In developed countries, HIV is now a treatable medical condition and the majority of those living with the virus and on treatment remain fit and well. However a significant number of people in the United Kingdom are unaware of their HIV infection and remain at risk of being infected and of passing their virus to others. Late diagnosis is the most important factor associated with HIV-related morbidity and mortality in the UK.

It is in this context that the British HIV Association has issued new guidelines for HIV testing recommending that “patients should therefore be offered and encouraged to accept HIV testing in a wider range of settings than is currently the case.”

Elizabeth at the Wisdom of Whores, thinks that the guidelines “are very nearly extremely sensible. But…” are making “very little sense” when recommending “testing just about everyone in the areas of the country where more than one in 500 adults is currently known to be infected with HIV [...]. More importantly, it creates a smokescreen behind which medics can hide.”

Elizabeth supports testing people who are most-at-risk – I prefer vulnerable and why will become clearer below, such as Gay men, people who came to the UK from Sub-Saharan Africa, Injecting Drug Users, sex workers, those who have sex with all these above and those who have unprotected sex with a lot of people, but she disagrees with this part of the guidelines:

An HIV test should be considered in the following settings where diagnosed HIV prevalence
in the local population (PCT/LA) exceeds 2 in 1000 population (see local PCT data):

1. all men and women registering in general practice
2. all general medical admissions.

The introduction of universal HIV testing in these settings should be thoroughly evaluated for acceptability and feasibility and the resultant data made available to better inform the ongoing implementation of these guidelines.

Elizabeth believes that offering and HIV test “to every school teacher in for a hip replacement, every maiden aunt moving to a new job in an area favoured by gay men” would make little sense.

First we should give a little credit to our GPs and safely assume that the maiden aunt moving to a new job in Soho or Canal Street, would not be offered an HIV test on this basis only. Second, why every school teacher in for a hip replacement should not be offered the opportunity of an HIV test?

Agreed, teacher with such need may not be immediately be seen as part of the “at-risk” category. But how do we know that for sure? How do we know that a teacher is not one of those who is having sex with someone “at-risk” and hence would fall in the category for which it is acceptable to offer an HIV test? Viagra does miracle giving a “second life” to male teacher in need of a hip replacement and it is a tad patronising to assume that women in a similar situation live in a convent (more on hip replacement needs and risk). It is also disregarding the possibility that these people may have been infected long before they were in need of a hip replacement as there are increasing evidence that HIV also affects the aged.

“Between 10-13% of all HIV-positive individuals in the United States are aged over 50, and the number is expected to rise due to both new infections of older people, and the ageing HIV population who are living longer due to the success of anti-HIV therapies.“

This is where the concept of vulnerability is more appropriate than that of risk.

Why not simply engage with the patient as suggested by Elizabeth, talk to them about their sex life? And that where I ask “what for?” First GP’s time is costly, second, asking a 60 years old who may have been infected 10 years earlier about his current sex life would provide little valuable information.

Selective HIV testing only makes sense in limited settings, where health budgets or qualified personal and infrastructures are limited such as in developing countries. In a developed country like the United Kingdom this is not the case (though….). Everybody above a certain age could be tested on a regular basis and put on treatment without placing a heavy burden on the NHS budget. Beside there are two more reasons to do this.

The first is ethical. When there is no guarantee that vulnerability is limited only to a group of people and when treatment can be offered to all, there is no reason to offer testing and treatment on a priority or at-risk basis. To do so would be unethical.

The second is a study by a group in Vancouver which “calculated that expanding antiretroviral therapy (ART) to everyone diagnosed with HIV with a CD4 count below 350 cells/mm3, would have a pronounced effect on transmission, by reducing viral load on a population level.“ As a result, the western Canadian province of British Columbia will implement a new, aggressive strategy to expand antiretroviral coverage in order to curb new HIV infections.

So, test, test more, test all, test often and treat.

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