NHS Tayside HIV Testing Guideline May 2013

1. NHS Tayside HIV Testing Guideline May 2013

2. The purpose of this presentation is to: • Provide an educational resource to support the implementation of the HIV testing guideline • Illustrate how the HIV testing guideline can be implemented • Explore common myths around HIV and HIV testing

3. Overview Why HIV testing is important: • Epidemiology of HIV in UK and Tayside • Consequences of undiagnosed infection • Healthcare Improvement Scotland Standards (2011) Overcoming barriers to HIV testing When to test for HIV How to test for HIV

4. HIV was more common in the UK in the 1980’s and 1990’s than it is now HIV has never been more common in the UK, or in Tayside, than it is today 1, 2

5. Number of people newly diagnosed and people living with diagnosed HIV infection: UK 1980-2011 73 400 diagnosed + 22 600 undiagnosed Estimated total 96 000 HIV in the United Kingdom: 2012 overview, HIV and STI Department, HPA, www.hpa.org.uk

6. 3462 living with diagnosed HIV in Scotland (2011)

7. HIV in Tayside There have been 709 HIV diagnoses made within Tayside since reporting began There are almost 300 people currently living with diagnosed HIV in Tayside in 2012 In 2011, 34 new diagnoses were made in Tayside. This is the greatest number of new diagnoses per year since reporting began 1999 2011 Data source: Health Protection Scotland www.hps.scot.nhs.uk

8. Men who have sex with men (MSM) are the risk group with the highest prevalence of HIV in the UK 1 in 20 MSM are living with HIV in the UK1 (1 in 11 in London)

9. Prevalent infection in the UK, 20111 n ~ 96 000 Prevalent infection in Scotland, 20112 n = 3478 Prevalent infection in Tayside, 20112 n = 258

10. New HIV diagnoses in the UK, 20111 n = 6280 New HIV diagnoses in Scotland, 20112 n = 362

11. MSM Black African men Black African women Pregnant women overall People who inject drugs Task: Can you match the risk group with the corresponding HIV prevalence? 2.2 in 1000 people 1.2 in 1000 people 24 in 1000 people 50 in 1000 people 47 in 1000 people The overall prevalence of HIV in the UK is 1.5 in 1000 people

12. MSM Black African men Black African women Pregnant women overall People who inject drugs 47 in 1000 people 25 in 1000 people 50 in 1000 people 2.2 in 1000 people 1.2 in 1000 people HIV prevalence per risk group, UK 20111 The overall prevalence of HIV in the UK is 1.5 in 1000 people

13. Undiagnosed HIV infection1 Approximately 24% of all people infected by HIV are unaware of their infection PWID are least likely to be undiagnosed Non-African born HTRS men are most likely to be undiagnosed 17% PWID 20% MSM 25% Black African women 30% Black African men 31% non-African born women 33% non-African born men undiagnosed

14. Individuals with undiagnosed HIV:  are 3 times more likely to pass on their infection than those with diagnosed infection  are twice as likely to have condom-less sex Individuals with diagnosed HIV:  have access to treatment to reduce viral load (biggest predictor of transmission)  have access to combination risk reduction interventions Undiagnosed HIV and onward transmission3

15. ~25% Unaware of Infection Accounting for: ~54% of New Infections ~75% Aware of Infection ~46% of New Infections Undiagnosed HIV accounts for >50% of all new infections Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006 Jun 26;20(10):1447-50.

