Expanded HIV testing in high-prevalence areas in England: results of a 2012 audit of sexual health commissioners

Authors


Abstract

Objectives

The aim of the study was to examine whether UK HIV testing guidelines which recommend the expansion of HIV testing in high HIV prevalence areas have been implemented in England.

Methods

An online survey tool was used to conduct an audit of sexual health commissioners in 40 high HIV prevalence areas (diagnosed prevalence > 2 per 1000) between May and June 2012. Responders were asked to provide details of expanded HIV testing programmes that they had commissioned in nontraditional settings and perceived barriers and facilitators involved in introducing expanded testing.

Results

The response rate was 88% (35 of 40). Against the key audit standards, 31% (11 of 35) of areas had commissioned routine testing of new registrants in general practice, and 14% (five of 35) routine testing of general medical admissions. The majority of responders (80%; 28 of 35) had commissioned some form of expanded testing, often targeted at risk groups. The most common setting for commissioning of testing was the community (51%; 18 of 35), followed by general practice (49%; 17 of 35) and hospital departments (36%; 13 of 35). A minority (11%; four of 35) of responders had commissioned testing in all three settings. Where testing in general practice took place this was typically in a minority of practices (median 10–20%). Most (77%; 27 of 35) expected the rate of HIV testing to increase over the next year, but lack of resources was cited as a barrier to testing by 94% (33 of 35) of responders.

Conclusions

Not all high HIV prevalence areas in England have fully implemented testing guidelines. Scale-up of existing programmes and continued expansion of testing into new settings will be necessary to achieve this.

Introduction

Traditionally, most diagnostic HIV testing in the UK has taken place in sexual health clinics and antenatal care, where high levels of testing coverage have been achieved (70% [1] and 97% [2], respectively). Nevertheless, half of the new HIV diagnoses made in the UK in 2011 took place after treatment should have been initiated [1], and around a quarter of infections remain undiagnosed. Early diagnosis of HIV infection combined with prompt initiation of antiretroviral therapy has clear individual and public health benefits [3-5].

National testing guidelines for the UK were issued in 2008 [6] and endorsed by the National Institute of Clinical Excellence (NICE) in 2011 [7]. These recommended the expansion of HIV testing in areas with a high prevalence of diagnosed HIV infection (> 2 per 1000), including the routine universal offer of HIV testing for general medical admissions and new registrants in general practice, as well as the expansion of targeted outreach testing in community settings. Following the publication of the guidelines, it is not clear to what extent they have been implemented on a national level. While there is some evidence that an increasing proportion of tests are taking place outside of traditional settings, particularly in general practice [8], this has been from a low starting point [9] and there are likely to remain missed opportunities for testing in nonspecialist medical settings [8, 10, 11].

Following the inclusion of late HIV diagnosis as an indicator in the national 2012 Public Health Outcomes Framework [12], we conducted an audit of sexual health commissioners in high-prevalence Primary Care Trusts (PCTs), organizations responsible for commissioning healthcare services in England, in order to establish to what extent they had implemented the 2008 national HIV testing guidelines. We also explored the perceived barriers and facilitators to the expansion of HIV testing outside of traditional settings.

Methods

Data from national HIV surveillance and the Office for National Statistics were used to identify high HIV prevalence areas in England, defined as areas with a prevalence of diagnosed HIV infection of > 2/1000 among 15−59-year-olds in 2011. Of the 152 PCTs in England, 40 met this definition. Lead sexual health commissioners in these PCTs were invited by email to complete the audit via a web-based survey tool.

The questionnaire asked whether responders were aware of existing HIV testing guidelines, whether they had commissioned expanded testing in a variety of services, what limitations were in place, and for details of the type of tests and funding mechanisms used. Responders were also asked which of a number of factors were acting as barriers to the introduction of routine testing. If no response was received within 4 weeks then an email reminder was sent, followed by attempted telephone contact if this was unsuccessful.

Using information from the questionnaire, we assessed whether high-prevalence PCTs had commissioned testing services to meet two key national testing standards: firstly, routine HIV testing of new registrants in general practice; and secondly, routine HIV testing of general medical admissions. Additionally, we collected information on the number and type of outreach testing services that had been commissioned in community settings.

Results

Of the 40 commissioners contacted for the audit, 35 responded, representing an 88% response rate. All responding commissioners were aware of recent HIV testing guidelines, and most (80%; 28 of 35) had introduced some form of expanded testing; most commonly in community settings (51%; 18 of 35), followed by general practice (49%; 17 of 35) and hospitals (37%; 13 of 35). A minority of PCTs had commissioned testing in all three of the above settings (11%; four of 35).

Areas with a higher prevalence were more likely to have commissioned expanded testing. Nearly all PCTs with a prevalence of diagnosed HIV infection > 5 per 1000 had commissioned some form of expanded testing (92%; 11 of 12), with 50% (six of 12) commissioning testing in general practice and 50% (six of 12) in hospitals. A third of PCTs with a prevalence of diagnosed HIV infection of between 2 and 3 per 1000 did not commission any form of expanded testing (33%; four of 12), with a third (33%; four of 12) commissioning testing in general practice and only one commissioning testing in hospitals (Fig. 1).

Figure 1.

