HIV testing and diagnosis are crucial in the response to the HIV epidemic, both globally and in the UK. In 2013, UNAIDS launched the 90:90:90 ambition, advocating that the epidemic can be reduced if 90% of people living with HIV know their status, 90% of those diagnosed receive treatment and 90% of those treated are virally suppressed. The UK exceeds the targets for access to treatment and viral suppression but is not yet achieving the target for diagnosis. The most recent national data estimates 13% of people living with HIV in the UK are unaware of their HIV status.
Timely diagnosis is also an ongoing challenge. In 2015, 39% of people who were newly diagnosed HIV positive in the UK were diagnosed late, increasing short- and long-term morbidity and mortality. Prompt HIV diagnosis also affords opportunities to reduce transmission of HIV to other people. Recognising primary HIV infection (PHI; recent HIV infection/seroconversion illness) is especially important due to high viraemia and, hence, risk of transmission. Assays used should be appropriate to capture all stages of HIV infection.
UK data from a wide range of clinical and community-based interventions have demonstrated that HIV testing is acceptable to patients, deliverable, cost-effective and saves lives. However, missed opportunities for early diagnosis of HIV in primary and secondary care continue to be well documented. Effective HIV testing strategies should be tailored to local populations and maximise the opportunity for testing in both non-clinical and clinical settings. Community testing initiatives have been found to be particularly effective among gay and bisexual men, and black African men and women. Sustainability of initiatives, such as opt-out testing, in wider medical settings will require local and or national policy (e.g. CQUINs, to incentivise all relevant stakeholders to embed HIV testing into their clinical pathways).
Self-sampling and self-testing have emerged as acceptable and convenient methods for accessing an HIV test. There is an increasing number of providers of such testing kits, which requires tight regulation. Users should be reminded to check the test kit has met the appropriate regulatory requirements, has a CE mark and is clearly intended for selfsampling and self-testing.
There are significant personal and social consequences of an HIV-positive diagnosis that should be recognised in any setting where HIV testing is being carried out. Arrangements should be in place for confirmatory testing and linkage to specialist HIV care services for clinical, laboratory and psychosocial assessment so that an appropriate management plan can be developed. Best outcomes for people with HIV-related pathology depend on rapid recognition and appropriate intervention, and everyone should be seen for this specialist assessment within 2 weeks of receiving an HIV-positive diagnosis. People newly diagnosed with HIV who have symptoms and/or signs attributable to HIV (including those of primary infection) may need immediate intervention and so should be able to access urgent (within 24 hours) specialist assessment. Rapid assessment and intervention also has an important role to play in the prevention of onward transmission of HIV. Prompt involvement of an HIV specialist is particularly important if an HIV diagnosis is made during a hospital admission where HIV may be a significant causal factor.
People differ in their emotional and psychological reaction to a diagnosis of HIV and subsequent adjustment. Access to HIV-appropriate emotional, psychological and peersupport services is particularly important (see Standard 6). Peer support can improve people’s knowledge, skills and confidence to manage their well-being and overall quality of life. It should be embedded in the clinical pathway to ensure everyone has access to peer support that is timely and meets the needs of the person, for example specific access to gay men’s peer support, young adults, or peer support that takes account of spirituality and religious identity, with an initial appointment as soon as possible after diagnosis.
Implications of the diagnosis for others, particularly sexual partners and children, need to be explored with the patient thoroughly and sensitively, facilitating disclosure of the diagnosis to others and supporting people living with HIV through the process. This requires access to practitioners with skills in partner notification (PN) without delay following a diagnosis of HIV (see Standard 5a).
The need for testing the children of parents living with HIV, irrespective of their age and health status, has been highlighted in Don’t Forget the Children. All new HIV-positive patients attending adult HIV services should have any children identified, tested or testing history obtained (and evidenced) and the information clearly documented. An illustration of how this can be approached when parents are reluctant is given in an appendix to the GMC guidance ‘Protecting children and young people: the responsibilities of all doctors’. This can be a very worrying and stressful experience for both parents and children, and needs to be handled sensitively and supportively with a partnership approach, bearing in mind that the health of the child/children, who may have acquired HIV, is a priority.