New NICE guidance supports HPA advice and BHIVA/BASHH/BIS guidelines on expanding HIV testing

The National Institute for Health and Clinical Excellence (NICE) has published guidance for increasing the uptake of HIV testing among men who have sex with men (MSM) and black African communities [1,2]. The guidance, which takes further the recommendations made by the British HIV association (BHIVA), the British Association for Sexual Health and HIV (BASHH) and the British Infection Society (BIS) in 2008 [3], advocates the development of  local strategies for testing in the two higher-risk groups, and emphasises the importance of providing culturally aware, confidential testing services, developed in collaboration with the relevant community and provided by well trained staff. 

Key conclusions of the NICE guidance are that in areas where more than two per 1000 of the local population aged 15 to 59 years are known to be living with diagnosed HIV infection, then:

a) primary care and general medical admissions professionals should consider offering and recommending an HIV test when registering and admitting new patients,

b) all health practitioners should offer and recommend an HIV test to anyone who has a blood test (regardless of the reason),

c) secondary and emergency care providers should offer and recommend HIV testing to all men admitted to hospital who have previously tested negative for HIV or have never been tested.

Eight pilot projects in London, Brighton, Leicester and Sheffield have shown expanded HIV testing in hospital, primary care and community settings to be acceptable and feasible [4], and have provided valuable information on how different models of testing can be implemented in each setting.

The pilot projects have shown that, when appropriate training has been carried out, an HIV test can be offered by a range of staff, including doctors, nurses and healthcare assistants.   Offer and recommendation of an HIV test with routine bloods collected at the time of admission to hospital offers a real opportunity for expanding testing with minimal changes to existing clinical pathways. The pilots have also illustrated the importance of documented pathways for referral and increased communication between HIV specialist services and primary care, hospital and community testing initiatives to minimise loss to follow-up of newly diagnosed patients.

The emphasis of current HPA advice on expanded HIV testing [4,5,6] is that in high prevalence areas an HIV test should be routinely offered and recommended to all general medical admissions to hospital and to new registrants in primary care.  The cost implications of testing in primary care may be greater should point of care tests be relied upon. These expanded HIV testing policies should be prioritised for implementation as soon as possible.

The expansion of large scale routine HIV testing into settings outside of sexual health, antenatal clinics and pregnancy termination services, and blood donors, has the potential to decrease the proportion of HIV positive individuals who are diagnosed late.  Patients diagnosed earlier in the course of their infection will have greatly improved outcomes if they are referred into appropriate care [7] and there are additional public health benefits of earlier diagnosis from reducing the onward transmission of infection [8].

References

1. National Institute for Health and Clinical Excellence, 2011.   Increasing the uptake of HIV testing among black Africans in England. NICE public health guidance 33. www.nice.org.uk/guidance/PH33
2. National Institute for Health and Clinical Excellence, 2011.   Increasing the uptake of HIV testing among men who have sex with men. NICE public health guidance 34. www.nice.org.uk/guidance/PH34
3. BHIVA, BASHH, BIS, 2008.  UK National Guidelines for HIV Testing 2008. http://www.bhiva.org/HIVTesting2008.aspx [Accessed 01/03/2011]
4. Health Protection Agency, 2010.  Time to test for HIV: Expanded healthcare and community HIV testing in England. http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1287145269283 [Accessed 01/03/2011]
5. Health Protection Agency, 2010.  HIV in the United Kingdom: 2010 report.  http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1287145264558 [Accessed 01/03/2011]
6. HPA, 2011.   Written Evidence Submitted to the House of Lords Select Committee on HIV and AIDS. 
7. Chadborn TR, Delpech VC, Sabin CA, Sinka K, Evans BG.   The late diagnosis and consequent short-term mortality of HIV-infected heterosexuals (England and Wales, 2000-2004).  AIDS  2006; 20(18):2371-9.
8. Marks G, Crepaz N, Janssen RS, 2006.  Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA.  AIDS 2006; 20(10):1447-50.

This report will be published in Health Protection Report Vol 5  No 12: 25 March 2011

Last reviewed: 23 March 2011