Expert
Advisory Group on AIDS (EAGA)
| HIV
testing : Guidelines for pre-test discussion |
Contents
Summary:
Since these guidelines were written, policy with respect to antenatal
testing has changed. All women in England are now offered and recommended
an HIV test as part of their antenatal care, not just those in high prevalence
areas.
The United Kingdom Health Departments recommend that named testing for
evidence of HIV infection should only be undertaken with informed consent,
individuals having received information about how HIV is transmitted,
the significance of both positive and negative results and a discussion
of the particular needs and interests relevant to the individual.
The discussion about HIV and HIV testing should now be part of mainstream
clinical care. Specialist counsellors may be required if the circumstances
of the individual attending for HIV testing are complex and time consuming
and further discussion is required.
This document is suitable for use by health care workers who may be involved
in pre-test discussion. The text reflects consultation with the Expert
Advisory Group on AIDS. Annex A details the result of a process audit
of the content of current pre-test discussion which was conducted by the
United Kingdom Health Departments in October 1994.
CONTENTS
ACTION
AIMS OF GUIDELINES
GENERAL IMPORTANCE OF THE HIV TEST
PRE-TEST DISCUSSION
SECTION A
SECTION B
ANNEX A: HIV PRE-TEST DISCUSSION QUESTIONNAIRE - summary of results
ANNEX B: POST-TEST COUNSELLING
ANNEX C: THE HIV ANTIBODY TEST
REFERENCES
ACTION
Health care workers and provider unit managers should:
- ensure that confidential pre-test discussion is offered to all those
who have decided they wish to have an HIV test (either by self referral
or referral by a practitioner). The discussion should be focused in
each case to address the specific needs of the client requiring a test
and the different clinical situations in which HIV testing is provided;
- monitor and evaluate the service;
- discuss the provision of the service with purchasers;
- ensure that staff receive appropriate training;
- monitor patient satisfaction with the service, and
- also ensure post-test counselling, and adequate support and services
for positive patients are available.
AIMS OF GUIDELINES
This guidance seeks to ensure that:
- individuals requesting an HIV test receive appropriate discussion
prior to testing (whether it be in hospital, primary care or community
settings) so that they can decide whether to have an HIV test in a properly
informed way, and
- the extent of provision of pre-test discussion reflects the varying
needs of different clinical situations.
This guidance was produced in response to concern that there is a lack
of consistency in the content of pre-test discussion. The guidelines are
not prescriptive but form the framework for an appropriate and adequate
discussion for health care workers.
Although post-test counselling is not covered in detail in this particular
document the main features are outlined in Annex B.
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GENERAL IMPORTANCE OF THE HIV TEST
The early detection of HIV infection by antibody testing may:
- allow the individual to obtain immediate optimum medical and supportive
health care;
- allow the individual to receive counselling and advice and take action
to prevent transmission;
- allow women who may have been infected to seek advice and make decisions
about conception, the management of pregnancy and breast feeding;
- allow the individual to protect their sexual partners from the risk
of infection;
- allow the collection of information on the spread of the epidemic
which assists prevention and service planning, and
- allow partner notification.
Reasons for pre-test discussion
The main reasons for pre-test discussion are that there is an opportunity
to:
- understand the indications for a test and know how they apply to individuals;
- ensure the individual understands what information the test result
will give him/her and the possible consequences (both the advantages
and difficulties) of a positive result for their future, thereby obtaining
full informed consent, and
- allow a discussion of preventive measures and/or reduction of risky
behaviour where appropriate.
Approaches to pre-test discussion
The approach of the health care worker involved in pre-test discussion
depends on whether:
- The individual is actively seeking the HIV test because of their perception
of their risk.
- HIV is a part of a differential diagnosis and if so whether the individual
is aware that the symptoms may be due to HIV.
- An HIV test is being done for purposes of screening eg for ante-natal
care, blood donation, insurance.
Any health care workers with appropriate skills and knowledge who conduct
pre-test discussion should ensure they are aware of current developments
in the management of HIV and AIDS. Health care workers who do not feel
able to conduct pre-test discussion should refer the individual seeking
an HIV test to another appropriately trained health care worker.
