Testing in non-sexual health settings

Since 2008, although testing in non-traditional settings has not become standard healthcare practice, there have been numerous pilot studies of testing in primary care, out-patient, acute and inpatient hospital settings in the UK. The Department of Health has adopted a policy whereby local health trusts can apply to conduct their own pilot-testing studies based on models pioneered in locations like Brighton and London.

By 2010, expanding HIV testing was an issue that interested so many researchers and healthcare workers that no less than a quarter of all presentations at that spring’s BHIVA/BASHH Conference concerned HIV testing.

The studies documented slow progress towards the routine use of HIV testing in non-traditional clinical settings; various prejudices, assumptions and practical obstacles had to be overcome, but there were also signs of healthcare staff embracing the acceptability of routine HIV testing.

Nonetheless, the surveys found that only a minority of patients with indicator conditions for HIV testing in hospital and primary care settings were receiving tests.

When patients were offered tests, acceptance rates were high, indicating that lack of HIV testing is more to do with clinician than patient education. Although in many settings the number of HIV diagnoses was no higher than the national average, in certain others – such as of hospital inpatients – it was over 20 times higher.

Studies of a large number of testing programmes were reviewed on aidsmap. Just as one example, in 2008, one large survey looked at all HIV tests performed by the laboratory at Guy’s and St Thomas’s Hospital in London, which covers the highest HIV-prevalence area in the UK.¹ The lab performed 41,095 tests for 36,392 people of whom 363 were HIV-positive. 18,872 tests came from STI clinic patients (1% positive) and 6197 from antenatal clinics (0.5% positive). Of the rest:

• 5746 came from GPs; the HIV-positive rate in these tests was actually higher than in STI patients (1.12%). Forty-three per cent of patients had indicator diseases, indicating that local GPs are becoming more aware of conditions suggesting an HIV test.
• 5303 came from hospital out-patients of whom 26 (0.5%) were HIV positive. Seventeen were new diagnoses of whom seven had attended Guy’s and St Thomas’s in the last year with indicator diseases without being tested. The average CD4 count in these seven patients was 190 cells/mm³. Some departments where patients typically present with high rates of indicator disease ordered very few tests, for instance gastroenterology (83 tests).
• 1225 came from hospital inpatients of whom 34 were HIV positive (2.77%). Of these patients, 62% had an AIDS-defining condition and the average CD4 count at testing was 62 cells/mm³. These patients spent an average 34 days in hospital with one patient admitted for nearly a year. The average cost of each case was £36,625.

Presenter Julie Fox commented that the majority of HIV-positive patients identified would have been missed by targeting high-risk groups. HIV testing needed to be broadened to all acute settings and be truly ‘opt-out’. HIV-testing rates have been made an incentivised performance indictor for the NHS in London, which should ensure more tests, but situations like the inpatients who had remained untested until admitted very ill were being logged as serious clinical incidents with a view to making non-testing an issue of clinical governance.