16. Late presenters Most important predictor of morbidity and short-term mortality BHIVA national audit 2006: 24% of all deaths in HIV-infected people were reported as “diagnosed too late for effective treatment” 4

17. MSM least likely to present late Heterosexual men most likely to present late

18. Cost of HIV3 Lifetime cost £280,000-360,000/patient Annual cost £13,000/patient Late diagnosis: Costs are twice as high in the first year Costs are 50% higher thereafter In-patient costs are 15-fold higher for late diagnoses

19. Cost effectiveness of HIV testing3 American studies • HIV testing is cost-effective when one individual diagnosed/1000 tests done • (not accounting for reduced costs for the prevention of onward transmission) UK cost effectiveness studies limited 1% shift of patients diagnosed early Up to £265k saving/year Implementation of NICE HIV testing guidelines 3500 new infections prevented £18 million treatment costs saved/year

20. Summary so far HIV has become increasingly common nationally and locally Risk factors change and vary nationally and locally Earlier diagnosis results in • Reduced morbidity and mortality • Reduced onward transmission • Cost savings

21. Barriers to HIV testing Awareness I’m not trained Fear of + result Perception of patient’s risk Perception of risk Stigma of testing Fear of causing offence Embarrassment Awareness “I’d rather not know” Time pressures

22. DH funded HIV testing pilots in England Expanded HIV testing Emergency Department x 1 Acute medical admissions x 3 Dermatology OPD x 1 Primary care x 3 Community x 4 HIV testing pilots5 • Acceptability to patients • 59-75% uptake in primary care • 62-91% uptake in hospital settings • Patient questionnaires • GP new registrations • 85% happy to have HIV test

23. Staff acceptability questionnaires Initial concerns Need for training ?How to answer difficult questions Time pressures to gain informed consent All fears assuaged after roll-out Offer of testing variable 21-62% Evidence of targeted testing AMU Brighton 39.7% offered HIV test 91% uptake Parallel seroprevalence study 6 new diagnoses *4 of these remain undiagnosed* HIV testing pilots5

24. HIS Standards for HIV, 20116 The NHS Board develops and promotes a written HIV testing policy • Identification of asymptomatic infection (6.1) • Identification of symptomatic infection (7.1) A critical case review is performed for all late presenters (7.2) Recognition of symptomatic HIV is included in local medical CPD programmes

25. NHST HIV Testing Guideline Consultation period August-December 2012 Endorsed by • Area Clinical Forum • Clinical Quality Forum • Improvement and Quality Committee Launched 13th May 2013

26. www.bbvmcntayside.scot.nhs.uk

27. Who can undertake an HIV test “It should be within the competence of any doctor, nurse and midwife to obtain consent for and conduct an HIV test” 7 (There are other non-clinical staff in non-clinical settings who are trained to provide HIV testing within Tayside)

28. Who should be tested for HIV?

29. Who should be tested for HIV?7 Universal testing in high prevalence areas Opt-out testing in certain clinical settings Screening of high risk groups Testing in the presence of “clinical indicators”

30. Who should be tested for HIV? Universal testing in high prevalence areas Opt-out testing in certain clinical settings Screening of high risk groups Testing on clinical grounds

31. Universal testing* In high prevalence areas in the UK (local prevalence >0.2%) HIV testing is recommended to • all general medical admissions • all new patients registering at general practice Tayside’s prevalence is <0.2% HPA - Colindale * The individual has the option to decline a test

32. Who should be tested for HIV? Universal testing in high prevalence areas Opt-out testing in certain clinical settings Screening of high risk groups Testing on clinical grounds

33. Opt-out HIV testing* Opt-out testing means that HIV testing would be considered part of the routine care for people attending certain services The test should be recommended to every individual regardless of the perceived individual risk This is a screening intervention for public health benefit * The individual has the option to decline a test

34. Opt-out HIV testing* Which services do you think should offer opt-out HIV testing to ALL individuals accessing their service? Termination of pregnancy services Antenatal services There is a higher prevalence of HIV in individuals accessing these services than in the background population The risks associated with undiagnosed HIV in these settings are unacceptably high GUM clinics Assisted conception services Drug dependency services * The individual has the option to decline a test

35. Who should be tested for HIV? Universal testing in high prevalence areas Opt-out testing in certain clinical settings Screening of high risk groups Testing on clinical grounds

36. Screening of high risk groups* People with identifiable risk factors should be routinely offered and recommended to have an HIV test An HIV test should be recommended regardless of their clinical presentation * The individual has the option to decline a test

