Search for a command to run...
The elimination of human immunodeficiency virus (HIV) transmission in the UK is now considered to be an achievable ambition. To attain this target all individuals living with undiagnosed HIV will need to be offered testing and commenced on antiretroviral therapy (ART). The early initiation of ART, regardless of CD4 cell count, has clear benefit for the individual (with avoidance of morbidity and mortality), their partners (avoidance of transmission by having an undetectable viral load) and public health (reduced community viral load and HIV transmissions). Although significant progress has been made in the UK, with falling HIV incidence and near universal ART coverage in those diagnosed, there remains a significant proportion who are undiagnosed (7% in 2018), present late (43% in 2018) [1], and continue to experience morbidity and mortality and contribute to the ongoing transmission of HIV. These guidelines include a number of recommendations regarding HIV testing. The approaches described need to be adopted and adapted based on local HIV prevalence data, populations and services. Not all approaches are relevant in all areas (e.g. seroprevalence-based testing). In areas of lower prevalence some approaches (e.g. indicator condition testing, risk groups and home sampling/testing) become increasingly important to ensure all those at risk are offered/able to request a test. However, in areas of high and extremely high prevalence, the other approaches should also be instigated in order to widen the potential reach of testing those with undiagnosed HIV. While cost-effectiveness of testing programmes is relevant for some approaches (e.g. indicator condition testing and high local seroprevalence), it should not be universally applied as the cut-off threshold for testing programmes as we work towards the elimination of HIV. All stakeholders should engage in devising a comprehensive approach best suited to their local situation. Given the clear benefits of treatment, both for the individual and public health, more needs to be done to ensure that all those living with HIV are diagnosed promptly and can rapidly access treatment and care. Those who test negative but remain at risk should have equitable access to combination prevention (including condoms, health promotion and pre-exposure prophylaxis [PrEP]). All testing programmes must ensure they have robust results governance processes and easily accessible pathways to either HIV treatment and care services or prevention services for those at ongoing risk. In some instances (e.g. in emergency departments) this may be provided most effectively in partnership (e.g. with local sexual health services). All healthcare workers should be able to offer an HIV test in their setting. Lengthy pre-test discussion is not required. Individuals should be made aware that they will be tested for HIV and informed how they will receive their result; for many clinical settings, opt-out testing* is the most effective method to increase testing coverage. Community testing, self-sampling and self-testing may increase access to testing for specific groups. An annual test is recommended for PWID, sex workers and MSM, and more frequently for those reporting higher risk behaviours or those also belonging to other groups. Self-testing and sampling and community testing should be provided for at-risk groups and in areas of high seroprevalence to increase testing uptake and frequency. HIV testing programmes should employ a universal (i.e. non-targeted) opt-out approach when comprehensive coverage is desirable. The window period for fourth-generation serological HIV testing is 45 days; this has been revised in light of published evidence. Barriers to testing include HIV stigma and reluctance to offer testing by healthcare professionals. Normalisation of HIV testing by integration into routine practice and education and training of healthcare workers are recommended to address these barriers; however, larger-scale interventions are likely to be required to have a meaningful impact on societal stigma and discrimination. The UK government has recently committed to the elimination of HIV transmission by 2030 [2]. To achieve this, individuals living with undiagnosed HIV infection will need to be identified through testing and commenced on ART, thereby eliminating the risk of further onward transmission. Those identified as being at ongoing risk of infection will require combination prevention (including condoms, frequent sexually transmitted infection [STI] and HIV testing, behavioural interventions and PrEP) to significantly reduce their risk of acquiring HIV infection. HIV treatment guidelines universally acknowledge the benefits of immediate ART, regardless of CD4 cell count, for an individual’s health. Individuals who are diagnosed promptly can expect a near-normal life expectancy. Furthermore, with an undetectable viral load on ART, people living with HIV do not transmit the virus to their sexual partners. This is referred to as treatment as prevention (TasP) and underpins the public health message: U = U (undetectable = untransmittable). Implementation of these approaches has resulted in significant reductions in the number of new HIV diagnoses for almost all groups in the UK. HIV testing is the gateway both for accessing effective treatment and for combination prevention, but improvements are required to ensure that all individuals can benefit equally. The term ‘HIV’ refers to HIV-1 throughout these guidelines, unless HIV-2 is specified. In 2018, there were an estimated 103 800 (95% credible interval 101 600–107 800) people living with HIV in the UK, of whom 93% were diagnosed and 97% were on ART. Of those individuals accessing care with a viral load result in 2018, 97% had an undetectable viral load [1]. Among adults receiving specialist HIV outpatient care in the UK in 2018, there were no significant differences in the proportions receiving ART by gender, ethnicity, age or mode of HIV acquisition (range 95–99%). Rates of viral suppression were similarly