HIV Testing of Patients at the Countess of Chester Hospital & Local General Practice
C O’Mahony and N Steedman (2008)
In the United Kingdom in 2006, there were approximately 7800 new diagnoses of HIV infection, the majority of which were heterosexual cases. Many did not fall into the traditional high risk categories and, as a result, many of these patients were a late diagnosis on the basis of severe HIV related complications. Early diagnosis of HIV before significant immune damage has occurred is of enormous benefit to the patient. Commencing triple therapy before permanent immune damage can actually restore the immune system to almost full potential. This now means that patients diagnosed early can be put on triple therapy and there is a strong possibility that if they respond to the drugs and the virus goes undetectable, they could have a normal life span and not suffer HIV related complications. From a humanitarian and economic point of view this now makes early diagnosis of HIV imperative.
General practice, medical and surgical specialties have generally been reluctant to engage in HIV testing, as it has been perceived as a specialist area and pre-test counselling has unfortunately acquired a totally unwarranted mystique that deters normal doctors from venturing into that area. Furthermore, many patients referred to a GUM clinic for “counselling” and HIV testing often don’t attend and the opportunity is lost. As a recent paper in the Royal College of Physicians Journal (Clinical Medicine, Volume 4, No.2 March/April 2004 pages 136-139) states “Clearly, the normalisation of the HIV Test in general medical settings has a part to play in increasing testing uptake, and in preventing deaths. By not offering HIV tests where clinically indicated general physicians are denying their patients access to appropriate life saving treatment. Routine referral to GUM services prior to testing may increase the stigma associated with testing, lead to delays and is likely to result in fewer people being tested”.
This was echoed in a recent letter from the department of health entitled ‘Improving the detection and diagnoses of HIV in non-HIV specialities including primary care (2007). ( Please see http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Sexualhealth/HIV/index.htm)
Recent experience in this Trust and in General Practice suggests HIV is not often considered in the differential diagnosis when it should be, and that there is still a perception that HIV testing is in some way unique, requiring skills not possessed by doctors.
Who and when to test for HIV ?
Assume the possibility of HIV related illness in the following clinical situations :-
infection with tuberculosis, atypical pneumonias (especially if not responsive)
cerebral lymphoma, symptoms of brain mass lesions, non-Hodgkin’s lymphoma, thrombocytopenia
herpes zoster in younger people
lymphadenopathy, chronic fatigue, weight loss, diarrhoea, night sweats, pyrexia of unknown origin
oral / oesophageal candidiasis or hairy leucoplakia.
primary infection with a seroconversion illness (eg. flu like illness, rash, meningitis, etc)
the presence of another intravenous or sexually transmitted infection, eg. syphilis, hepatitis B, C, or past history of these, or serological markers of past infection.
Unusual or sudden development of severe psoriasis, giant molluscum contagiosum
Don’t forget, HIV testing is now routinely done antenatally, so if someone has had a pregnancy recently, the chances are that they have already been tested for HIV. The same also goes for a blood transfusion, so it’s worth enquiring about a history of donations.
Written consent is not necessary. Inform patients that you are recommending a blood test for a variety of conditions, usually to outrule the possibility. For example, in somebody with lymphadenopathy you would be recommending blood for CMV, toxoplasma, EBV, hepatitis B, C and HIV. The mortgage / life insurance topic is no longer a problem, as the Association of British Insurers have assured us that all forms now only ask if an individual has ever tested positive or is awaiting the results of a test. There is no need to venture into the murky waters of sexual history or sexual orientation. Sometimes the patient initiates this discussion and wants to disclose information.
The test itself
A normal clotted blood sample (red top tube) is sent to Microbiology. This same sample can be tested for other viral pathogens, as only a tiny amount is needed for the HIV test. The antibody test is usually positive within 6-8 weeks of infection, but a 3-month window period is accepted as being 100%. It does not need a ‘Danger – Infection’ sticker on it unless it is highly likely that the HIV test will be positive.
Result to patient
A discussion about getting the result is critical, as some patients who have never considered the possibility before, only become anxious once the blood has been taken. A follow-up outpatient appointment a month later is too long. Routine HIV testing is performed every weekday in the Serology Laboratory at the Countess, and if the blood is there by 9-am in the morning the result will be available by 4-pm that afternoon. If the patient is an inpatient, it should be easy to get the result and inform the patient whilst they are still in. If it’s an outpatient consultation, then discuss with the patient if they are happy to wait until their next appointment for the result. Ensure patients, address and phone numbers are correct; a mobile phone is extremely useful.
Positive HIV test result
Although not an obligation it would be wise to discuss a positive result with a member of the Sexual Health / GUM Clinic / HIV Team before engaging the patient. The team have given hundreds of HIV positive results over the years, and have the experience to cover all eventualities. A health adviser, doctor or nurse can even give the result if that’s appropriate or at least be present, or immediately available when the result is given. It is always a harrowing time. The Sexual Health / GUM / HIV Team will deal with all further issues and discussions over who needs to be told, and who else might need to be tested.
Testing patients after occupational exposure
If consent can be obtained from the index patient then HIV testing can be done and a rapid test can sometimes be performed which takes about four hours. In the rare exceptional circumstances when a patient refuses or is unconscious, testing of an existing blood sample can be performed after consultation with an experienced colleague. See GMC Guidance on ‘serious communicable diseases” – website: www.gmc-uk.org/standards/serious.htm
Contacts in GUM / Sexual Health Clinic.
Reception / Appointments: 01244 363091
Sue Owen – Tel: 01244 363085
Dr Colm O’Mahony (ext 3097)
Dr John Evans-Jones (ext 3093)
Dr Nicola Mullin (ext 3093)
Department of Genito-Urinary Medicine
Countess of Chester Hospital
NHS Foundation Trust