Training in pre-test discussion may be facilitated by publications such
as
HIV and AIDS: The Issues - A teaching pack for doctors (DH 1992)
Guidelines for offering voluntary named HIV antibody testing to women
receiving ante-natal care (DH 1994)
HIV and AIDS: Issues in Primary Care – Educational Pack for GPs
(DH 1994)
and those from DH-funded projects such as Caring for people with sexually
transmitted diseases including HIV disease (ENB 1994). The pack for
hospital doctors is available in the libraries of postgraduate medical
centres, medical schools and main hospitals. The pack for General Practitioners
has been distributed to Regional Advisers in general practice, GP tutors,
trainee course organisers and undergraduate departments of general practice
in England and Wales.
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PRE-TEST DISCUSSION
There are five main components of pre-test discussion. These are:
- Ensuring the individual understands the nature of HIV infection; provision
of information about HIV transmission and risk reduction.
- A discussion of risk activities the individual may have been involved
in with respect to HIV infection including the date of the last risk
activity and the perception of the need for a test.
- Discussion of the benefits and difficulties to the individual, his
or her family and associates of having a test and knowing the result
whether positive or negative.
- Providing details of the test and how the result will be provided.
- Obtaining an informed decision about whether or not to proceed with
the test.
In Section A these are described in greater detail. In Section
B the application of the 5 components in a variety of clinical situations
is described.
SECTION A
In order to set a framework for the consultation, the health care worker
will wish to ask the individual why they are seeking the test. If, however,
the individual does not wish to discuss his/her risk activities but simply
states a wish to have the test, the health care worker should proceed
directly to stage 3 of the discussion. Where sexual activity or drug taking
is not thought to be relevant to the reason for having a test (for example,
where patients are attending after having been notified in a look back
exercise), the patient should be asked if they are willing to answer such
questions.
1. DISCUSSION ABOUT THE NATURE OF HIV INFECTION, TRANSMISSION AND
RISK REDUCTION
Depending on the reason for the tests and the individual’s own knowledge
of HIV infection the health care worker may need to discuss:
- modes of transmission;
- the difference between HIV and AIDS, and
- methods which reduce transmission that the individual currently uses
or should be encouraged to use.
Written material should be available on general risk reduction strategies
to supplement the discussion.
2. RISK ACTIVITIES AND THE NEED FOR A TEST
In order to make an informed decision, the individual may wish to
discuss with the health care worker:
- The individual’s and the health care worker’s perception of risk activities
including any differences and the last date of involvement in risk activity
such as;
- unsafe sexual practice;
- history of drug use and especially injecting exposure;
- history of exposure to blood/blood production transfusion particularly
prior to screening of donations and heat treatment of factor VIII;
- tattooing;
- occupational risk, and
- overseas travel with exposure to high risk activity.
The level of risk and the need for a test for each individual will vary
over time and therefore further discussion may be required on any future
encounter with the individual. No assumption should be made about whether
an individual belongs to a "high risk group", as it is the level
of the risk activity that has occurred that is important in the context
of deciding whether an HIV test is indicated.
3. DISCUSSION OF THE ADVANTAGES AND DISADVANTAGES OF TESTING AND
THE IMPLICATIONS OF THE POSITIVE OR NEGATIVE RESULT FOR THE INDIVIDUAL
A brief discussion regarding the advantages and disadvantages should
be offered by asking what the individual perceives as the main advantages
if they perceive any disadvantages. Too much information at this stage
may make decision making more difficult.
Advantages which may be raised are:-
- Allowing the individual to form strategies to protect subsequent sexual
partners.
- Allow interventions to reduce vertical transmission (See section on
pregnant women).
- Allow for appropriate medical care.
- Allow effective prophylactic care.
- Allowing decisions about their future to be made.
- Reduction of needless anxiety about HIV infection.
Disadvantages that may be raised are:-
- Psychological complications.
- Possible adverse impact on relationship including family, partners
and work.
- Possible restrictions for those who are positive on testing eg travel.
It is at this point that the health care worker may encourage the individual
to consider how they may cope with a positive result. They may also be
encouraged to consider the social and psychological support available
and who they might decide to tell of their diagnosis to allow them to
plan future action.
4. THE TEST PROCEDURE AND RESULT GIVING
The test procedure and details of when and how the result will be
given should be explained. A brief discussion regarding positive, negative
and indeterminate results will be needed with information about follow
up (See Annex C).
5. OBTANING INFORMED CONSENT
Consent for test should be obtained prior to testing and is required
on each occasion that the test is requested (See Annex
C). The health care worker obtaining consent should make a written
note that consent has been given.
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SECTION B
While not intended to be prescriptive, these guidelines set out the main
components of pre-test discussion. The time allotted and the emphasis
placed in discussion of these components will reflect the individual needs
of the person who attends for HIV testing.