high [1]. With 7% of people with HIV living with undiagnosed infection, the main area where progress is needed therefore is testing. There has been a significant decline in new HIV diagnoses in the UK in the past few years from a peak of 6278 in 2014 to 4453 in 2018 [1]. This decline, while evident in both MSM and black African populations, is most marked among MSM, particularly in London. The decline in new HIV diagnoses reflects a decrease in incidence, which began in 2012, and is most likely to be due to increases in testing, repeat testing and prompt initiation of ART (i.e. TasP). More recently PrEP has contributed to the continuing decline. Significant differences are observed in the most affected populations in testing coverage and rates, and consequent late presentation; these vary by ethnicity, age and locality [1]. It is therefore essential that planning of interventions to increase HIV testing is done in the context of the local epidemic to achieve maximum impact without risk of stigmatising potentially vulnerable communities. Monitoring and evaluation of such programmes should be carried out to assess effectiveness and inform future adaptations. With expansion of testing settings to non-specialist services, time to linkage to HIV specialist care will be an important metric to monitor. HIV testing should be voluntary and confidential, with easy, equitable and free access. Individuals should be aware they are being tested for HIV and that testing is voluntary; they should be informed how their result will be managed. Lengthy pre-test discussion is not required. How much additional information is provided will vary to an extent based on the setting, the purpose of testing and the individual being offered a test. How information is delivered should be adapted to the circumstances. Basic information should include how results can be accessed, the advantages of testing, availability and effectiveness of treatments, prevention and the window period. Not all situations will require all this information, which in many cases can be provided in written form (leaflet or website link). The General Medical Council (GMC) provides guidance on obtaining consent for any medical investigation and this should be adhered to regardless of setting [3]. HIV-related stigma continues to be reported and feared by people living with HIV, compounded for some by pre-existing stigma based on actual or perceived membership of different social groups (e.g. groups based on gender identity, religion, class, ethnicity and sexuality). HIV testing, including the offer of a test, can have similar associations for both individuals and healthcare workers. Easy, equitable, non-discriminatory access to HIV testing in all settings should be available to all individuals who wish to test or for whom testing should be recommended. All patient-related information and testing behaviour and outcome data should be kept according to information governance standards and national legislation, regardless of setting. Similarly, robust results governance should be in place for all testing programmes, regardless of setting. In some settings this may be more effectively provided in collaboration with another service (e.g. local sexual health service). In all settings, irrespective of who is delivering the testing, there should be clear, agreed pathways to HIV treatment and care services delivering timely linkage to care. For those who test negative and remain at risk there should be clear pathways/signposting to prevention services. An undiagnosed prevalence of 0.1% is consistently considered to be cost-effective for HIV screening [4]. The evidence shows a greater cost-effectiveness in settings and populations where the undiagnosed prevalence is higher. In antenatal settings, a lower threshold of 0.0075% has been estimated, due to the large extended lifetime costs of an infant acquiring HIV vertically [5]. The estimated prevalence of undiagnosed HIV in England in 2018 was 0.016% (95% confidence interval [CI] 0.012–0.024%) among those aged 15 to 74 years. Thus, universal population testing in the UK is not supported by cost-effectiveness evidence. Estimates of the undiagnosed prevalence of HIV vary by at-risk population and geography, therefore testing is recommended for all patients in high and extremely high prevalence areas and those in high-risk groups elsewhere because the undiagnosed prevalence is likely to be much higher than in the general population. It is worth noting that since this evidence was published, the cost of HIV treatment has decreased and life expectancy has increased leading to a likely downward revision of the cost-effectiveness threshold. The cost-effectiveness threshold for testing programmes can be applied where relevant (e.g. high/extremely high areas and indicator condition with the on elimination of HIV transmission it should not be as where there is an identified need for testing, and all individuals the recommended should be offered a test. These guidelines were by the HIV the for and HIV and the The the for the evaluation and of evidence and the of recommendations The of the who were by and a of In of all were to to the by an of Community groups people living with HIV were to the Community The purpose and that were identified as an from the guidelines were agreed by the were agreed and a by an information of the (including the of populations, and and the can be on the website The for the guidelines the period from to and from 2014 and For and healthcare evidence was identified and by with in the the into that these guidelines are public health guidelines and on different of and the of evidence for and and the of All training in the of the the evidence. reflects the of the evidence of the to the healthcare the evidence is (e.g. we the term the healthcare should in almost all situations this evidence is robust we the term The guidelines were published for public for and was The who were in all of the For local prevalence All sexual partners of an individual diagnosed with HIV should be offered and recommended an HIV