HIV testing: increasing uptake among people who may have undiagnosed HIV

NICE and Public Health England


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Offering and recommending HIV testing in different settings

Local prevalence

  • Offer and recommend HIV testing based on local prevalence and how it affects different groups and communities. Use Public Health England's sexual and reproductive health profiles and local data to establish:
    • local HIV prevalence, including whether an area has high prevalence or extremely high prevalence
    • rates of HIV in different groups and communities

Specialist sexual health services (including genitourinary medicine)

  • Offer and recommend an HIV test to everyone who attends for testing or treatment
  • Ensure both fourth-generation serological testing and point-of-care testing (POCT) are available

GP surgeries

  • In all areas, offer and recommend HIV testing 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 HIV in Europe's HIV in indicator conditions
    • is known to be from a country or group with a high rate of HIV infection
    • 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
    • is a trans woman who has sex with men and has not had an HIV test in the previous year
    • reports sexual contact (either abroad or in the UK) with someone from a country with a high rate of HIV
    • discloses high-risk sexual practices, for example the practice known as 'chemsex'
    • is diagnosed with, or requests testing for, a sexually transmitted infection
    • reports a history of injecting drug use
    • 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)
  • In areas of high and extremely high prevalence, also offer and recommend HIV testing to everyone who has not previously been diagnosed with HIV and who:
    • registers with the practice or
    • is undergoing blood tests for another reason and has not had an HIV test in the previous year
  • Additionally, in areas of extremely high prevalence, consider HIV testing opportunistically at each consultation (whether bloods are being taken for another reason or not), based on clinical judgement
  • Offer and recommend repeat testing to the people mentioned above
  • If a venous blood sample is declined, offer a less invasive form of specimen collection, such as a mouth swab or finger-prick

Community settings

  • Providers of community testing services (including outreach and detached services) should set up testing services in:
    • areas with a high prevalence or extremely high prevalence of HIV, using venues such as pharmacies or voluntary sector premises (for example, those of faith groups)
    • venues where there may be high-risk sexual behaviour, for example public sex environments, or where people at high risk may gather, such as nightclubs, saunas and festivals
  • Recognise that not all community settings are appropriate for providing testing services, for example because tests should be undertaken in a secluded or private area (in line with British HIV Association guidelines)
  • Ensure that people who decline or are unable to consent to a test are offered information about other local testing services, including self-sampling. See making decisions using NICE guidelines for more information about consent
  • Ensure that lay testers delivering tests are competent to do so and have access to clinical advice and supervision

Increasing opportunities for HIV testing

Point-of-care testing

  • Offer point-of-care testing (POCT) in situations where it would be difficult to give people their results, for example if they are unwilling to leave contact details
  • Explain to people at the time of their test about the specificity and sensitivity of the POCT being used and that confirmatory serological testing will be needed if the test is reactive

Self-sampling

  • Consider providing self-sampling kits to people in groups and communities with a high rate of HIV 
  • Ensure that people know how to get their own self-sampling kits, for example, by providing details of websites to order them from

Repeat testing

  • When giving results to people who have tested negative but who may have been exposed to HIV recently, recommend that they have another test once they are past the window period
  • Recommend annual testing to people in groups or communities with a high rate of HIV, and more frequently if they are at high risk of exposure (in line with Public Health England's HIV in the UK: situation report 2015). For example:
    • men who have sex with men should have HIV and sexually transmitted infection tests at least annually, and every 3 months if they are having unprotected sex with new or casual partners
    • black African men and women should have an HIV test and regular HIV and sexually transmitted infection tests if having unprotected sex with new or casual partners
  • Consider the following interventions to promote repeat testing:
    • call–recall methods using letters or other media, such as text messages or email, to remind people to return for annual testing
    • electronic reminders in health records systems to prompt healthcare professionals to identify the need for testing during appointments and offer it if needed

People who decline a test

  • If people choose not to take up the immediate offer of a test, tell them about nearby testing services and how to get self-sampling kits

Partners of people who test positive

  • Partners of people who test positive should receive a prompt offer and recommendation of an HIV test through partner notification procedures

