HIV testing in dermatology – a national audit

Reducing the number of individuals presenting with late-stage human immunodeficiency virus (HIV) remains a key health priority in the United Kingdom. ¹ Late HIV diagnosis (a CD4 cell count of <350 cells/mm³ within three months of diagnosis) is associated with a ten-fold increased risk of death within one year when compared to earlier diagnosis and an increased transmission risk. ² A 2015 UK government report describes the percentage of new, late-stage HIV diagnoses as ‘stubbornly and unacceptably high’, given 40% of individuals have late-stage disease at diagnosis. ³

An audit in 2012 compared the practice of HIV testing by UK dermatologists against national guidelines published by the British HIV Association (BHIVA).^4,5 These guidelines advise testing for HIV in all patients with severe/recalcitrant psoriasis or seborrhoeic dermatitis, multi-dermatomal/recalcitrant herpes zoster and suspected Kaposi’s sarcoma. Rating the likelihood of HIV testing for specific skin conditions between 1 and 10 (1 = never test, 10 = always test), severe/recalcitrant psoriasis scored 5, and both severe/recalcitrant seborrhoeic dermatitis and multi-dermatomal/recalcitrant herpes zoster scored 7. Since 2012, additional strategies have been implemented to increase HIV awareness and testing, such as national HIV testing week, and advising all patients attending healthcare departments in high HIV-risk areas to be tested. We decided to re-audit attitudes and practice of HIV testing by UK dermatologists including hospital practitioners and general practitioners with special interest in dermatology (GPwSI).

An anonymous, internet-based survey was sent to UK dermatologists. There were 50 responses (22 consultants, 17 GPwSI, seven associate specialists and four registrars); this relatively small number probably reflects the increasing number of internet-based surveys circulating, allowing less time for practitioners to reply to them all. The likelihood of HIV testing for specific cutaneous diagnoses was rated 1–10 (1 = never test, 10 = always test). The median testing likelihood for severe/recalcitrant seborrhoeic dermatitis was 6.2; severe/recalcitrant psoriasis 4.8; multidermatomal/recalcitrant herpes zoster 6.5 and Kaposi’s sarcoma 9.4. Consultants, followed by registrars, were most likely to check HIV status in patients with severe inflammatory dermatoses, with GPwSI least likely. All respondents believed HIV testing was an appropriate part of their role. Figure 1 illustrates the breakdown of testing likelihood within different dermatological groups. The commonest reasons cited as barriers to testing were concerns of offending patients (52% respondents), patients attending with relatives/friends (41%), lack of knowledge when testing is appropriate (31%), feeling uncomfortable with HIV testing counselling (29%), being unsure of follow-up procedures (21.4%) and time restraints (19%). Overall confidence in HIV counselling was 7.7 (1 = not at all comfortable, 10 = very comfortable), with consultants’ and registrars’ confidence levels both 8.7, whilst GPwSIs’ and associate specialists’ levels of 6.5 and 6.7, respectively. Only 24% of responders were aware of the BHIVA guidelines for HIV testing. A large proportion of respondents (100% of registrars, 94% of GPwSI, 71% of associate specialists and 45% of consultants) believed that increased training in HIV testing would be beneficial.

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Figure 1.

Likelihood of initiating HIV testing for indicator diseases in different professional dermatology groups. 0 = never test, 10 = always test (Kaposi’s sarcoma has been omitted due to almost all persons testing for HIV if suspecting this condition). *p < 0.05, **p < 0.01.

This audit reveals that HIV testing in key indicator skin conditions remains below the standard set out in national guidelines and that the practice has not changed markedly since 2012. Furthermore, GPwSI have a lower likelihood of testing and lower confidence with counselling when compared to dermatology consultants, registrars and associate specialists. This is likely due to dermatology specialists seeing these cases more frequently in practice and thus being more comfortable with initiating HIV testing and counselling. Specialists were also more likely to be aware of the BHIVA guidelines (31%) when compared to GPwSI (12%), which may also contribute to an increased likelihood of testing. Notably, multiple other dermatological conditions were cited as triggers for HIV testing which were not included in the BHIVA guidelines, including recurrent unexplained candidiasis and exanthems with lymphadenopathy. European guidelines state that, in addition to the indications above, HIV testing should be performed in patients with unexplained lymphadenopathy, oral hairy leukoplakia and candidiasis. Oesophageal/bronchial/tracheal candidiasis is classed as an AIDS-defining condition. ⁶ There is therefore a discrepancy between European and national guidelines for initiating HIV testing. The reasons for this are unclear; however, it is important for guideline development groups to communicate with one another to promote HIV testing in all key indicator diseases.

There has been some discussion on the concept of universal HIV testing; however, it is still in its infancy. The United States Centers for Disease Control and Prevention now recommends opt-out non-targeted HIV testing for all outpatients, identifying emergency departments as especially well placed for introducing this mandate. ⁷ There appears to be a poor uptake of this recommendation currently. ⁸ Within centres which are offering routine opt-out testing, there is a highly variable uptake, although uptake is higher than opt-in testing. ⁹ More data are required before conclusions can be drawn as to whether this directive is cost-effect; however, initial research has shown that universal HIV testing is likely to be cost-effective in the UK. ¹⁰

In summary, UK-wide education of dermatology practitioners to increase knowledge of, and comfort undertaking HIV testing is necessary to aid timely diagnoses of HIV. Universal testing appears to be a cost-effective mandate and may be a realistic healthcare goal in the UK in the future.