectious
Diseases and Sexual Health, Bradford
Teaching Hospitals Foundation Trust
The UK guidelines suggest that an HIV test should be
considered in all men and women registering in general
practice and all general medical admissions in areas where
diagnosed HIV prevalence exceeds 2 in 1,000 among people
aged 15-59 years. Removing barriers to and widening HIV
testing will undoubtedly present some challenges to non-HIV
specialists, including GPs and practice nurses. Reluctance to
raise the issue of testing, along with a perceived lack of
confidence and training to ‘pre-test counsel’ patients and
deliver positive results, are among these challenges.
early HIV infection
cThe opportunity to diagnose
should not be missedd
21
How To
Table 2: Clinical conditions associated with HIV infection
Possible condition
Symptoms
Lungs
Pneumocystis
pneumonia (PCP)
Life-threatening condition with insidious onset.
Persistent dry cough for a few weeks; increasing
shortness of breath/reduced exercise tolerance;
difficulty taking full breath; fever
Tuberculosis
Cough, fever, sweats, shortness of breath, weight loss,
haemoptysis; enlarged lymph nodes
Brain and
nervous
system
Cryptococcal meningitis (may
present with headaches alone),
cerebral toxoplasmosis, primary
cerebral lymphoma, progressive
multifocal leucoencephalopathy
Headache, neck stiffness, photophobia; focal
neurological signs suggesting intracranial spaceoccupying lesion; peripheral neuropathy, especially
sensory change or loss; confusion, memory loss,
disinhibition; fits
Eyes
Cytomegalovirus (CMV)
infection of the retina
‘Floaters’; reduced vision; scotomas
Causes blindness if not treated early
Skin
Kaposi’s sarcoma
Dark purple or brown intradermal lumps
Fungal, eg tinea cruris, tinea pedis
Viral, eg shingles, molluscum
contagiosum, warts, herpes simplex
Bacterial, eg impetigo, folliculitis
Others, eg seborrhoeic dermatitis,
psoriasis
Severe, recurrent or difficult-to-treat symptoms
Oral candidiasis
Thick white plaques on the buccal mucosa;
can be scraped off
Oral hairy leukoplakia
Whitish corrugations, typically on the side of
the tongue; cannot be scraped off
Kaposi’s sarcoma
Purple tumour, characteristically on the palate
CO
PY
RI
RE GH
PR T
O SH
DU ER
CT BO
IO RN
N E
PR G
O IBB
HI S
BI LI
TE M
D IT
ED
Routine universal (‘opt-out’) HIV testing has,
however, been widely and successfully adopted in
settings such as sexual health clinics and antenatal
services. The two recently announced pilots of HIV
testing in general practice, together with projects in
hospital and the community, are designed to
evaluate the acceptability and effectiveness of this
strategy throughout the NHS.
The guidelines also extend recommendations for
universal testing to termination of pregnancy
services, drug dependency programmes and
services for those diagnosed with tuberculosis,
hepatitis B, hepatitis C and lymphoma. HIV testing
should also be routinely offered and recommended
to patients shown in Table 1, all of whom may
present in primary care.
Affecting
Table 1: People to be routinely
offered and recommended HIV
testing
G All
patients diagnosed with a sexually
transmitted infection
G All
Mouth
sexual partners of men and women known
to be HIV-positive
G All
men who have disclosed sexual contact
with other men
G All
female sexual contacts of men who have
sex with men
G All
patients reporting a history of injecting drug
use
G All
men and women known to be from a
country of high HIV prevalence (>1%)*
G All
men and women who report sexual contact
abroad or in the UK with individuals from
countries of high HIV prevalence.*
* For an up-to-date list of these countries, see
http://www.unaids.org/en/KnowledgeCentre/
HIVData/Epidemiology/latestEpiData.asp
Gingivitis, dental abscesses
Upper and
lower GI
Oesophageal candidiasis
Dysphagia suggestive of oesophageal problem;
likely to have recurrent oral thrush
Diarrhoea
Persistent mild or severe acute symptoms
Genital herpes, warts, candida
May be more severe
Any STI
Consider possible HIV
Blood
Changes on full blood counts
(subtle or severe)
Unexplained neutropenia, anaemia, thrombocytopenia
Tumours
Lymphoma
Lymphadenopathy, fevers, sweats, abdominal masses
Cervical cancer
Vaginal bleeding or discharge; cytological abnormalities
Genitals
Based on: Medical Foundation for AIDS and Sexual Health. HIV testing in primary care
Testing should, of course, be offered when HIV,
including primary HIV infection, enters the
differential diagnosis (Table 2). It is especially
important to consider the possibility of
immunosuppression if the patient has had any of
these conditions or in those with unusual
presentations or undiagnosed illness.
