HIV testing no longer needs special status

Before highly active antiretroviral therapy (HAART) was introduced, the advantages to infected individuals of knowing their HIV status were minimal, and counselling before HIV testing was the recommended practice.^w1 This usually limited testing by relying on people who were obviously at risk presenting themselves for testing. Such groups included injecting drug users and men who have sex with men and their sexual contacts. Targeting of these groups will become an increasingly less useful concept as HIV continues to spread into the population that is conventionally not at risk.

KUTZUTOMO KAWAI/PHOTONICA

HIV can affect anyone

Do we need to reconsider if routine voluntary counselling and testing is appropriate today? Since 1991 heterosexual transmission of HIV has been the most common mode of transmission in the United Kingdom.^w2 Currently, nearly half of those infected heterosexually and a quarter of infected men who have sex with men in the United Kingdom are undiagnosed.^w3 A quarter of newly diagnosed patients in the United Kingdom in 2002 were diagnosed late with serious immunosuppression.^w3 Unless further initiatives are undertaken the epidemic will worsen. Possible initiatives would be to lower thresholds for HIV testing by reducing the emphasis on pre-test counselling.

Reasons for low HIV testing rates and thus low detection rates include concerns about confidentiality, legal and insurance issues, self perceptions of low risk in those who would test positive, denial, dislike of counselling, and wishing to avoid anxiety when waiting for results.^{w4 w5} Fear and denial are the commonest obstacles to HIV testing among those acknowledging that they have been at risk.^w6

Additionally doctors' awareness of the effectiveness of early interventions is low and they may not encourage HIV testing.^{w7 w8} The most common reason, however, is lack of time for pre-test counselling, even in genitourinary medicine clinics.^w9 Average times for counselling are not less than 21 minutes with 18% of people requiring two sessions.^w1

Low detection rates imply longer duration of infections, which imply increased risk of HIV transmission. In an unpublished study, 70 randomly selected, HIV positive patients attending our centres were estimated to have been infected for a mean of 8.5 years. In that study, for only 56% had doctors broached HIV testing, only 6% of patients had ever declined HIV testing, and 46% of those who were HIV positive reported that their explicit consent to testing should not have been needed. Such results need to be replicated, but implications are clear.

Lowering the threshold for HIV testing will lead to early diagnosis and treatment of infected individuals, which may prevent the development of AIDS and the transmission of infection.^w10 w11

What is the role of voluntary counselling and testing? Voluntary counselling and testing has been accepted practice for more than 10 years. Uptake of voluntary counselling and testing, however, has been poor, even in those with high risk sexual activities.^w2 Sizeable proportions of infected people never attend genitourinary medicine clinics for voluntary counselling and testing even if referred. In addition, it seems that pre-test counselling is, on balance, not dramatically effective in reducing high risk sexual activity.^w12

Many HIV infected individuals receive medical attention before they are diagnosed and opportunities for testing may have been discouraged by the “need” to perform or organise voluntary counselling and testing. Such patients would include, for example, those with persisting lymphopenia, neutropenia, or thrombocytopenia. A routine approach to testing would almost certainly increase the number of early HIV diagnoses, which would then allow concentration on subsequent informed counselling and education of patients and their partners and possible reduction in spread of infection.

Highly active antiretroviral therapy has rendered HIV similar to other serious diseases. We believe that HIV testing should be widely accepted, without conventional voluntary counselling and testing, as patients at risk of cancer do not receive voluntary counselling and testing before chest x rays, or patients with chest infections do not routinely receive voluntary counselling and testing before stains for acid fast bacilli on sputum are requested.

The current combination of reluctance of busy doctors to initiate pre-test counselling and denial by patients has resulted in late diagnosis and ongoing spread of infection. We propose that if a patient freely consents to be investigated, a doctor can initiate tests aimed at excluding serious diseases without an in depth discussion of all possible results, provided that the test result, positive or negative, should benefit the patient.

Routine voluntary counselling and testing was appropriate to the 1980s. Times have changed. The benefits of early diagnosis of HIV are multiple. HIV testing should now not be accorded any special status. Doctors should now undertake the test by using the same approach as used in any other test with serious implications.

