Increasing HIV testing in non-genitourinary settings: a follow-up study in general practice and a new study in a hospital setting

Sirs: In 2009, we wrote to IJSA about efforts to increase HIV testing among our local general practitioners (GPs). Five months after brief advice on HIV testing (a 1-page document) was sent to our local GPs, there was a 20% increase in HIV tests requested by GPs. ¹

Pleased with this success, we felt it would be worthwhile sending similar advice to our hospital consultants. In addition, we decided to review the number of HIV tests sent from GPs several months after the original study, to see if the increase in HIV testing had been sustained.

HOSPITAL HIV TESTS

Our acute hospital (Lancashire Teaching Hospitals NHS Foundation Trust, UK) is a large foundation trust in the heart of Lancashire, split across two separate sites: Royal Preston Hospital and Chorley and South Ribble District General Hospital. The trust provides a range of secondary care services to a population of over 370,000. Due to the large number of doctors working at the trust, we felt the most practical way of distributing our advice would be to create a document that could be emailed to all the consultants (approximately 240) for further dissemination among their teams. This was sent via the trust medical director along with an encouraging email from him. The document was similar to that sent to GPs: a double-sided A4 sheet. One side was a guide to the practical aspects of HIV testing, the other side a summary table of common clinical indicator diseases (adapted from the UK national guideline on HIV testing ² ). The document was sent out on 1 April 2009.

In order to make the hospital study comparable to the previous GP study, where we had used a five-month follow-up period, we compared five-month timeframes again. Our virology lab provided us with the number of HIV test requests coming from within the acute hospital setting. We discounted tests ordered as part of routine screening in antenatal clinics, as this policy has been in place for several years following the adoption of widespread opt-out antenatal screening.

In the five months before the consultant letter was sent, 187 HIV tests had been ordered from inpatient wards. In the five months after the letter, this had risen to 237 tests – an increase of approximately 27%. To confirm this was not a spurious result, we went back further and checked the period of 5–10 months before the letter was sent. There had been 191 tests ordered, similar to the five months before the letter was sent (see Table 1).

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Table 1

Number of inpatient HIV test requests before and after the letter was sent

	Number of inpatient HIV tests
Time period
10–5 months before letter was sent (1 June 2008–31 October 2008)	191
5–0 months before letter was sent (1 November 2008–31 March 2009)	187
Letter sent to consultants
0–5 months after letter was sent (1 April 2009–31 August 2009)	237
5–10 months after letter was sent (1 September 2009–31 January 2010)	225
12–17 months after letter was sent (1 April 2010–31 August 2010)	215

As with our previous study on increasing GP HIV testing, the total figures are small and should be interpreted cautiously. However, it is very interesting how comparable these figures are to the previous study (see Table 2), and it is once again heartening that such a simple exercise has increased our testing rates.

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Table 2

Number of HIV test requests from general practitioners (GPs) before and after the letter was sent

	Number of GP HIV tests
Time period
10–5 months before letter was sent (3 February 2008–2 July 2008)	108
5–0 months before letter was sent (3 July 2008–2 December 2008)	105
Letter sent to GPs
0–5 months after letter was sent (3 December 2008–2 May 2009)	126
5–10 months after letter was sent (3 May 2009–2 October 2009)	110
12–17 months after letter was sent (3 December 2009–2 May 2010)	109

IS TESTING SUSTAINED?

To see if this effect was sustained, we reviewed test requests one year later. Tables 1 and 2 demonstrate that, unfortunately, testing rates fell in both GP and hospital settings – more so in general practice.

It would have been useful to measure the true increase in the number of hospital-based tests by looking at how many patients ‘eligible’ (according to national guideline ² ) for an HIV test were admitted during each time frame. Unfortunately these data were difficult to determine the way the study was conducted. It was more straightforward to simply monitor the number of HIV tests requested from the local laboratory in response to our prompting letter. The bottom line is that simple advice and encouragement can increase HIV testing in both general practice and hospital medicine, but this increase is not sustained. Clearly we must seek ways of keeping HIV testing on the radars of our clinical colleagues.