BMJ  2005;330:492-493 (5 March), doi:10.1136/bmj.330.7490.492

Editorial

HIV testing

Should no longer be accorded any special status

Before highly active antiretroviral therapy (HAART) was introduced, the advantages to infected individuals of knowing their HIV status were minimal, and counselling before HIV testing was the recommended practice.¹ This usually limited testing, by relying on people who were obviously at risk presenting themselves for testing. Such groups included injecting drug users and men who have sex with men and their sexual contacts. Targeting of these groups will become an increasingly less useful concept as HIV continues to spread into the population that is conventionally not at risk. Do we need to reconsider if routine voluntary counselling and testing is appropriate today?

Since 1991 heterosexual transmission of HIV has been the most common mode of transmission in the United Kingdom.² Currently, nearly half of those infected heterosexually and a quarter of infected men who have sex with men in the United Kingdom are undiagnosed.³ A quarter of newly diagnosed patients in the United Kingdom in 2002 were diagnosed late with serious immunosuppression.³ Unless further initiatives are undertaken the epidemic will worsen. Possible initiatives would be to lower thresholds for HIV testing by reducing the emphasis on pre-test counselling.

Reasons for low HIV testing rates and thus low detection rates include concerns about confidentiality, legal and insurance issues, self perceptions of low risk in those who would test positive, denial, dislike of counselling, and wishing to avoid anxiety when waiting for results.^{4 5} Fear and denial are the commonest obstacles to HIV testing among those acknowledging that they have been at risk.⁶

Additionally doctors' awareness of the effectiveness of early interventions is low and they may not encourage HIV testing.^{7 8} The most common reason, however, is lack of time for pre-test counselling, even in genitourinary medicine clinics.⁹ Average times for counselling are not less than 21 minutes with 18% of people requiring two sessions.¹

Low detection rates imply longer duration of infections, which imply increased risk of HIV transmission. In an unpublished study, 70 randomly selected, HIV positive patients attending our centres were estimated to have been infected for a mean of 8.5 years. In that study, for only 56% had doctors broached HIV testing, only 6% of patients had ever declined HIV testing, and 46% of those who were HIV positive reported that their explicit consent to testing should not have been needed. Such results need to be replicated, but implications are clear.

Lowering the threshold for HIV testing will lead to early diagnosis and treatment of infected individuals, which may prevent the development of AIDS and the transmission of infection.^{10 11}

What is the role of voluntary counselling and testing? Voluntary counselling and testing has been accepted practice for more than 10 years. Uptake of voluntary counselling and testing, however, has been poor, even in those with high risk sexual activities.² Sizeable proportions of infected people never attend genitourinary medicine clinics for voluntary counselling and testing even if referred. In addition, it seems that pre-test counselling is, on balance, not dramatically effective in reducing high risk sexual activity.¹²

Many HIV infected individuals receive medical attention before they are diagnosed and opportunities for testing may have been discouraged by the "need" to perform or organise voluntary counselling and testing. Such patients would include, for example, those with persisting lymphopenia, neutropenia, or thrombocytopenia. A routine approach to testing would almost certainly increase the number of early HIV diagnoses, which would then allow concentration on subsequent informed counselling and education of patients and their partners and possible reduction in spread of infection.

Highly active antiretroviral therapy has rendered HIV similar to other serious diseases. We believe that HIV testing should be widely accepted, without conventional voluntary counselling and testing, as patients at risk of cancer do not receive voluntary counselling and testing before chest x rays, or patients with chest infections do not routinely receive voluntary counselling and testing before stains for acid fast bacilli on sputum are requested.

The current combination of reluctance of busy doctors to initiate pre-test counselling and denial by patients has resulted in late diagnosis and ongoing spread of infection. We propose that if a patient freely consents to be investigated, a doctor can initiate tests aimed at excluding serious diseases without an in depth discussion of all possible results, provided that the test result, positive or negative, should benefit the patient.

Routine voluntary counselling and testing was appropriate to the 1980s. Times have changed. The benefits of early diagnosis of HIV are multiple. HIV testing should now not be accorded any special status. Doctors should now undertake the test by using the same approach as used in any other test with serious implications.

(tirbad{at}yahoo.com), Department of Genitourinary Medicine, Royal Infirmary of Edinburgh, Edinburgh EH4 1EW

Department of Genitourinary Medicine, Royal Infirmary of Edinburgh, Edinburgh EH4 1EW

---

Competing interests: None declared.