test HIV for testing may not be for of sexual were to be by (i.e. the living with HIV was on ART with a undetectable viral testing will also be by other potential risk behaviours of the without HIV. These guidelines do not and or the relevant of and guidance should be there are no UK seroprevalence data available on of HIV screening among who for antenatal care is high While remains this uptake is cost-effective when the benefit to both the and the the cost-effectiveness of universal antenatal HIV as as in the late in both and [5]. antenatal screening for HIV in where the prevalence of the population and was to be cost-effective cost information from into the costs of HIV testing, the additional antenatal and care training of healthcare and lifetime medical care for who HIV the that universal HIV screening was cost-effective at or an undiagnosed HIV prevalence of cost life Similarly, in the the cost-effectiveness of antenatal screening was to be high in populations with an undiagnosed prevalence as as 0.0075% in was not testing to reduce the number of individuals living with HIV who are of their infection in areas where undiagnosed prevalence is high at based on and the need to target HIV testing to any specific potentially further of these However, undiagnosed prevalence be and available do not local England has of the diagnosed prevalence available for To to more effectively those at increased risk of late a to diagnosed HIV prevalence in local in England as of the of the HIV testing guidelines This based on prevalence of diagnosed high local based on and extremely high local based on the was applied to national late HIV data, of late HIV diagnoses were to in high and extremely high prevalence local This that of this guidance potentially impact on of late diagnoses the data, based on the national HIV data An indicator condition is any medical condition with an undiagnosed HIV seroprevalence This may be due to either transmission with HIV (e.g. and or There are few data to recommendations on routine testing in groups with HIV incidence and prevalence other than in MSM, in most groups repeat testing should be by the of individual behavioural risk or the of indicator of patients of a of sexual health services that of for HIV of an negative test Thus, it may be the that testing more frequently than in in the of specific clinical is of annual testing in UK populations at a prevalence of is in high-risk MSM cost-effectiveness of MSM and that HIV testing for MSM was or cost-effective a period for both with annual testing and with testing either fourth-generation or testing. with was cost-effective a period with a fourth-generation test, testing with or was not cost-effective of sex workers in that it was not cost-effective to test sex workers for HIV more frequently The for testing recommendations in MSM is in the UK national guidelines on the sexual health of MSM of risk for HIV infection in MSM is based on including for PrEP guidance and evidence HIV incidence by the of in the of HIV PrEP In a of MSM diagnosed with a in a at for whom MSM of were diagnosed with a new and there were new cases of HIV In a of and were diagnosed with an specialist sexual health services in of these an HIV test the sexual health the with an of The high of HIV acquisition observed in MSM in the of the of PrEP and in the of the that MSM and UK for PrEP but who are or do not wish to should receive for HIV testing which may include interval self-sampling and testing. MSM offered self-testing testing testing in a had a of HIV risk An of HIV testing in MSM who had had an HIV test in the years an increase in uptake of but no significant in the incidence of repeat testing significantly increased for HIV testing in MSM in the UK and from UK that may be more effective in MSM than other risk groups but effectiveness is such as for testing affected populations significant with healthcare testing, including and of stigma early and repeat HIV testing among high-risk populations is in the time from infection to treatment initiation HIV self-testing the test and the result at self-sampling a at to a and receiving the results at a and community testing in or as of with no all offer to testing sexual health services and other medical The proportion of HIV diagnoses made sexual health services has increased on the testing and delivered on a than testing, high may increase HIV testing uptake among populations and to screening may be provided by community clinical governance must be to ensure services. In of more is needed to the evidence regarding for and linkage to care. In evidence for HIV self-sampling and self-testing is to a number of and the with no available from relevant to the UK context on MSM and there are data on self-sampling and self-testing in other groups or the general population. HIV self-sampling and self-testing in the UK has been based on request To have been in All have a and of greater than and are either or To be and in the UK, HIV need to be marked by the to ensure the test can be or in some are not available in the UK. However, in where they are the of are by some groups including those MSM who test frequently and of are considered when they the of HIV or there is a of a a test is not to HIV and testing is required. that may benefit from HIV self-testing include those with a high prevalence of HIV, vulnerable populations who may be likely to access testing and those who test frequently due to ongoing risk. HIV self-testing is among different groups and in different settings The most benefits of self-testing are and not to a healthcare and of in a to HIV testing services, in testing testing and of an HIV with no evidence of and increase in behaviour evidence of with such as testing, or health or to self-testing include of out the test, the outcome or having a test result without any immediate of experience with self-testing and of the availability of a self-testing are also reported While self-testing can HIV testing, the and have a window period than fourth-generation which that a HIV infection is the HIV have been