The BHIVA guidelines, 2008

In 2008, new HIV-testing guidelines for the United Kingdom were published.¹ Although they fell short of US-style universal opt-out testing, they recommend opt-out HIV testing at GP practices and in hospitals where local prevalence of undiagnosed HIV infection is greater than 1 in 1000, as well as providing a list of indicator diseases where HIV testing should be offered alongside any other tests.

The guidelines urge healthcare workers of all specialities to consider HIV testing in a wide range of situations and settings. It is part of a package of recommendations to reduce the number of late and undiagnosed HIV infections in the UK. The guidelines were produced by the British Association for Sexual Health and HIV (BASHH), the British HIV Association (BHIVA) and the British Infection Society (BIS).

In addition to all men and women attending sexual health clinics and all women attending antenatal services, the guidelines now recommend that opt-out HIV testing should also be performed in the following settings:

• All women attending services for termination of pregnancy.
• All men and women registering with drug-dependency programmes reporting a history of injecting drug use.
• All individuals known to be from a high-prevalence country.
• All men who have disclosed sexual contact with other men.
• All men and women who report sexual contact with individuals from areas of high HIV prevalence, abroad or in the UK.
• All men and women registering in primary care where undiagnosed HIV prevalence estimates in the local population exceed 1 in 1000.
• All general medical admissions from a population where the local undiagnosed HIV prevalence exceeds 1 in 1000.
• All men and women diagnosed with tuberculosis, hepatitis B, hepatitis C and lymphoma.
• Any other patients presenting for health care where HIV enters the differential diagnosis, including primary HIV infection (see list of indicator conditions below).

In local areas where there is already a recognised high prevalence of diagnosed HIV infection, it is assumed that there will also be a high prevalence of undiagnosed infection. In these cases, it is recommended that HIV tests should be offered to all people aged 15 to 59 who register at primary care services or who are admitted to hospital as inpatients.

This is the case for 25 of the 31 Primary Care Trust areas in London, as well as areas such as Brighton & Hove, Manchester, Blackpool, Salford, Bournemouth and Eastbourne that have historically had high HIV prevalence. However, there are other areas which have experienced more recent increases in HIV prevalence, including Luton, Watford, Harlow, Southend-on-Sea, Reading, Slough and Crawley.

In total, 20% of the English population live in areas where universal opt-out testing is now recommended. However, given the novelty of this policy, the guidelines urge that the introduction of universal testing is thoroughly evaluated for acceptability and feasibility.

The guidelines also include a list of indicator conditions, similar to those proposed by the European AIDS Clinical Society in October 2007.² As well as all AIDS-defining illnesses, other illnesses and conditions associated with HIV are listed. These include:

• peripheral neuropathy
• dementia
• recurrent herpes zoster (shingles)
• chronic diarrhoea of unknown cause
• weight loss of unknown cause
• anal cancer or pre-cancer
• lung cancer
• testicular cancer
• head and neck cancer
• glandular fever-like syndrome (primary HIV infection)
• any sexually transmitted infection.

The guidelines say that “it should be within the competence of any doctor, midwife, nurse or trained heath care worker – to obtain consent for an HIV test.”

They also recommend that all men who have sex with men, and injecting drug users should have annual HIV tests, but these should be more frequent than once a year “if clinical symptoms are suggestive of seroconversion”.

The 2008 guidelines note in their introduction that they are “intended to facilitate an increase in HIV testing in all health-care settings as recommended by the UK Chief Medical Officers and Chief Nursing Officers in order to reduce the proportion of individuals with undiagnosed HIV infection with the aim of benefiting both individual and public health.”

Their aim is to “encourage ‘normalisation’ of HIV testing” by doing away with lengthy pre-test counselling. “The discussion only needs to cover the benefits of testing to the individual; discussion of window period and whether repeat testing is needed; and details of how the result will be given,” state the guidelines. “Written consent should be discouraged,” they add, “as this exceptionalises the test and discourages health care providers from offering it.”

However, the guidelines note, “for this change in approach to be beneficial and ethically acceptable, it is imperative that following a positive HIV diagnosis, a newly diagnosed individual is immediately linked into appropriate HIV treatment and care,” within 48 hours of receiving the result at the very latest.