HIV Infection - Testing for Adults Protocol

1. Objectives
2. Who to test
   • Clinical presentations where an HIV test should be recommended to patients (diagnostic testing)
   • Other situations where an HIV test is recommended (screening)
3. Offering an HIV test
4. Alternative Providers of HIV testing
5. The HIV test
6. Giving results
7. Referrals/care pathway/advice for HIV positives and those who require in depth discussion and/or refuse testing
   • Referral form
8. Community support
9. Appendix 1. History of development of the guideline
10. Appendix 2. Clinical Indicator Diseases for Adult HIV infection
11. Appendix 3. LTH HIV testing patient information leaflet
12. Appendix 4. HIV testing flowchart
13. Appendix 5 Frequently Asked Questions
14. Appendix 6. Community support

1. Objectives

1. Inform all doctors and other relevant healthcare professionals of current HIV testing guidance, situations where testing is indicated and referral pathways.
2. Simplify and mainstream HIV testing procedure in order to empower all doctors and other relevant healthcare professionals to be able to offer an HIV test.
3. Increase HIV testing volumes.
4. Reduce the proportion of undiagnosed HIV infection. This will reduce late diagnosis of HIV and its associated increased morbidity and mortality.

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2. Who to test

New NICE guidance (NG60 published in December 2016) ‘HIV testing: increasing uptake among people who may have undiagnosed HIV’ provides clear guidance regarding who HIV testing should be offered to and recommended for depending on the local HIV prevalence and how it affects different groups and communities. (https://www.nice.org.uk/guidance/ng60/chapter/Recommendations#offering-and-recommending-hiv-testing-in-different-settings)

Local prevalence figures: Leeds local prevalence = 2.48/1000 i.e. high prevalence area. HIV prevalence in MSM in Leeds is ~3%. Diagnosed HIV prevalence in Black Africans in Yorkshire and Humber is 53.7/1000 (2015 PHE data). 48% of people with HIV are diagnosed late in Yorkshire and Humber (2015 PHE data).

As Leeds is a high prevalence area for HIV (2.48 per 1000 - PHE 2015 data) HIV testing should be offered and recommended to everyone:

1. On admission to hospital, including emergency departments, who has not previously been diagnosed with HIV and who is undergoing blood tests for another reason.
2. Attending their first appointment (followed by repeat testing in line with NICE guidance) at drug dependency programmes, termination of pregnancy services and services providing treatment for:
   1. hepatitis B & C
   2. lymphoma
   3. tuberculosis.
3. Attending for testing or treatment at specialist sexual health services.
4. In the community setting who has not previously been diagnosed with HIV and who:
   1. registers with the GP practice or
   2. is undergoing blood tests for another reason and has not had an HIV test in the previous year.

As the current NICE guidance (NG60) recommends widespread testing in high prevalence areas such as Leeds testing based on individual clinical presentation is no longer necessary, however, if anyone presents with the below (Appendix 2) AIDS-defining or clinical indicator conditions and they have not had an HIV test in the last year an HIV test should be offered and recommended.

In all areas regardless of HIV prevalence, offer and recommend HIV testing on admission to hospital, including emergency departments, to everyone who has not previously been diagnosed with HIV and who has symptoms that may indicate HIV or HIV is part of the differential diagnosis (for example, infectious mononucleosis-like syndrome), in line with the below (Appendix 2) British Association for Sexual Health and HIV, British HIV Association and British Infection Society’s joint ‘UK National Guidelines for HIV testing guidelines 2008.’ https://www.bashhguidelines.org/media/1067/1838.pdf

Clinical presentations where an HIV test is recommended in all areas (Appendix 2):

Other situations where an HIV test is recommended in all areas:
Offer and recommend HIV testing on admission to hospital, including emergency departments, to everyone who has not previously been diagnosed with HIV and who:

1. is known to be from a country or group with a high rate of HIV infection (>1%*)
2. if male, discloses that they have sex with men, or is known to have sex with men, and has not had an HIV test in the previous year
3. is a trans woman who has sex with men and has not had an HIV test in the previous year
4. reports sexual contact (either abroad or in the UK) with someone from a country with a high rate of HIV (>1%*)
5. discloses high-risk sexual practices, for example the practice known as 'chemsex'
6. is diagnosed with, or requests testing for, a sexually transmitted infection
7. reports a history of injecting drug use
8. discloses that they are the sexual partner of someone known to be HIV positive, or of someone at high risk of HIV (for example, female sexual contacts of men who have sex with men).