high An at UK MSM and black African individuals a new HIV of had not tested for HIV, described the as and the service Of the who were all reported testing and with HIV services linkage to care self-testing vary from In the of reported the to into care a particularly the result was however, the evidence of actual linkage into care is and further is required in the of emergency who an HIV test higher HIV testing among individuals provided with an HIV with those who were offered a national self-sampling service has been offered to populations in England a The service was by of local at some the period to The service with a a of at a cost of test The individuals who had tested for HIV of and of that of MSM who a result from an HIV self-sampling were to care self-sampling services are important for testing access in where individuals may have to to The services are and confidential, can be a and there is no need to a to the test. is considered by some have that obtaining a is test and of access to from healthcare UK HIV self-sampling in a service that from to significantly for at for by were also higher for In a of HIV testing, in and the HIV testing all target groups at higher coverage than testing, increased testing of high-risk behaviour and HIV Community are to and HIV testing. have that in these settings is and cost-effective of voluntary and testing services in that there is the services were in national and most were and In a of more than HIV in MSM in there were new diagnoses and of those diagnosed were to care and a of had tested for HIV in that HIV high of test uptake testing* to increase coverage and HIV testing. of testing in care settings have been to be with This approach the with coverage and a of different healthcare settings testing is as practice in antenatal and sexual health and is effective of testing from test offer the high to patients to increase offer in (e.g. education and and can to increased test but are to in care settings and the term home sampling and testing for HIV may increase the of testing in groups but not all individuals testing is and effective in some areas but may not be or for in care It has been as a to HIV testing in these settings There are for routine HIV on through and self-testing and which can be in the in the community setting or as a home test. The window period of a test can be as the time interval to infection and of that the window period when HIV can be consistently by the test in of window to offer the test, at the most and to patients the window period include of the the test and the individual’s HIV have since the of the in window time for of HIV guidelines fourth-generation HIV with sampling as the with also available are testing should be according to pathways in with local do not or as of routine this may as evidence the of in cases of (e.g. HIV or on PrEP) pathways in with local that window for different HIV screening and the for results and data from and to the window period for and fourth-generation and the of a test result the window period. For the of a HIV test result was and and for fourth-generation the were and were from this and are to have window than and HIV the HIV-1 test HIV-1 test for by the from HIV in the of HIV and results was with period from to HIV data to the window period for test. The window period data for of screening test are in including (i.e. the number of by which time of HIV a screening The that of HIV be identified by fourth-generation by 45 and most by All were of infection by PrEP and early ART initiation in infection can the HIV or HIV in a setting in which the HIV viral load is likely to be guidelines on the of HIV PrEP that test results in individuals or PrEP should be with a and further for and the of should be informed information to HIV on PrEP is and may including and increase in the of in a repeat in a the negative should be considered and with HIV on PrEP should repeat testing and PrEP and for more near to cut-off in screening (including either or on results of in on or of and and to of test results from a of to PrEP with to in serological to HIV infection Barriers to HIV testing can at including health healthcare and of or may as a to of testing. interventions to and HIV testing have been The most and effective of routine HIV testing has been the of universal HIV testing in antenatal in the UK and This is offered on a opt-out as of routine care. The uptake is near universal with coverage and this with of the has to the near elimination of transmission of HIV in the UK opt-out HIV testing as of a sexual health for patients sexual health has been similarly and is to patients and these the of routine HIV testing in other clinical settings has been to HIV testing in services for and have had results of patients medical services such as emergency and medical in areas of high prevalence have that patients have few to the offer of a test and when offered the uptake is high It was in an area of high prevalence in that individual practice HIV testing increased by for additional general who a and that this increase was years of other have no to request consent from patients for testing. Although this was as it and confidence it was not in the term the of the more robust approach has been to HIV testing into routine that the offer of the test practice with no additional required This to HIV testing, the test of the routine work for all patients with no consent required that required for any routine test. of the and can be by agreed standards including for the of and for for including people in and provides a for on of adults aged years and who to on their (including the The to England and In the with for which there is a Medical guidance In on is published by the and the on how to assess treatment of patients who is available in the relevant of practice for and is the should be of the test result as as a a should be made on according to the (e.g. at risk and or or or other or or or more in infection other of or or or or or or other or or other of or or more in or The the and the and and for of the guidelines and