Promoting awareness and uptake of HIV testing

Content

  • Materials and interventions for promoting awareness and increasing the uptake of HIV testing should be designed in line with NICE's guidelines on behaviour change: general approaches and behaviour change: individual approaches and patient experience in adult NHS services
  • Provide promotional material tailored to the needs of local communities. It should:
    • provide information about HIV infection and transmission, the benefits of HIV testing and the availability of treatment
    • emphasise that early diagnosis is not only a route into treatment and a way to avoid complications and reduce serious illness in the future, but also reduces onward transmission
    • detail how and where to access local HIV testing services, including services offering POCT and self-sampling, and sexual health clinics
    • dispel common misconceptions about HIV diagnosis and treatment
    • present testing as a responsible act by focusing on trigger points, such as the beginning of a new relationship or change of sexual partner, or on the benefits of knowing one's HIV status
    • address the needs of non-English-speaking groups, for example, through translated and culturally sensitive information
  • Ensure interventions to increase the uptake of HIV testing are hosted by, or advertised at, venues that encourage or facilitate sex (such as some saunas, websites, or geospatial apps that allow people to find sexual partners in their proximity). This should be in addition to general community-based HIV health promotion
  • Promote HIV testing when delivering sexual health promotion and HIV prevention interventions. This can be carried out in person (using printed publications such as leaflets, booklets and posters) or through electronic media
  • Ensure health promotion material aims to reduce the stigma associated with HIV testing and living with HIV, both among communities and among healthcare professionals
  • Ensure health promotion material provides up-to-date information on the different kinds of HIV tests available. It should also highlight the significantly reduced window period resulting from the introduction of newer tests such as fourth-generation serological testing

Methods of raising awareness

  • Use or modify existing resources, for example TV screens in GP surgeries, to help raise awareness of where HIV testing (including self-sampling) is available 
  • Consider a range of approaches to promote HIV testing, including:
    • local media campaigns
    • digital media, such as educational videos
    • social media, such as online social networking, dating and geospatial apps
    • printed materials, such as information leaflets

Reducing barriers to HIV testing

  • Advertise HIV testing in settings that offer it (for example, using posters in GP surgeries) and make people aware that healthcare professionals welcome the opportunity to discuss HIV testing
  • Staff offering HIV tests should:
    • emphasise that the tests are confidential. If people remain concerned about confidentiality, explain that they can visit a sexual health clinic anonymously.
    • be able to discuss HIV symptoms and the implications of a positive or a negative test
    • be familiar with existing referral pathways so that people who test positive receive prompt and appropriate support
    • provide appropriate information to people who test negative, including details of where to get free condoms and how to access local behavioural and preventive interventions
    • recognise and be sensitive to the cultural issues facing different groups (for example, some groups or communities may be less used to preventive health services and advice, or may fear isolation and social exclusion if they test positive for HIV)
    • be able to challenge stigmas and dispel misconceptions surrounding HIV and HIV testing and be sensitive to people's needs
    • be able to recognise the symptoms that may signify primary HIV infection or illnesses that often coexist with HIV. In such cases, they should be able to offer and recommend an HIV test
  • Ensure practitioners delivering HIV tests (including those delivering outreach POCT) have clear referral pathways available for people with both positive and negative test results, including to sexual health services, behavioural and health promotion services, HIV services and confirmatory serological testing, if needed. These pathways should ensure the following:
    • people who test positive are seen by an HIV specialist preferably within 48 hours, certainly within 2 weeks of receiving the result (in line with UK national guidelines for HIV testing 2008). They should also be given information about their diagnosis and local support groups
    • practitioners in the voluntary or statutory sector can refer people from HIV prevention and health promotion services into services that offer HIV testing and vice versa

Terms used in this guideline

Chemsex

  • This term is commonly used to describe sex between men that occurs under the influence of drugs taken immediately before and/or during the sexual session. The drugs most commonly associated with chemsex are crystal methamphetamine, GHB/GBL, mephedrone and, to a lesser extent, cocaine and ketamine

Extremely high prevalence

Fourth-generation serological testing

  • Fourth-generation tests detect HIV antibodies and p24 antigen simultaneously. This means they have the advantage of reducing the time between infection and testing HIV positive to about 1 month

High prevalence

Lay tester

  • A non-clinical practitioner who has been trained to carry out HIV tests

Point-of-care testing

  • Point-of-care tests (POCT) or 'rapid' tests are a common way to test for HIV. They are easy to use when an alternative to venepuncture is preferable, for example outside conventional healthcare settings and if it is important to avoid a delay in obtaining a result. However, they have reduced specificity and sensitivity compared with fourth-generation laboratory tests. This means there will be false positives, particularly in areas with lower HIV prevalence, and all positive results need to be confirmed by serological tests

Public sex environments

  • Public sex environments are public areas where people go to engage in consensual sexual contact (both same sex and opposite sex)

Self-sampling

  • Self-sampling HIV kits allow people to collect their own sample of blood or saliva and send it by post for testing. They usually receive negative results by text message

Self-testing

  • Self-testing kits allow people to perform their own HIV test in a place of their own choosing and get an immediate result (typically within 15–20 minutes)

Window period

  • The window period is the time between potential exposure to HIV infection and when a test will give an accurate result. The window period is 1 month for a fourth-generation test and 3 months for older tests

References

full guideline available from...
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/NG60

National Institute for Health and Care Excellence and Public Health England. HIV testing: increasing uptake among people who may have undiagnosed HIV (Joint NICE and Public Health England guideline). December 2016.





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