Features of primary HIV infection or
‘seroconversion’ illness typically occur at around two
22
Urgent/life-threatening condition
to four weeks following infection. An individual
may present with symptoms suggestive of
glandular fever, including lymphadenopathy,
pharyngitis, myalgia, rash, fever and headache. A
blotchy rash on the trunk and orogenital or
perianal ulceration may also be present, and are
more specific to primary HIV infection.
Symptoms of primary HIV infection may be nonspecific and be attributed to other common viral
illnesses, but the opportunity to diagnose early HIV
infection should not be missed. A negative result in
a patient at risk of infection should be repeated
after a week and consideration should be given to
onward referral to specialist HIV services.
How To
Table 3: Advantages and
disadvantages of HIV testing
Advantages:
G Appropriate
perceived at risk of HIV but who
refuse testing may benefit from
referral to specialist services
where the reasons for not
testing can be further explored.
THE ‘WINDOW PERIOD’
Blood samples are currently the
most reliable specimen and are
recommended for primary care.
Recommended first-line assays
test for both HIV antibody and
p24 antigen (it may be advisable to check which
assay your screening laboratory uses). These
fourth-generation assays may reduce the ‘window
period’ between infection and a positive test to
around one month.
A repeat test three months after potential
exposure is, however, still recommended in order to
exclude any possibility of infection. Rapid tests using
capillary blood and saliva, and giving results within
15 minutes, are used in specialist settings, and in
the future may replace venous blood samples.
CO
PY
RI
RE GH
PR T
O SH
DU ER
CT BO
IO RN
N E
PR G
O IBB
HI S
BI LI
TE M
D IT
ED
HIV testing is voluntary and requires informed
consent. Any doctor, nurse, midwife or trained
healthcare worker can obtain consent for and
conduct an HIV test. Written consent is unnecessary,
but the offer of a test should be documented in the
patient’s notes, as should any reasons for refusal of
a test. The discussion should also cover the benefits
of testing. There should also be clear arrangements
about how the result will be given.
Common concerns expressed by patients
about HIV testing are around confidentiality,
insurance and the other issues listed in Table 3.
Patients having an HIV test may be particularly
concerned about confidentiality. Recent General
Medical Council (GMC) guidance on disclosing
information about serious communicable diseases
states that you should make sure that information
you hold or control about a patient’s infection
status is at all times effectively protected against
improper disclosure.
HIV can affect an individual’s ability to get life
insurance, mortgages and other financial products,
but this is also the case with other chronic illnesses.
The Association of British Insurers’ code of practice
also states that questions about past HIV testing or
a negative result should not be asked. Individuals
should only be asked if they have ever tested
positive or are awaiting the result of an HIV test.
medical care
G
Interventions to prevent mother-to-child
transmission
G
Prevention of onward transmission
G
Enables decisions about the future
POST-TEST DISCUSSION
Negative result
In the event of a negative HIV result, it is good
practice to discuss safer sex issues and offer further
screening for sexually transmitted infections (STIs) if
not already performed. The need for a repeat test
should also be discussed with the patient if she is
still within the window period.
Positive result
Giving an HIV-positive result is the same as
breaking bad news in any other clinical situation.
The result should be given in a confidential
environment by the requesting clinician or team
rather than a third party. Important points to discuss
NIBSC/Science Photo Library
PRE-TEST DISCUSSION
Table 4: Issues to discuss when
the HIV test is positive
G
Confidentiality
G The
G
need for a confirmatory test
Coping in the short term
G Any
immediate medical problems
G Arrangements
to be seen by the HIV specialist
team
G
Reassurance that effective treatment is
available and most people living with HIV
remain well
G
Care about disclosure of HIV status to others
at this consultation are shown in Table 4. Clear care
pathways for early referral to the local HIV specialist
team should be in place.
CONCLUSIONS
Early HIV testing saves lives. By normalising the
testing process and clarifying misconceptions, the
aim is to encourage clinicians to consider HIV
testing in all settings, including primary care. The
ultimate result should be to reduce undiagnosed
infection and enable people living with HIV to
receive appropriate treatment and care.
Disadvantages:
G
Psychological difficulties
G
Possible impact on relationships
G
Possible restrictions, eg on travel
G
Possible insurance implications
Some patients require more in-depth, pre-test
discussion and support before proceeding with an
HIV test. These may include young people, and
people with mental health problems or in whom
English is not the first language. Individuals
G HIV
in primary care: an essential guide for GPs, practice nurses and other members of the primary
healthcare team: www.medfash.org.uk
G Professional
information and UK National Guidelines for HIV Testing 2008 from the British HIV
Association: www.bhiva.org/files/file1031097.pdf
G Health
G Patient
Protection Agency. HIV in the United Kingdom: 2009 report. www.hpa.org.uk
information from the Terrence Higgins Trust: www.tht.org.uk
G General
Medical Council. Confidentiality: disclosing information about serious communicable diseases:
www.gmc-uk.org
23