• HIV is a treatable medical condition
• The majority of those living with the virus in the UK are well
• Approximately 5% are unaware of their HIV infection in the UK
• their own health is at risk
• they may pass on the virus
• Late diagnosis is the most important factor associated with HIV-related morbidity
• HIV testing should occur in a wide variety of settings
• Obtain informed consent for an HIV test in the same way as for any other medical investigation

• Patients presenting with clinical features compatible with HIV
• When primary HIV infection is a differential diagnosis
• Patients presenting with Covid-19
• Anyone exposed to HIV risk e.g. needlestick injury
  • both the person exposed and potential source

Primary HIV infection (PHI)

• Symptomatic PHI occurs in approximately 80% of individuals infected by HIV
• typically 2–4 weeks after infection
• Typical symptoms include a combination of any of:
  • fever
  • rash (maculopapular)
  • myalgia
  • pharyngitis
  • headache/aseptic meningitis
• Resolves spontaneously within 2–3 weeks
• If PHI suspected, contact on-call genito-urinary physician

Clinical indicator diseases for adult HIV infection

Respiratory

• Pneumocystis pneumonia
• Tuberculosis
• Bacterial pneumonia
• Aspergillosis

Neurology

• Cerebral toxoplasmosis
• Primary cerebral lymphoma
• Cryptococcal meningitis
• Progressive multifocal leucoencephalopathy
• Aseptic meningitis
• Space occupying lesion of unknown cause
• Guillain-Barré syndrome
• Transverse myelitis
• Peripheral neuropathy
• Dementia
• Leucoencephalopathy

Dermatology

• Kaposi's sarcoma
• Severe/recalcitrant seborrheic dermatitis/psoriasis
• Multidermatomal or recurrent herpes zoster

Gastroenterology

• Persistent cryptosporidiosis
• Oral candidiasis
• Oral hairy leukoplakia
• Chronic diarrhoea/weight loss of unknown cause
• Salmonella, Shigella or Campylobacter
• Hepatitis B/C infection

Oncology

• Cervical cancer
• Non-Hodgkin’s lymphoma
• Anal cancer/intraepithelial dysplasia
• Lung/head and neck cancer
• Seminoma
• Hodgkin’s lymphoma
• Castleman’s disease

Gynaecology

• Vaginal intraepithelial neoplasia
• Cervical intraepithelial neoplasia Grade 2 or above

Haematology

• Any unexplained blood dyscrasia

Ophthalmology

• Cytomegalovirus retinitis
• Infective retinal diseases

ENT

• Lymphadenopathy of unknown cause
• Chronic parotitis
• Lymphoepithelial parotid cysts

Other

• Mononucleosis-like syndrome
• Pyrexia of unknown origin
• Anyone with a mother who is HIV positive no matter what age
• Anyone who has a partner who is HIV positive
• Men who have sex with other men
• Female sexual contacts of men who have sex with men
• Patients reporting use of injecting drugs
• Anyone from a country of HIV prevalence >1%
• Anyone who has had sex in a country of HIV prevalence >1%
• Anyone who has had sex with someone from a country of HIV prevalence >1%
• All pregnant women

Who can test?

• Doctor, nurse, midwife or trained healthcare worker

Pre-test discussion

• Give adequate information about the test and the virus to enable patient to make an informed decision
• does not require lengthy pre-test HIV counselling unless patient requests or needs this
• If patient refuses test, explore reasons for refusal
• ascertain not because misunderstanding about the virus or the consequences of testing
• Discuss any concerns about insurance cover or criminal prosecution for transmission of the virus
• correct any factual inaccuracies
• Agree arrangements for communicating result with patient at time of testing

Special groups

• Children and young people
• Learning difficulties or mental health problems
• English not their first language
• Such patients may need additional help and time to make a decision
• ensure they have understood what is proposed and why
• ensure understand what a positive/negative HIV result means (some patients could interpret ‘positive’ as good news)

Testing where patient lacks capacity to consent (including unconscious patient)

• See Consent without capacity guideline
• Discuss with consultant in genitourinary medicine or ID service
• Assessment of capacity relates to the specific issue: consent to HIV testing
• Start from presumption that patient has capacity to make this decision
• Consider whether they understand what decision they are being asked to make and can weigh up the information relevant to the decision

Temporary lack of capacity to consent

• Defer testing until they regain capacity
• unless testing is immediately necessary to save patient’s life or prevent serious deterioration of their condition

Permanent lack of capacity to consent

• Seek a decision from any person with relevant powers of attorney or follow the requirements of any valid advance statements
• If patient has not appointed an attorney or there is no advance directive, HIV testing may be undertaken where this is in patient’s best interests

The source patient in a needlestick injury or other HIV risk exposure

• Obtain consent from source patient before testing
• If source patient lacks capacity, discuss with infectious diseases or genitourinary medicine consultant
• The person obtaining consent must be a healthcare worker other than person who sustained the injury
• See Post-exposure prophylaxis

Documentation

• Document offer of an HIV test in patient’s notes together with any relevant discussion:
• if patient refuses test, document reasons
• Written consent is usually not necessary

Confidentiality

• Testing clinician (or team) must give result of HIV test (if positive) directly to patient
• not via any third party (including relatives or other clinical teams) unless patient has agreed

• Clear procedures as to how patient will receive result must be in place, especially where result is positive
• Face-to-face provision of HIV test results is strongly encouraged for:
• ward-based patients
• patients more likely to have an HIV-positive result
• those with mental health issues or risk of suicide
• those for whom English is a second language
• young people <16 yr
• those who may be highly anxious or vulnerable

HIV negative result – post-test discussion

• Inform all patients of genitourinary clinical services and provide telephone number for self-referral
• If still within window period after a specific exposure, discuss need to repeat test at 3 months to definitively exclude HIV infection
• Seek specialist advice from/referral to genitourinary medicine or ID service in the following situations:
• those at higher risk of repeat exposure to HIV infection who may require advice about risk reduction or behaviour change, including post-exposure prophylaxis
• if reported as reactive or equivocal, refer to genitourinary medicine or ID service (may be undergoing seroconversion)

HIV positive result – post-test discussion

• Before informing patient of positive result, discuss follow-up programme with infectious diseases/genitourinary specialist
• For all new HIV positive diagnoses, test a second sample
• Testing clinician must give result personally to patient in a confidential environment and in a clear and direct manner
• If patient’s first language not English, consider using an appropriate confidential translation service
• Refer to genitourinary medicine or ID service who will arrange appointment within 72 hr
• genitourinary medicine/ID specialist team will perform more detailed post-test discussion
• including assessment of disease stage, proposed treatment and partner notification

Further information

www.bhiva.org