Editorials

HIV pre-test discussion

Britain's Department of Health has recently introduced revised guidelines for pre-test discussion on HIV antibody testing.¹ These have been circulated to all doctors, district general managers and chief executives of NHS trusts. The guidelines update the first booklet (1985),² which led to most HIV tests being offered at genitourinary medicine clinics and few being done in general medical care.³

The new guidelines confirm that named testing for HIV infection should only be undertaken with informed consent, and that individuals should have information about HIV transmission, the significance of a positive and negative result, and be able to discuss their particular needs and concerns. They also advise that discussion and testing should now be part of mainstream clinical care. Specialist counsellors should be available to provide additional expertise for complex cases and for those who test positive.

The new guidelines are welcome for several reasons. Firstly, using the word "discussion" rather than "counselling" highlights the need for a dialogue when obtaining informed consent, to elicit as well as pass on information.⁴ The original booklet's recommendation on counselling training could imply that the discussion needs to be carried out by a specialist counsellor.² The mystique surrounding the content of counselling could further serve to deter doctors from raising the subject of HIV with their patients.⁵ The new guidelines, however, provide a framework for discussion in a variety of clinical situations; for example, when a patient asks to be tested, or during differential diagnosis, or in routine screening for tissue or organ donation.

Secondly, the potential advantage of early diagnosis and treatment of HIV infection^{6 7} can only be realised if testing is done by all doctors as part of mainstream clinical care. A recent unlinked anonymous survey in England and Wales demonstrated that a significant number of HIV infections were clinically undetected, particularly among pregnant women.⁸ The constant pressure on NHS funding, and the development of more effective but costly antiviral regimens, will undoubtedly affect specialist HIV services. Together with the increased need for testing, this must mean that many more medical services will become involved. This could also have advantages as it would extend HIV prevention into primary care and the general hospital, and will augment the public health campaigns.⁹

The guidelines also raise some important issues. Widening the responsibility for discussing HIV might increase the amount of work for doctors. In the short term this could be regarded as a problem. However, doctors already use these skills in their daily practice when counselling patients about a variety of serious conditions.¹⁰ Applying these skills to HIV can be facilitated by training, which should start during the undergraduate years.¹¹

The 1985 document encouraged health authorities to give specialist counsellors the task of discussing the test. The new guidelines state that any health care worker with appropriate knowledge and skill can do it. We believe that the time has come to shift the major responsibility for testing to the principal health care provider, namely the doctor, who can delegate this task to other health care workers, for example, midwives in antenatal screening. Clinical involvement is important as it is a diagnostic test, bringing with it the necessity for accountability, confidentiality, and the establishment of appropriate medical care if the test is positive.

The time and effort spent on ensuring informed consent for HIV testing may encourage doctors to consider how much information is provided to people having tests for other conditions. If so, the practical framework provided by these guidelines will be useful.

AIDS counselling co-ordinator Royal Free Hospital and School of Medicine, London NW3 2QG

Senior registrar Royal Brompton Hospital, London SW3 6NP

Riva Miller, Marc Lipman 

1. Department of Health. Guidelines for pre-test discussion on HIV testing. PL/CMO/(96)1 London: Department of Health, 1996.
2. Department of Health and Social Security. Introduction of a test for HTLV 111 Antibody CMO(85)12. London: Department of Health and Social Security, 1985.
3. Squire B, Elford J, Bor R, Tilsed G, Salt H. Bagdades E, et al. Open access clinic providing HIV-1 antibody results on day of testing: the first twelve months. BMJ 1991;302:1383-6.
4. Bor R, Miller R, Johnson M. A testing time for doctors:counselling patients before an HIV test. BMJ 1991;303:905-7.
5. Miller R, Bor R. Pre-HIV antibody testing -- too much fuss? Genitourinary Medicine 1992;68:9-10.
6. Dunn DT, Newell ML, Ades AE, Peckham CS. Risk of human immunodeficiency virus type 1 HIV transmission through breastfeeding. Lancet 1992;340:585-8. [Medline]
7. Anonymous. Recommendations for prophylaxis against pneumocystis carinii pneumonia for adults and adolescents infected with human immunodeficiency virus. MMWR Morb Mortal Wkly Rep 1992;41:1-11.
8. Unlinked Anonymous HIV Surveys Steering Group. Unlinked anonymous HIV seroprevalence monitoring programme in England and Wales -- data to the end of 1994. London:Department of Health, 1995.
9. House of Commons Official report (Hansard) 1996 February 5; 569:cols 3-4.
10. McLauchlan CAJ. Handling distressed relatives and breaking bad news. BMJ 1990;301:1145-9.
11. Department of Health. HIV and AIDS: The issues. A teaching pack for doctors. London: Department of Health, 1992.