* for up to date prevalence by county http://www.unaids.org/en/regionscountries/countries

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3. Offering an HIV test

Any doctor or other relevant healthcare professional can offer a test.

THE FOLLOWING IS RECOMMENDED:

• Information on HIV should be delivered by leaflet (LTH HIV test leaflet recommended). This is in two parts which should be given to the patient. The first part provides information about the test and the second provides health education/prevention advice.
• Verbal consent from the patient is sufficient and should be documented in the case records

LTH HIV test leaflet

The leaflet can be downloaded and printed in English (Appendix 3). Leaflets translated into Farsi, French, Portuguese, Lingala, Swahili and Urdu are also available.

The current GMC guidance on ‘Consent: Patients and Doctors making decisions together’ provides a framework for good practice when offering an HIV test. Informed consent should be obtained and patients have a right to refuse an HIV test.

1. Guidance on good practice for HIV testing has been produced by:
   • National Institute for Clinical Excellence (2016) NG60 ‘HIV testing: increasing uptake among people who may have undiagnosed HIV.’ https://www.nice.org.uk/guidance/ng60
   • Medical Foundation for Sexual Health and HIV (MEDFASH) - HIV in Primary Care 2016 (European edition) http://www.medfash.org.uk/uploads/files/p1b2t4231lu3ud1c1i5ekp2peo6.pdf
   • The British Association for Sexual Health and HIV and British HIV Association (2008) https://www.bashhguidelines.org/media/1067/1838.pdf

Frequently Asked Questions by patients about HIV testing (Appendix 5)
Comatose patients - Seek GUM/ID Consultant advice.

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4. Alternative providers of HIV testing

The following are situations where you may consider referral to another provider for HIV testing:

• Patient declines HIV testing
• Patient requires counselling, additional information and/or risk reduction interventions
• Patient requests a rapid HIV test (Point of Care Test)
• Patient wishes to be tested elsewhere

Leeds Sexual Health, Yorkshire MESMAC and BHA Leeds Skyline provide HIV testing services in Leeds. Details for these services are available on the Leeds Sexual Health website: http://leedssexualhealth.com/

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5. The HIV test

The standard method of testing is to send a sample of venous blood in a red top tube to the Microbiology Lab and request ‘HIV serology’. Negative results are usually available within 24 hours and positive results within 1-2 working days.

For very ill patients where the diagnosis will affect management, urgent testing (including out of hours) is available but requires authorisation from a virologist. The on-call clinical virologist will need to be contacted via LTHT switchboard if out-of-hours, otherwise via the virology / serology lab.

The latest fourth generation HIV tests used are very sensitive and detect both antibody and antigen. The majority of infections can be detected within 1 month of exposure but patients who have been at high risk should be advised to retest at 2 months after exposure to exclude infection. Rapid (Point of Care) HIV tests on finger prick blood, which provide a result within 5-20 minutes, are performed by Leeds Sexual Health and two third sector organisations in Leeds (see the Leeds Sexual Health website for details: http://leedssexualhealth.com/).

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6. Giving results

Giving an HIV positive result is the same as breaking bad news in any other clinical situation.

The person/team who consents the patient is responsible for giving the result and discussing the referral.

If the HIV test result is positive the patient should be told that this is a provisional positive result which will require confirmation by a second blood test. The confirmatory test can either be performed by the team who initially performed the test or by the HIV team after referral has been made.

The 3 bulleted points detailed below are at the end of the patient leaflet and should be explained to the patient.

• Treatment for HIV is very effective. Very few people who are diagnosed with HIV now die from the disease.
• Medical confidentiality is assured.
• HIV is common in the UK and many people are being managed by specialist staff.

