HIV: Stop, think, test
By Sheonaidh Johnston, Policy Officer, NAT
Do you know the symptoms of HIV? How often do you offer a HIV test, to whom? These are the questions healthcare workers are being told to consider as emerging research shows the extent to which undiagnosed early HIV infection is fuelling the spread of HIV in the UK.
There are now over 80,000 people living
with HIV in the UK. Thanks to improved treatment many are living well, but
there are still significant challenges to overcome and today in the UK people
still become seriously ill or die as a result of HIV related illnesses. A third
of people with HIV remain undiagnosed and unaware of their status. In addition
a third of people diagnosed with HIV are diagnosed late, after the point at which
they should have started treatment. In a 2006 BHIVA national audit of deaths
amongst HIV-positive people, 35 per cent of all HIV-related deaths were a
result of the people being diagnosed too late to be effectively treated.
As well as the risk to the individual caused by late diagnosis, there is also evidence that undiagnosed HIV is fuelling the spread of HIV in the UK. Between 30-50 per cent of all new infections are thought to be caused by those who are themselves undiagnosed and recently infected. In the early stages of infection there is much more HIV in the body, making it easier for the virus to be passed on. By simply increasing early diagnosis we have the potential to make huge strides in preventing new infections and also improving health outcomes of those with HIV.
One of the most worrying aspects of late diagnosis of HIV is the number of people who have been presented with HIV-related symptoms on previous occasions but have not been offered a HIV test. Between 70-90 per cent of people will experience ‘sero-conversion’ symptoms soon after infection (in the period called primary infection) caused by the rapid replication of virus in the body. Symptoms of primary HIV infection are most frequently sore throat, fever and rash occurring at the same time, usually within two to six weeks of infection. Whilst taken separately these are common complaints, together this triad of symptoms, particularly when coupled with recent risky behaviour, should suggest possible HIV and require a HIV test.
Unfortunately, these symptoms are often ignored by the individual and if they do present for care they are easily missed or attributed to other causes, such as glandular fever, by the treating healthcare worker. A review of cases in Brighton demonstrated that symptoms were misdiagnosed in 15 of 20 GP presentations and in three cases out of seven in A&E. Often people will be told to come back in a few weeks if the symptoms persist, giving time for the amount of HIV in the body to drop (as the immune system responds) and the symptoms to pass. Individuals may then show no signs of HIV for many years and therefore not present again until they are very sick.
Early diagnosis is also hampered by misconceptions over the ‘three month window period’ for antibodies to emerge. Testing technology has improved significantly in recent years and the 4th generation assay test can detect antigens in the majority of cases from about 12 days after infection. Even with an antibody only test, 90 per cent of individuals have detectable antibodies within four weeks. This means most people can be diagnosed well before the ‘three month’ window period and should be offered a test.
Clearly there is an urgent need to improve HIV diagnosis. That is why the British HIV Association, British Association of Sexual Health and HIV and British Infection Society (BHIVA, BASHH and BIS) have launched new guidelines on testing for HIV in September 2008. The guidelines aim to improve diagnoses of HIV by focusing on offering universal testing in specific services and introducing routine testing in high prevalence areas.
These guidelines have enormous implications for healthcare workers across the NHS. One of the most significant changes is the introduction of routine testing in high prevalence areas. The guidelines recommend offering a HIV test to all men and women when they register with a new GP, and to all general medical admissions, in areas where diagnosed prevalence HIV is more than two in 1000 population. Figures produced by the Health Protection Agency (HPA) and available at www.hpa.org.uk will tell you the prevalence rate in your PCT.
The guidelines also recommend the introduction of universal testing in a range of settings, irrespective of local HIV prevalence. Universal testing in antenatal services has been a huge success with the estimated proportion of infected women diagnosed before delivery increasing from around 70 per cent in 2000 to about 95 per cent in 2005. The new guidelines are extending universal testing from antenatal and GUM into termination of pregnancy services, drug dependency programmes, and healthcare services for TB, hepatitis B, hepatitis C and lymphoma. These are all areas where there is evidence of higher than average HIV prevalence and where routine testing could help improve diagnoses.
These changes will require many more doctors, nurses, midwifes and other healthcare workers to offer and conduct tests in routine situations. For some this may be daunting. But by offering testing more routinely it may help remove the stigma that can surround taking a HIV test. The experience of antenatal screening highlights how providing HIV testing part of a range of routine tests offered during pregnancy increases acceptability. If we can do the same in many more settings there is real opportunity to reduce the number of people who remain undiagnosed.
The challenge for us all is to improve training for clinicians, nurses, GPs and other healthcare workers so that they recognise risks and symptoms relating to primary HIV infection and feel comfortable offering HIV tests. This will allow for tests to be offered as soon as individuals present with primary infection symptoms, helping to reduce the burden of undiagnosed HIV and the transmission of new infections. You can help meet this challenge. Take this information away with you and put it into practice. Read the testing guidelines and make sure you’re following them. When you see the triad of primary infection symptoms, think HIV and offer a test.
To
read NAT’s report on Primary HIV Infection go to: www.nat.org.uk
The
new HIV testing guidelines are available from: www.bhiva.org.uk
Guidance
for non-specialists on HIV diagnosis in primary and secondary care is available
from: www.medfash.org.uk