References

1. Department of Health. Guidelines for pre-test discussion on HIV testing. www.advisorybodies.doh.gov.uk/eaga/pdfs/guidelineshivtestdiscuss.pdf (accessed 19 Nov 2004).
2. Health Protection Agency. HIV and other sexually transmitted infections in the United Kingdom in 2002. Annual report. Part one: HIV infection. London: HPA, 2003.
3. Health Protection Agency. The national CD4 surveillance scheme. 2002 survey results. www.hpa.org.uk/infections/topics_az/hiv_and_sti/hiv/epidemiology/cd4.htm#2001 (accessed 13 Oct 2004).
4. Burns F, Mercer CH, Mercey D, Sadiq ST, Curran B, Kell P. Factors that may increase HIV testing uptake in those who decline to test. Sex Transm Infect 2004;80: 249.[Free Full Text]
5. Spielberg F, Branson BM, Goldbaum GM, Lockhart D, Kurth A, Celum CL, et al. Overcoming barriers to HIV testing: preferences for new strategies among clients of a needle exchange, a sexually transmitted disease clinic, and sex venues for men who have sex with men. J Acquir Immune Defic Syndr 2003;32: 318-27.
6. Seigel K, Raveis VH, Gorey E. Barriers and pathways to testing among HIV infected women. AIDS Educ Prev 1998;10: 114-27.[ISI][Medline]
7. Kellock DJ, Rogstad KE. Attitudes to HIV testing in general practice. Int J STD AIDS 1998;9: 263-7.[Abstract/Free Full Text]
8. Burns F, Mercer CH, Mercey D, Sadiq ST. Barriers to HIV testing: a survey of GUM clinic attendees. Sex Transm Infect 2004;80: 247.[Free Full Text]
9. British Co-operative Clinical Group. Screening for HIV infection in genito-urinary medicine clinics: a lost opportunity? Sex Transm Infect 2000;76: 307-10.[Abstract/Free Full Text]
10. Palella FJ Jr, Deloria-Knoll M, Chmiel JS, Moorman AC, Wood KC, Greenberg AE, et al. Survival benefits of initiating antiretroviral therapy for HIV infected persons in different CD4 cell strata. Ann Intern Med 2003;138: 620-6.[Abstract/Free Full Text]
11. Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li C, Wabwire-Mangen F, et al. Viral load and heterosexual transmission of human immuno-deficiency virus type-1. Rakai Project Study Group. N Engl J Med 2000;342: 921-9.[Abstract/Free Full Text]
12. The EXPLORE Study Team. Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomised controlled study. Lancet 2004;364: 41-50.[CrossRef][ISI][Medline]

This article has been cited by other articles:

• Obermeyer, C. M., Osborn, M. (2007). The Utilization of Testing and Counseling for HIV: A Review of the Social and Behavioral Evidence. Am. J. Public Health 97: 1762-1774 [Abstract] [Full text]  
• Brewster, M. F (2007). HIV exceptionalism must end. BMJ 335: 60-60 [Full text]  
• Frith, L (2005). HIV testing and informed consent. J. Med. Ethics 31: 699-700 [Full text]  
• (2005). Renewed Interest in Routine HIV Screening. AIDS Clin Care 2005: 2-2 [Full text]  

Rapid Responses:

Read all Rapid Responses

Does Insanity Confer Immunity to HIV?

Arunachalam Kumar
bmj.com, 5 Mar 2005 [Full text]

HIV, dying of ignorance?

Ford Hickson
bmj.com, 5 Mar 2005 [Full text]

Absolutely!

Shashikiran Umakanth, et al.
bmj.com, 5 Mar 2005 [Full text]

Why just stop with HIV testing

Trevor G Stammers
bmj.com, 5 Mar 2005 [Full text]

HIV testing Should no longer be accorded any special status

James E Parker
bmj.com, 7 Mar 2005 [Full text]

is HIV different from other infections?

vijayashankara nanjegowda
bmj.com, 7 Mar 2005 [Full text]

Time for HIV medicine to move on

Jim Boddington
bmj.com, 7 Mar 2005 [Full text]

Misconceptions about HIV transmission in the UK: men who have sex with men, not heterosexuals, remain at greatest risk of acquiring HIV in the UK

Neil D Macdonald, et al.
bmj.com, 7 Mar 2005 [Full text]

Commonsense, & Good public health practice too

Mary E. Schramm
bmj.com, 7 Mar 2005 [Full text]

Simple, Rapid, FDA Approved, Oral Fluid HIV Testing is Part of The Solution

David C Oxley
bmj.com, 9 Mar 2005 [Full text]

Normalising HIV testing is a good idea - but not necessarily because it will lower incidence

Fergus P (Gus) Cairns
bmj.com, 9 Mar 2005 [Full text]

HIV is not "Different"

Des Spence
bmj.com, 9 Mar 2005 [Full text]

HIV does need a special response

Heather B Worth
bmj.com, 10 Mar 2005 [Full text]

Response to McDonald et al.

Kaveh Manavi
bmj.com, 10 Mar 2005 [Full text]

Making HIV testing routine must be done sensitively

Mary B Poulton
bmj.com, 14 Mar 2005 [Full text]

Response to Jim Boddington Re: Time for HIV medicine to move on

Mary B Poulton
bmj.com, 14 Mar 2005 [Full text]

HIV Testing

Fiona R Middleton, et al.
bmj.com, 16 Mar 2005 [Full text]

Re: HIV Testing

Peter J Flegg
bmj.com, 17 Mar 2005 [Full text]

Go on, you know you can - the normalising of HIV testing.

Fiona Burns, et al.
bmj.com, 17 Mar 2005 [Full text]

Bring about Change and Discussion.

Martin. F. Brewster
bmj.com, 22 Mar 2005 [Full text]

There are special issues in HIV testing of looked after infants

Douglas E Simkiss, et al.
bmj.com, 24 Mar 2005 [Full text]

May testing without pre-test counselling favour the access to HIV testing?

Nicoletta Orchi, et al.
bmj.com, 1 Apr 2005 [Full text]