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7. Referrals/care pathway/advice for HIV positives

NB As of 1st August 2017 LTHT provide HIV treatment and care for all people living with HIV and who access HIV services in Leeds, Dewsbury and Wakefield. 

Patients should be seen within 48 hours for specialist assessment.

Refer by letter, email or fax (if urgent telephone) – see referral form.

LGI – Brotherton Wing Clinic (HIV out-patient service) - within working hours.

Brotherton Wing Clinic, Block 11, Level A/B, Brotherton Wing, LGI, LS1 3EX
Email: leedsth-tr.GuSecretaries@nhs.net
Fax: 0113 3926387
Reception phone: 0113 3926762
HIV Consultant / ST via Brotherton Wing Clinic secretaries: 0113 3926142 or 0113 3922944
HIV CNS phone numbers: 0113 3926057 or 0113 3923116

SJUH – J20 (Department of Infectious Diseases and Travel Medicine) - 24 hour cover

Daytime: HIV on-call ST or Consultant via secretaries' office ext 0113 2066614 / 2065468 or fax 0113 2066984.

Out of Hours: On call ST or Consultant via J20: 0113 2069120 or 0113 2065621 or LTHT trust switchboard (0113 2432799).

Refer any other patients who require or request in depth discussion/information including those who decline HIV testing.

HIV testing comatose patients. Specific advice can be obtained from a Consultant in Infectious Diseases or GUM.

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8. Community Support

The following agencies provide support for those affected by HIV (see Appendix 6 for details)

Leeds Skyline Service


Yorkshire MESMAC Group
http://www.mesmac.co.uk/

THT-Terrence Higgins Trust
http://www.tht.org.uk/

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Appendix 1 - History of the protocol

Two UK national audits confirmed local anecdotal evidence that diagnosis of HIV is often delayed resulting in substantial morbidity and mortality. Guidance from national specialist societies (British HIV Association and British Association for Sexual Health and HIV) in 2008 stressed the importance of removing barriers to and encouraging wider HIV testing by mainstreaming and simplifying the process. There have been similar issues in the US and guidance published by CDC in September 2006 recommended opt-out testing in certain medical settings. Opt out universal HIV testing for in antenatal clinics has been in place in Leeds since 2000/01 and refusal rates are extremely low.

• Since the mid 2000’s, all patients diagnosed with Tuberculosis at the Leeds Chest Clinic have been recommended HIV testing and information has been given by a patient information leaflet recommended by the British Thoracic Association. In 2007 discussions occurred within the Departments of Genitourinary Medicine and Infectious Diseases and Travel Medicine to simplify HIV testing in line with guidance from national specialist societies, the Royal College of Physicians and the GMC and recommendations from the Chief Medical and Nursing Officers in 2007 and 2009. A care pathway for referral of HIV+ves was developed as well as those who require in depth discussions. There was consultation with the Departments of Haematology and Virology. The protocol was updated in 2009, 2011 2012, 2015 & 2017 in line with national guidance.
• In 2008 the British Association of Sexual Health and HIV/British HIV Association/British Infection Society included advice to offer unselected screening for populations where the prevalence of HIV is greater than 2/1000. In March 2011 the National Institute for Clinical Excellence (NICE) recommended offering HIV screening for all men who have sex with men and to all those from Black African communities living in England.
• Following the NICE guidance, Leeds PCT set up the ‘Increasing the uptake of HIV testing - NICE guideline implementation Task Group’ whose members include primary and secondary care providers, community providers and commissioners. The HIV testing for adults protocol and appendices have been reviewed and approved by the group. The HIV testing leaflets were also reviewed and approved by those affected by HIV.
• In 2015 routine opt-in HIV testing was implemented for the acute medical admissions ward at SJUH taking. This has project continues and has been in place for just over 2 years and is supported by a band 5 nurse. All patients 16-65yrs admitted to this ward and not already known HIV positive are supposed to be offered an HIV test but this relies on the medical staff to implement. Over the first 23 months of this project just over 7000 HIV tests performed, 61% target population tested, prevalence 2.22/1000.
• Business plan currently being produced by GUM/ID/Virology to enable LTHT to offer and recommend HIV testing on admission to hospital, including A&E, to everyone who has not previously been diagnosed with HIV, has not been tested for HIV within the last year and who are undergoing blood tests for another reason as per NICE guidance NG60 (2016).

