Much of this year’s European AIDS Conference (Belgrade, Serbia, 12 – 15 October 2011) has been a heady mix of hardcore treatment science and treatment advocacy. This is perhaps best demonstrated by the prominent role played by the European AIDS Treatment Group (EATG) during what is essentially a medical and scientific event.
Another key issue impacting across the HIV sector, in Europe and elsewhere, is poor uptake of the HIV test. If a person is not diagnosed, he or she cannot receive appropriate treatment and support, risks increased chances of morbidity and mortality, and higher likelihood of passing on the virus to sexual partners. Barriers to testing, and the implications of late presentation, were important topics covered this morning on this, the third conference day.
A key problem is that the HIV test is rarely, in any country, offered routinely. Usually, it is suggested only to patients who ‘fit’ a known at-risk group. HIV is simply not considered as a possible diagnosis even when a person has symptoms that, for those of us working in the HIV sector, are clearly a consequence of infection. Findings presented today from a recent audit by the British HIV Association (BHIVA) (2008) suggested that up to 25% of patients had a missed opportunity for a test before their subsequent, positive test. In another, French study, ‘late presenters’ –people presenting for an HIV test who are symptomatic, or with a CD4 count of less than 350cells/mm3 – account for one third of all patients entering the HIV care system from 2003-2009.
The implications of a late presentation are immense, with increased chance of mortality within five years, and the need for more aggressive initial treatment. There is also, according to an Italian study, a much higher cost implication (an increase of 70%) for treatment services, mainly because the person may be hospitalised, requiring intensive care to stabilise their condition.
A solution is to scale up routine testing, especially in non-specialist healthcare settings. In this way, HIV is detected much earlier, and the complications of late presentation avoided. There are barriers though, and the commonest reasons for ‘general’ patients not being offered an HIV test, suggested by both UK and French studies, include: lack of time; lack of information; and problems getting an appropriate blood sample (using certain rapid testing kits). Interestingly, in recent French study (2010) investigating the extent of HIV testing in private general practice, only 4% of patients refuse if a test is offered. This is not a patient problem; it is a failure in the health system.
An intriguing solution is one supported by a European group, HIV in Europe, a pan-European initiative launched in Brussels in 2007. HIV in Europe works to increase and expand HIV testing, and in a study supported by the group, the feasibility of HIV testing on the basis of ‘indicative diseases’ was explored in 2009. Here, patients from 16 sites in 14 countries (totalling 3,588 cases) were offered an HIV test if they were admitted to the health system with one or more of eight indicative conditions, which included: any sexually transmitted disease; hepatitis B or C; malignant lymphoma; and seborrhoeic dermatitis.
The findings – that HIV prevalence in the 3,588 people was 1.8% (higher that the European average, ranging from 0.1-1%) – confirm that this approach, based on clinical rather than social categories, is useful for detecting ‘hidden’ HIV. As with the BHIVA audit above, this study also found there were missed opportunities, where patients found to be HIV positive had been admitted previously with similar symptoms, but not offered an HIV test.
Undiagnosed HIV is one of the major challenges to public health in Europe, especially in areas with a rapidly changing epidemic. Increasing uptake of HIV tests is the most effective way to ensure people infected with HIV – but unaware – are able to receive prompt treatment and care. These studies provide important insights into the extent of HIV testing ‘failure’, and highlight areas of improvement that may lead to better detection. HIV cannot remain ‘hidden’ if we are to be successful in our fight against the virus.
SOURCES:
The HIV Indicator Diseases across Europe Study can be found here: www.hiveurope.eu/Project3IndicatorDiseases/tabid/72/Default.aspx
The BHIVA testing audit, ‘2010-11 survey of HIV testing policy and practice and audit of new patients when first seen post-diagnosis’, is available here (in PowerPoint form): www.bhiva.org/NationalAuditReports.aspx