37. Screening of high risk groups* Which of these groups should be routinely offered an HIV test? Female partners of bisexual men Adults from endemic areas People who inject drugs Heterosexual men Men who have sex with men Partners of people living with HIV Children from endemic areas Healthcare workers Anyone with multiple sexual partners Sexual partners from endemic areas People in prison History of iatrogenic exposure in an endemic area * The individual has the option to decline a test

38. Screening of high risk groups* Which of these groups should be routinely offered an HIV test?    Female partners of bisexual men  Adults from endemic areas People who inject drugs Heterosexual men   Men who have sex with men Partners of people living with HIV   Children from endemic areas Healthcare workers   Anyone with multiple sexual partners  Sexual partners from endemic areas  People in prison History of iatrogenic exposure in an endemic area * The individual has the option to decline a test

39. Screening of high risk groups High prevalence areas are: Sub-Saharan Africa Caribbean Thailand Regular screening should be recommended based on on-going risk HIV testing should be recommended for children born to HIV+ or untested mothers from endemic areas Adults from endemic areas Men who have sex with men The prevalence of HIV in these risk groups is higher than the background population Regular screening should be recommended based on on-going risk Female partners of bisexual men Children from endemic areas People who inject drugs Sexual partners from endemic areas Partners of people living with HIV History of iatrogenic exposure in an endemic area

40. Screening of high risk groups This is not a discriminatory risk factor Anyone with multiple sexual partners People in prison A custodial sentence is a good opportunity to test people with particular risk factors for blood borne viruses but is not a risk group itself There is no evidence that this group has a higher prevalence of HIV Healthcare workers This is not a discriminatory risk factor Heterosexual men

41. Who should be tested for HIV? Universal testing in high prevalence areas Opt-out testing in certain clinical settings Screening of high risk groups Testing on clinical grounds

42. Testing on clinical grounds7 When HIV falls within the differential diagnoses and HIV test should be performed regardless of risk factors (a risk assessment is not necessary)

43. More than 50% of people living with HIV are asymptomatic until they present with symptoms of advanced immunosuppression Approximately 80% of people who acquire HIV experience symptoms of primary HIV infection (seroconversion illness) which usually presents within 2-4 weeks of infection

44. Primary HIV Infection HIV may present with the following transient symptoms: • Myalgia • Headache/aseptic meningitis • Lymphadenopathy • Fever • Pharyngitis • Maculopapular rash • Recommendations: • Adults presenting with a “glandular fever-like” illness, where the EBV IgM is negative should be offered an HIV test • Adults presenting with aseptic meningitis should be tested for HIV

45. Symptomatic HIV HIV is a multi-system disease • Opportunistic Infections • AIDs-related cancers • Other clinical indicators

46. These are “AIDs-defining “conditions and represent HIV-associated immunosuppression until proven otherwise These conditions are more common in people with HIV and testing is recommended These conditions are epidemiologically linked to HIV and testing is recommended The UK National HIV testing guideline recommends HIV testing in these presentations

47. These are “AIDs-defining “conditions and represent HIV-associated immunosuppression until proven otherwise These conditions are more common in people with HIV and testing is recommended These conditions are epidemiologically linked to HIV and testing is recommended The UK National HIV testing guideline recommends HIV testing in these presentations

48. Testing on clinical grounds If you would like further information about specific systems or specific clinical indicators please contact the BBV MCN team We are happy to provide tailored teaching within your department or clinical area

49. Pre-test counselling is considered best practice The perception that specific training for pre-test counselling is required is a barrier to HIV testing. It also contributes to the stigma around HIV and HIV testing. It is recommended that the same level of counselling and consent is required as for any other serious medical condition

50. What does a patient need to know? That they are being tested for HIV What the benefits of testing are How and when they can expect to receive results That results will not be given to a third party Written information can be made available Available in 6 languages