Appendix 2. Clinical Indicator Diseases for Adult HIV infection

Appendix 3. LTH HIV testing patient information leaflet

Appendix 4. HIV testing flowchart

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Appendix 5 - Frequently asked questions about HIV testing

Why do you test for HIV in this department?
We routinely perform an HIV test for people with many different kinds of health problem. This is because HIV can be a cause of some conditions, or contribute to making them worse.

There are good reasons for knowing your HIV status.

If you get a negative HIV test result:

• you have the reassurance that you do not have HIV
• we do not have to worry about HIV affecting the way we treat your current condition
• you can continue to take steps to reduce your chances of contracting HIV.

If you get a positive HIV test result:

• you will have more control over who to tell, and when, than if you found out when you were ill with HIV infection.
• you can take steps to avoid passing it on to your sexual partners.
• there are effective treatments that will stop you getting ill with HIV-related diseases.
• the earlier HIV treatment is started, the better the outcomes.
• we can adjust the treatment for any other condition you have, if necessary, to make sure that treatment is most effective.

How will I get the result?
We will discuss how we give you the results of all the tests when you take them.

What does a negative result mean?
This means you DO NOT have HIV infection. However, if you have possibly been exposed to HIV infection in the past two months you will need to be tested again in a few weeks to check the result.

Why would I need to test again?
This is because it can take up to two months for HIV to show up on some blood tests, although many tests can detect it sooner than that. If you have been infected before the test is able to detect HIV, the result might not be accurate so you would need to test again to check the result of your first test.

Will my GP be informed of a negative HIV test result?
It is standard practice to inform your GP of the results of all tests carried out in hospital. This gives your GP a more complete picture of your treatment here and helps us to work better together to ensure you get the care you need.

Will having a negative HIV test result stop me getting life insurance?
The Association of British Insurers (ABI) have issued clear guidance to insurance companies that a negative HIV test result must have no bearing on any insurance applications and that they are not to ask GPs if an applicant has ever had an HIV test. GPs have been advised by both the ABI and the British Medical Association that they should not answer the question if it is asked.

Can I have written confirmation of my result?
If you need written confirmation of a negative HIV test result eg for the purposes of employment, or for travel to a country with strict controls on admitting people with HIV, this will normally be provided by your GP as for any other medical report request. You should be aware that GPs will most likely make a charge for this service.

Frequently asked questions about a positive HIV test result

What does a positive result mean?
This means you DO have HIV infection, but does NOT automatically mean you have AIDS.

What happens next?
We will refer you to be seen by a specialist from the HIV team within 48 hours for an initial assessment. They will do more tests to find out if you need treatment at this stage.

What about telling my family?
The general rule is that all medical information is confidential to you, so it is up to you to decide who to tell about a positive HIV test result and we will not inform anyone of the result unless you ask us to. If you want support in telling your family about your HIV status, the HIV team can advise you as they have experience in doing this.

Will my family or friends get HIV from me?
There is no risk of passing HIV to your family or other people through regular household and social contact. However, it can be passed sexually if you are not on HIV treatment or your HIV is not well controlled on treatment. In these circunstances you will need to think about protecting your sexual partner from HIV by using condoms. PrEP is also an option for your partner(s) to protect them from getting HIV thorough sexual contact until your HIV is well controlled on treatment. Once people living with HIV are established on HIV treatment and their HIV is well controlled they can’t pass HIV on through unprotected sex. The HIV team will provide you with more information about this.

Will my partner or my children have to be tested?
The HIV team will advise you on this and will help to arrange to get your partner and/or children tested if it is necessary.

Will I have to tell my employer if I am HIV-positive?
Once again, the HIV team will be able to advise you fully on this. There is no law that requires you to tell your employer that you have HIV. However, if your employer is made aware of your HIV status through their own medical checks or because you choose to tell them, it is important to know that people with HIV are protected from discrimination at work from the point of diagnosis under the Disability Discrimination Act. For some occupations, eg in certain healthcare settings, there may be a restriction on what you can do if you have HIV and your HIV is not well controlled on treatment so that the risk of passing on HIV to patients is avoided. This is specialist area and there is specialist advice available for those who are healthcare workers.

