A survey of HIV care in the UK: results of British HIV Association (BHIVA) National Audit 2010

INTRODUCTION

In 2009, the number of people living with HIV in the UK reached an estimated 86,500 and a quarter of these were unaware of their infection. ¹ In an effort to reduce the number of late diagnoses, the UK National Guidelines for HIV Testing (2008) were produced with the intention of increasing HIV testing in all health-care settings. ²

In 2010, as part of the British HIV Association (BHIVA)'s National Audit Programme, we audited the impact these guidelines have had on HIV care in the UK and recently reported one aspect regarding newly diagnosed HIV cases and missed opportunities for testing. ³ Here we report a further aspect of the audit which examined various aspects of clinical practice.

METHODS

Clinical leads of all UK sites known to BHIVA as providers of adult HIV services were invited to complete an on-line survey. Selected recommendations from the 2008 National HIV Testing Guidelines ² were assessed as target outcomes and the percentages of sites and subjects meeting these recommendations were calculated. Target outcomes assessed included: (1) HIV testing should be offered to all patients attending genitourinary (GU) medicine, antenatal, tuberculosis, viral hepatitis, drug dependency and termination of pregnancy services, (2) routine HIV test result (not reference laboratory confirmed) should be available within 72 hours of the test being performed, (3) a fourth generation antigen/antibody test should be used for HIV diagnosis. Results for each clinical site were returned to clinicians for local dissemination among colleagues.

RESULTS

One hundred and eighty-nine sites were invited to participate and 132 (70%) responded to the survey, of which 111 (84%) were GU medicine departments, 10 (8%) HIV non-GU medicine, 7 (5%) infectious diseases and four (3%) combined all three. HIV caseload was fewer than 100 patients at 32 (24%) sites, between 101 and 200 patients at 29 (22%), between 201 and 500 patients at 38 (29%), between 501 and 1000 patients at 19 (14%) and over 1000 patients at 13 (10%), with one not stated.

A high proportion of sites had been active in promoting HIV testing within their local clinical setting (Table 1).

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Table 1

Action taken to promote HIV testing

Action taken	%
Presentation to colleagues from other departments	90%
Presented case of late HIV diagnosis at Grand Rounds	86%
Issue of HIV testing raised in cases presented by other specialties in Grand Rounds	83%
Trained clinicians from other departments	76%
Initiated/supported introduction of routine testing in another department	62%
Discussed need for increased testing with Trust medical director	52%
Advised on setting up/expansion of community testing	52%
Introduced HIV care pathway(s) for other departments	51%
Displays or road shows for staff in other departments	27%
Requested medical director to consider routine testing in all general medical admissions	16%

Table 2 shows how respondents believed HIV testing was provided in other local clinical settings. In almost 100% of cases, HIV testing is offered routinely to antenatal patients and those attending GU medicine services. HIV testing is less routine in other services and is offered selectively in A&E, acute medical admission units (AMU) and medical outpatient departments. In all cases, the AMUs offering HIV testing are in areas with a diagnosed prevalence of HIV of >2 per 1000 population. ⁴ Twenty-one (16%) sites reported that at least some local GP practices offer testing routinely to new patients at registration, of which 12 are located in high-prevalence areas and nine adjacent to these areas. A further 16 (12%) sites reported plans to do so.

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Table 2

The provision of HIV testing in various clinical services

Service	Number (%) of sites where testing is recommendedroutinely	Number (%) of sites where testing is recommendedselectively	Number (%)of sites where testing is not done	Did not answer/unsure N (%)
GUM/sexual health	130 (98)	1 (1)	0	1 (1)
Antenatal	128 (97)	0	0	4 (3)
Tuberculosis	92 (70)	26 (20)	1 (1)	13 (9)
Hepatitis	66 (50)	44 (33)	1 (1)	21 (16)
Drugdependency	61 (46)	24 (18)	3 (2)	44 (34)
Termination ofpregnancy	32 (24)	21 (17)	36 (27)	43 (32)
Accident & emergency	1 (1)	69 (52)	44 (33)	18 (14)
Medical admissions	3 (2)	96 (73)	21 (16)	12 (9)
Medical outpatients	0	96 (73)	22 (17)	14 (10)

Reported turnaround times for non-urgent confirmed positive HIV test results (not reference laboratory confirmation) were within 24 hours at 16 (12%) sites, 1–2 days at 49 (37%), 3–4 days at 26 (20%), 5–7 days at 26 (20%), more than a week at 12 (9%) and not answered at 3 sites (2%).

One hundred and twenty-one (92%) sites use fourth generation antigen/antibody tests as their routine assay to diagnose HIV infection. Seven (5%) sites do not routinely use a fourth generation assay, of which one routinely uses point-of-care testing (POCT) and four (3%) were unsure or did not answer. POCT is in use in 70 (53%) sites in some (non-routine) circumstances. Fifty-seven (43%) sites report routine use of RITA (Recent Infection Testing Algorithm) for all new diagnoses.

DISCUSSION

The 2010 BHIVA audit has provided the first national data regarding the impact of the 2008 National HIV Testing guidelines on clinical practice in the UK. It is encouraging that many sites are actively promoting HIV testing in their local area. However, the main finding is that HIV testing is not being offered routinely in patients attending tuberculosis, viral hepatitis, drug dependency and termination of pregnancy services, which is inconsistent with both the HIV National Testing Guidelines and the respective guidelines of the clinical conditions/services.^5–7 This requires urgent action locally to ensure testing is being offered to these patients and that education is provided to health-care providers if not.

While it is encouraging that a number of sites report their local GPs are beginning to offer HIV testing to new patients, it is disappointing that HIV testing is not being offered more routinely in AMUs, medical outpatients and A&E departments. While HIV testing in general medical admissions is only recommended routinely in areas with HIV seroprevalence >2 per 1000 ² (and indeed the small number of sites reporting routine testing in AMU are in these areas), the majority of sites offer no testing at all. There have been a number of studies demonstrating the feasibility of offering HIV testing in such settings^8,9 and a greater expansion of testing is needed in these areas to impact on the proportion of patients diagnosed late with HIV.

A further recommendation from the audit would be to ensure routine HIV tests results are available within 72 hours and that fourth generation antigen/antibody tests are used. Urgent re-audit of this is necessary to ensure labs are currently meeting the guidelines.

Overall, there is certainly evidence of providers of HIV care promoting increased testing and education in HIV in their local area. However, greater effort is required both at a local and national level to increase education about HIV testing and to make it routine in those settings where it is currently lacking.