Expanded HIV testing

Most sexual health commissioners for areas in England with a high HIV prevalence have introduced some form of expanded HIV testing, but only a small minority is fully following national guidance. The figures come from an audit of the 40 primary care trusts with an HIV prevalence above 2 per 1000.

Although national HIV testing guidelines recommend the routine testing of all patients newly registering with a GP, this has been commissioned by less than one third (31%). Similarly, the recommendation for routine screening of new medical admissions to hospital has been implemented by one in seven (14%). A larger number had commissioned some expanded testing in these settings, but it was not universal.

Half the commissioners (51%) had followed the guidelines to fund outreach community testing, often carried out by the voluntary sector in settings such as saunas, health centres and churches.

Only 11% of primary care trusts had expanded testing in all three settings – general practice, hospital and community outreach. Commissioners cited a lack of resources and the re-organisation of the NHS as barriers to introducing expanded testing.

The findings suggest that – apart from in GUM and antenatal clinics – HIV testing remains largely opportunistic or targeted. A significant reduction in the late diagnosis of HIV is unlikely to occur unless British HIV Assocation (BHIVA) and National Institute for Health and Care Excellence (NICE) guidelines are more closely followed.

Pre-test counselling

A large American study has shown that offering risk-reduction counselling to people taking an HIV test had no impact on sexual behaviour or sexually transmitted infections (STIs). The research lends support to recommendations in current testing guidelines that only a brief discussion is provided before HIV testing.

However, the counselling intervention was not intended to be a discussion of the pros and cons of testing, leading to the individual giving informed consent – it was focused on developing a plan to reduce sexual risk taking.

The randomised control trial, conducted in sexual health clinics, compared the outcomes of providing rapid, point-of-care HIV testing with either risk-reduction counselling, or with information alone.

Six months later, there were no differences in the rates of STIs, condom use or partner numbers between the two groups.

However, counselling was much more expensive to provide. The authors recommend that resources be focused on increasing the number of people who test, so that universal testing can be achieved, rather than delivering risk-reduction counselling.

Sexually transmitted infections

Although the number of diagnoses of sexually transmitted infections in the UK is very high in comparison with many other countries, it is possible that this is partly because other countries have inadequate sexual health services.

This is the implication of the latest data to be released by the European Men who have sex with men Internet Survey (EMIS), which in 2010 combined the UK’s Gay Men’s Sex Survey with parallel surveys in 25 European languages.

Across Europe, just under a third of respondents had been screened for sexually transmitted infections (STIs) in the past year. Men who had been screened were then asked, in non-medical language, what the screening consisted of.

Their responses showed that whereas blood tests (for HIV, syphilis and viral hepatitis) were common across Europe, far fewer men gave a urine sample, had a rectal swab or were physically examined. This is likely to leave infections such as chlamydia, gonorrhoea and warts profoundly under-diagnosed.

Whereas men living in London, Manchester and Birmingham commonly reported a full range of diagnostic procedures, these were reported by very few men living in several other European cities including Berlin, Brussels, Cologne, Barcelona, Zurich, Madrid and Paris. This suggests that comparisons of STI rates between European countries need to be treated with caution.

A second study this month has shown that gay men who do not have anal sex are still at high risk of syphilis and gonorrhoea.

Hepatitis C reinfection

A study from England, Germany and Austria has reported high rates of hepatitis C reinfection in gay men who have been co-infected with HIV and hepatitis C.

There is an epidemic of sexually transmitted hepatitis C among gay men living with HIV. Risk factors for transmission include ulcerative sexually transmitted infections, unprotected anal sex, use of sex toys, fisting and drug use. Hepatitis C is a serious liver infection but successful treatment provides a cure; spontaneous clearance is also a possibility. Diagnosis within six months of infection (during the acute stage) substantially increases the probability that treatment can clear hepatitis C. The British HIV Association recommends testing for hepatitis C after high-risk exposure but doesn’t make a recommendation on regular testing.

The study included data on 646 HIV-positive men who were diagnosed with hepatitis C during acute infection (the first months of infection). Most were successfully treated, while 12% spontaneously cleared the virus.

However, 113 men (18%) subsequently acquired hepatitis C again, an average of three years later. Almost all were men who have sex with men, two-thirds were taking HIV treatment and their average age was 38.

Moreover, 19 men were reinfected a third time, and three individuals a fourth time.

The results highlight the need for the development of effective health promotion for men with hepatitis C and HIV co-infection, in order to reduce the risk of reinfection.

NAM has published four leaflets about hepatitis C for people living with HIV, including 'How hepatitis C is passed on during sex', which provides clear information on sexual transmission for gay men. Find out more about these leaflets at: www.aidsmap.com/hep-c-basics

Case study: faith work

Faith and religion are key to the lives and identities of many black Africans living in England (in the 2011 census, 70% are Christian and 21% are Muslim). A number of organisations, including HIV Prevention England partners, are working with faith communities on HIV prevention and support for people living with HIV.

Working in Corby, Sunrise Family Support has already established relationships with three churches and hopes to work with more – significant numbers of African people attend seven churches in the town. Making contact with church leaders is not always easy; a gradual approach may be needed to build trust. Discussion of HIV tends to focus on compassion and care for people who have HIV, rather than condoms and sexuality. “I am a Christian and I know the kind of things we don’t want to talk about,” says Enady Muza of Sunrise.

The group has been invited to speak to Sunday congregations, emphasising that HIV is “out there”. In the case of a local Pentecostal church, the first approach was centred on introducing the group and appealing for volunteers. Subsequently, one of the church leaders invited them to attend a meeting for mothers and daughters, where Sunrise members spoke about how older women can help girls to take care of their health and to be empowered in relationships with boyfriends. The importance of knowing your HIV status was discussed and while participants were initially reluctant to take up the group’s offer of rapid HIV testing, that changed when the pastor’s wife stepped forward and was the first person to test. In the end, 35 people were tested.

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