Will my GP be informed of a positive HIV test result?
If your HIV test is positive, we believe it is best to inform your GP because:

• they provide your general (non-HIV-related), out-of-hours and emergency care
• they need to know if you are taking HIV treatment so they can avoid drug interactions when prescribing other medicines
• they will know to look out for any HIV-related problems which could otherwise be missed
• they can refer you to local social, counselling and support services if you need them
• they can support your family members to deal with the diagnosis, but they will not tell anyone in your family about it unless you give them permission to do so, and will not do this without discussing it with you first.

However, it is not essential to tell your GP and some people still choose not to. It is important, however, to be aware that if your HIV was diagnosed through one of the Leeds hospitals e.g. LGI or SJUH and you have a Leeds GP that this result may automatically be visible to your GP. If you have concerns about your GP knowing you have HIV, please contact the HIV team to discuss it.

What about mortgages or insurance?
Many companies provide repayment mortgages for people with a range of long-term or serious medical conditions like diabetes or cancer, and this includes HIV because of the advances in HIV treatment.

Regarding new applications for life insurance, the 2008 guidance from the Association of British Insurers (ABI) and the British Medical Association (BMA) states that “Insurers may ask whether someone has had a positive test result, or is receiving treatment for HIV/AIDS” in a medical report form and doctors are expected to answer truthfully. This does not mean that you will not be able to get any life insurance cover, but you will probably have to go to a specialist insurer, it may be more costly and the cover may be limited but this is no different from other long-term medical conditions e.g. diabetes.

However, for someone who already has life insurance and is diagnosed with HIV, the guidance states “Existing life insurance policies will not be affected in any way by taking an HIV test, even if the result is positive. Providing that the applicant did not withhold any material facts when the life policy was taken out, life insurers will meet all valid claims whatever the cause of death, including AIDS-related diseases. Material facts the applicant might need to reveal include information about activities that increase the risk of HIV infection.” The HIV team will be able to refer you to people who provide specialist advice about these matters.

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Appendix 6 - Community Support

Leeds Skyline
4th Floor Gallery House, 131 The Headrow, Leeds, LS1 5RD
Telephone number: 0113 244 9767

Leeds Skyline provides support for anyone in Leeds and its environs living with or affected by HIV. They provide one-to-one emotional support; support groups; advice and information on treatment, immigration, housing, welfare benefits; hardship grants; trainings and workshops and more.

Services Provided: Advice, information, resources, links, Advocacy, Exercise, nutrition and complimentary therapies, Financial advice, debt advice and hardship fund, Housing advice, Support for carers, Support groups, peer support and counselling.

Yorkshire MESMAC Group
22/23 Blayds Yard, Leeds LS1 4AD
Telephone number: 0113 244 4209

Yorkshire MESMAC Group supports the sexual health and wellbeing of Lesbian gay, bisexual and trans, adult and youth, and provides social support for people living with HIV. From their centres in Leeds, Bradford, Wakefield, Scarborough and York they conduct work on HIV and STI awareness, stigma and prejudice, counselling and more.

Services Provided: Advice, information, resources, links, Advocacy, Exercise, nutrition and complimentary therapies, Housing advice, Other, Support for carers, Support groups, peer support and counselling, telephone helpline
Email address: leeds@mesmac.co.uk
http://www.mesmac.co.uk/

THT-Terrence Higgins Trust
Telephone number: 0808 802 1221

THT was one of the first charities to respond to the HIV epidemic and has been at the forefront of improving the nation's sexual health ever since. They run an HIV Helpline called THT Direct, and provide sexual health and HIV support services through a strong national network of local community-based branches.

Services Provided: Advice, information, resources, links, Advocacy, Financial advice, debt advice and hardship fund, Housing advice, Policy and campaign work, Support groups, peer support and counselling, telephone helpline
Email address: info@tht.org.uk
http://www.tht.org.uk/