Abstract
Following the publication of the UK national guidelines for HIV testing 2008, we carried out a local audit to determine the level of awareness of these guidelines among doctors working in Sunderland Royal Hospital, Sunderland, UK. An email questionnaire was distributed. Over two-thirds of respondents were unaware of the publication of the guidelines. Only 36% of respondents felt comfortable in offering a patient testing for HIV. The majority of doctors who responded lacked knowledge and confidence in issues surrounding HIV management and diagnosis, suggesting that better dissemination of information and training is still needed.
INTRODUCTION
In September 2008, the joint British HIV Association (BHIVA)/British Association of Sexual Health and HIV (BASHH)/British Infection Society (BIS) UK national guidelines for HIV testing were published to facilitate an increase in HIV testing in all health-care settings. 1 It is estimated that one-third of people currently living with HIV in the UK remain undiagnosed. 2 A previous audit carried out by BHIVA shows that 17% of new HIV diagnoses have a clinical episode likely to be HIV-related in the year prior to diagnosis, which represents a missed opportunity for testing. 3 We carried out an audit to ascertain the degree of awareness of these new guidelines locally, as well as medical practitioners' knowledge of HIV and their opinions around testing for it.
METHODS
In December 2008, an email questionnaire was distributed to 324 doctors, working in fields other than HIV, at Sunderland Royal Hospital, Sunderland, UK. One email reminder was sent to people who had not responded within three weeks. Questions were all multiple-choice and were grouped into five themes (Table 1).
Example of the email questionnaire that was distributed
HAART = highly active antiretroviral therapy; GU = genitourinary
RESULTS
We received 70 responses within the study period: 34 from consultants and 36 from junior doctors, giving an overall response rate of 21.6%. Of those who responded, 67% were unaware of the guidelines, 26% were aware of them but had not read them and only 3% were aware of and had read them. The scale of undiagnosed HIV in the UK was under-estimated by 57.5% of respondents and 65% underestimated the predicted life-expectancy of someone on highly active antiretroviral therapy. In the preceding 12 months, 53% of respondents had not considered HIV in the differential diagnosis of any patient seen, 29% had tested 1–5 patients, 11% had tested >5 patients and 7% had referred to genitourinary (GU) medicine for testing. Overall, only 36% of respondents felt comfortable carrying out an HIV test, with 62% indicating that they would prefer GU medicine to provide this service. The main barrier to HIV testing was seen as lack of training (Table 2). Finally, when a selection of 17 clinical indicator diseases for adult HIV (as outlined in the guidelines) were given, only one respondent agreed that testing was appropriate in all scenarios; 30% of doctors would not have tested for HIV in any of the indicator diseases presented.
Reported barriers to HIV testing
DISCUSSION
Sunderland Royal Hospital serves an area of low HIV prevalence in the north east of England. The relatively low response rate to our questionnaire may reflect the fact that for many doctors working there HIV is not seen as an important or relevant issue. In addition to this, respondents to our questionnaire appear to lack confidence in testing for HIV, primarily due to a perceived lack of training. Many senior doctors may have had minimal or even non-existent formal training in HIV testing. However, possibly more concerning is that in a recent survey of UK junior doctors, who graduated in 2004, less than half of them felt they could conduct an appropriate HIV pre-test discussion and only 59% felt confident that they could recognize clinical indicators suggestive of HIV. 6
Concerns about the pre-test discussion, patient acceptance and the consent process all ranked highly in the reported barriers to HIV testing. This perhaps relates to the historical belief that HIV testing is in some way different from other medical investigations. Interestingly, a survey of patient opinion from people undergoing renal dialysis recently reported that 74.3% of patients receiving dialysis would be happy to be screened for all blood-borne viruses, including HIV, with no formal counselling or consent at all. 7 While this approach cannot be advocated, it does appear to support the current recommendation that the only essential elements of the pretest discussion are the benefits of testing to the individual and details of how the result will be given. 1
Perhaps the most significant finding from our audit was that the majority of respondents were unaware of the publication of the national guidelines for HIV testing. This suggests that better publicity and dissemination of the information contained within them is still needed. Our local audit led to a presentation of our findings at the hospital weekly medical meeting and the recommendation that enhanced training on HIV testing be introduced into our trust junior doctors teaching programme. It is our belief that nationally GU medicine/HIV services should take a proactive lead within their local hospitals to increase HIV testing and reduce undiagnosed HIV in the UK.