Proportion of areas offering expanded testing in each medical setting by local prevalence of diagnosed HIV infection.

Against the first testing standard, 31% (11 of 35) of high-prevalence PCTs had commissioned routine testing of new registrants in general practice; however, only a small minority of practices (median 10–20%) participated in areas where this took place. A higher proportion of PCTs met the first testing standard within London (38%; nine of 24) than outside London (18%; two of 11) but the difference was not significant (χ2 = 1.31; P = 0.25). Several forms of testing in general practice were reported other than routine testing of new registrants. Testing was limited to individuals belonging to high-risk groups in 20% (seven of 35) of PCTs, including men who have sex with men (MSM), recent migrants and people from countries with a high HIV prevalence, as well as patients with clinical indicator conditions. HIV testing was included as part of a programme of broader opportunistic sexually transmitted infection (STI) screening in general practice in 17% (six of 35) of PCTs. Point of care testing was commonly used in general practice (10 of 15; 67%), either solely (four of 15; 27%) or together with serological testing (six of 15; 40%).

Against the second testing standard, 14% (five of 35) had commissioned routine testing of general medical admissions in a hospital covering their area. There was no evidence of a difference in the proportion of PCTs meeting the second standard in London (12.5%; three of 24) compared with outside London (18.2%; two of 11). The most common hospital setting for testing was in emergency departments (26%; nine of 35), followed by general medical admissions (17%; six of 35) and medical assessment units (17%; six of 35). Routine untargeted testing was offered in most instances; in two PCTs testing was limited to individuals belonging to high-risk groups only. Laboratory testing was commonly used in hospitals (seven of 10; 70%).

Community testing had been commissioned in 51% (18 of 45) of high-prevalence PCTs, taking place via outreach programmes carried out by charities and voluntary sector organizations. Population groups targeted by outreach programmes included MSM (in six PCTs), Africans (four), sex workers (two), injecting drug users (one) and homeless people (one). Community testing settings included saunas, polyclinics, pharmacies, prisons, churches and health centres. Point of care testing alone was used in 63% (10 of 16) of community settings.

Lack of resources – time, staffing or funding – was cited as a barrier to the introduction of expanded testing by 94% (33 of 35) of commissioners, followed by the reorganization of the National Health Service (NHS) (66%; 23 of 35) and the training needs of clinical staff (61%; 22 of 35). Few commissioners considered patient acceptability or the lack of a clear referral pathway to be important barriers (Table 1). The majority of commissioners (74%; 26 of 35) expected the rate of HIV testing carried out in their area to increase over the course of the next year, with none anticipating a decrease in testing.

Table 1. Perceived barriers to expanded HIV testing
Perceived barriersn (total = 33*)%
  1. *Two commissioners did not complete this section of the audit.
Lack of resources − time, staffing or funding3194
Training needs of clinical staff2267
NHS reorganization2370
Cost of available testing kits2061
Level of awareness and education among public2061
Professional resistance/lack of clinical leadership1958
Patient acceptability1133
Lack of clear care pathway for those testing positive618

Discussion

The results of this audit, the first to examine levels of expanded testing in all high-prevalence areas in England, show that there are high levels of awareness of HIV testing guidelines among commissioners, and the majority (74%) believed that the rate of testing in their area would increase over the course of the next 12 months. Most respondents had commissioned some form of expanded HIV testing (80%) in their area; however, only a minority covered the two medical settings mentioned in national testing guidelines, namely new registrants in general practice (31% of PCTs) and general medical admissions (14%). Where respondents had commissioned testing for new registrants in general practice, this was often limited to a small number of practices.

Evidence for the effectiveness of expanded testing derives from modelling of the individual- and population-level impact of earlier diagnosis. Modelling work from the USA and France suggests that screening of the general population in medical services is likely to be cost effective, particularly when targeted at high-prevalence areas [13, 14]. Modelling of the UK HIV epidemic has shown that higher rates of testing combined with timely initiation of antiretroviral therapy can result in reduced HIV incidence [15].

Testing pilots have demonstrated the feasibility and acceptability of HIV testing in nontraditional settings [16-19], which ties in with the results of this audit, with the most commonly cited barriers to testing relating to lack of resources and clinical training needs, rather than patient acceptability. This is consistent with research which indicates increased normalization of testing [20]. Nevertheless, clinical audits suggest that there remain missed opportunities for testing among both general medical admissions [8] and patients in general practice [10, 11]. The results of this audit confirm that routine HIV testing in these settings has been commissioned in only a minority of high-prevalence areas, and prioritizing the introduction of routine testing in these settings will be necessary to fully implement national testing guidelines.

There are clear opportunities to improve the coverage of HIV testing in England, and the introduction of expanded testing in high-prevalence areas will form a key part of any national HIV testing strategy. The higher proportion of PCTs in London offering testing of new registrants in general practice may be related to the inclusion of late HIV diagnosis as an indicator in the 2009 London Sexual Health Strategic Framework. Following the inclusion of this indicator at a national level in the 2012 Public Health Outcomes Framework [13], and the implementation of changes to responsibilities for commissioning HIV testing within the NHS, it will be important to monitor changes in the commissioning of testing over time.

Acknowledgements

We thank all the commissioners who participated in the audit.

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