Kaveh Manavi, specialist registrar in genitourinary medicine
Email: tirbad@yahoo.com

Philip D Welsby, consultant in infectious diseases
Department of Genitourinary Medicine, Royal Infirmary of Edinburgh, Edinburgh, EH4 1EW


studentBMJ 2005;13:133-176 April ISSN 0966-6494

1. Department of Health. Guidelines for pre-test discussion on HIV testing. www.advisorybodies.doh.gov.uk/eaga/pdfs/guidelineshivtestdiscuss.pdf (accessed 19 Nov 2004).
2. Health Protection Agency. HIV and other sexually transmitted infections in the United Kingdom in 2002. Annual report. Part one: HIV infection. London: HPA, 2003.
3. Health Protection Agency. The national CD4 surveillance scheme. 2002 survey results. www.hpa.org.uk/infections/topics_az/hiv_and_sti/hiv/epidemiology/cd4.htm#2001 (accessed 13 Oct 2004).
4. Burns F, Mercer CH, Mercey D, Sadiq ST, Curran B, Kell P. Factors that may increase HIV testing uptake in those who decline to test. Sex Transm Infect 2004;80:249.
5. Spielberg F, Branson BM, Goldbaum GM, Lockhart D, Kurth A, Celum CL, et al. Overcoming barriers to HIV testing: preferences for new strategies among clients of a needle exchange, a sexually transmitted disease clinic, and sex venues for men who have sex with men. J Acquir Immune Defic Syndr 2003;32:318-27.
6. Seigel K, Raveis VH, Gorey E. Barriers and pathways to testing among HIV infected women. AIDS Educ Prev 1998;10:114-27.
7. Kellock DJ, Rogstad KE. Attitudes to HIV testing in general practice. Int J STD AIDS 1998;9:263-7.
8. Burns F, Mercer CH, Mercey D, Sadiq ST. Barriers to HIV testing: a survey of GUM clinic attendees. Sex Transm Infect 2004;80:247.
9. British Co-operative Clinical Group. Screening for HIV infection in genito-urinary medicine clinics: a lost opportunity? Sex Transm Infect 2000;76:307-10.
10. Palella FJ Jr, Deloria-Knoll M, Chmiel JS, Moorman AC, Wood KC, Greenberg AE, et al. Survival benefits of initiating antiretroviral therapy for HIV infected persons in different CD4 cell strata. Ann Intern Med 2003;138:620-6.
11. Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li C, Wabwire-Mangen F, et al. Viral load and heterosexual transmission of human immuno-deficiency virus type-1. Rakai Project Study Group. N Engl J Med 2000;342:921-9.
12. The EXPLORE Study Team. Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomised controlled study. Lancet 2004;364:41-50.

       

           

	Responses published this month

Articles	Responses
EDITORIALS HIV testing no longer needs special status       Kaveh Manavi, Philip D Welsby (April 2005)	Layla McCay (April 03, 2005) Read this response

	EDITORIALS HIV testing no longer needs special status       Kaveh Manavi, Philip D Welsby (April 2005)
	Layla McCay (April 03, 2005)       PRHO, Victoria Infirmary, Glasgow laylamccay@hotmail.com
	Pre-test HIV counselling occurs to ensure every patient is able to provide informed consent for the test being undertaken. But why does HIV testing specifically require informed consent at all? Ideally, informed consent should be obtained for all medical investigations and interventions. In practice, blood testing for other life-altering diseases (such as tumour markers for various cancers) is routinely undertaken with little discussion with the patient of the test's implications, much less an indepth counselling session about the patient's risks, the meaning of a positive/negative result, how they would cope and what would happen if a positive result should be found, all essential components of HIV pre-test counselling. The practice of counselling for HIV testing confers a stigma upon the disease which is detrimental to those affected by it. This stigma must dissuade many an at-risk patient from having a simple yet important test that could significantly prolong their life. It is the doctor's duty to investigate a patient's presenting symptoms. If an HIV test is a rational and important investigation as part of that patient's diagnostic pathway, I believe that test should be undertaken, just as one would request a chest x-ray for suspected lung cancer, or a CEA blood test for suspected colon cancer. And discussion about the implications of any of these tests should be equally thorough.