As described in this section those who have attended on several occasions
for a test will require more emphasis to be placed on risk reduction strategies
than repeated explanation of the test procedure. Those who are attending
for their first test may require greater attention to be paid to the nature
of disease and how it is transmitted.
1a) Individuals actively seeking an HIV test for the first occasion
Here a pre-test discussion session involving all 5 stages is desirable,
supplemented by written information.
Referral or follow up for further counselling may be necessary where
an individual does not understand the discussion through, for example,
difficulties in language comprehension, or if the individual appears
to need further help for other reasons.
1b) Individuals actively seeking an HIV test who have had previous
tests
The individual should be encouraged to discuss recent exposure to
risk activity. However, if an individual returns repeatedly, with
no evidence of involvement in risk activities, there may be a need
to ascertain whether there is inappropriate anxiety which may need
to be addressed.
If the individual is felt to have been at risk, the discussion may
simply proceed to obtaining consent for the test.
2a) When HIV is part of a differential diagnosis and the individual
is unaware that symptoms may be due to HIV
Here the need for a test has been ascertained by the health care
worker from the individual’s clinical state. Stage 2 of pre-test discussion
may therefore need to be explained, possibly briefly if the individual
is ill, in the context of his/her symptoms.
Stages 1-5 will need to be followed as indicated but the length of
the discussion, in particular information provision, will need to
be tailored to the individual’s clinical state. For example, it would
be inappropriate to enter into lengthy discussion of risk reduction
or the pros and cons of the test when the individual is very unwell,
although only in exceptional circumstances should a test ever be performed
without informed consent.
2b) When HIV is part of a differential diagnosis and the individual
is aware the symptoms may be due to HIV
If the individual has had previous tests, discussion may be brief
(see example 1b).
3) Individual is offered HIV test as part of wider screening procedure
The 3 examples described below demonstrate that HIV testing which
takes place in a screening situation requires a condensation of the
pre-test discussion format due to practical considerations.
3a) Ante-natal care
In ante-natal clinics midwives are well placed to undertake pre-test
discussion. Women in ante-natal clinics are likely to have less knowledge
of HIV than those actively seeking testing and they will be receiving
information about a wide range of other issues. HIV testing is often
most appropriately dealt with in the context of obtaining consent
for these tests although a specific consent to an HIV test must be
obtained. It may be helpful to provide written information in addition
as part of the general package of information provided.
For women tested in both high and low prevalence areas, the advantages
and disadvantages of the test are described as in standard pre-test
discussion.
However, in outlining the advantages of knowledge of serostatus for
a pregnant woman, certain additional factors should be mentioned.
These are that:
- knowing her HIV status permits the woman to make informed choices
about the management of her pregnancy;
- advice on the avoidance of breast feeding may be given as transmission
of HIV from mother to child frequently takes place via breast milk;
- plan and arrange for early monitoring of the baby’s health;
- prophylactic treatment for the mother and child (if HIV positive)
may be given earlier which may prevent development of severe opportunistic
infections, and
- there is an opportunity for clinicians to discuss the use of AZT
(Zidovudine) as treatment to significantly reduce the risk of transmission
to the foetus.
As a policy of offering ante-natal HIV testing to all women in high
prevalence areas is already encouraged*, women can be informed that
the test is voluntary, confidential and part of the general ante-natal
care in their area. Where ante-natal testing is not routinely offered
in ante-natal care i.e. in low prevalence areas, more time may need
to be allotted to assessment of risk and the need for a test (stage
2). During discussion with a woman who seeks a test by self referral,
the procedure for discussion is similar to example 1a.
*Since these guidelines were written, policy with respect to antenatal
testing has changed. All women in England are now offered and recommended
an HIV test as part of their antenatal care, not just those in high
prevalence areas.
In all clinical centres where unlinked anonymous HIV testing is being
carried out, patients are informed by posters (in 15 different languages)
and leaflets. However, it should be emphasised to women attending
such centres that if they wish to be informed of the result they should
seek voluntary confidential named testing.
3b) Blood donation
At the time of donation, time constraints prevent all the stage of
pre-test discussion being worked through, for all individuals.
Therefore, risk assessment and the need for a test (stage 2) occurs
at an earlier stage when potential donors invited to attend are sent
information to allow them to exclude themselves if they fall within
one of several higher risk categories. On arrival for donation of
blood, individuals are given information in the form of an AIDS leaflet
which would substitute for stages 2 and 3 of pre-test discussion.
Stages 4 and 5 of pre-test discussion occur on registration, when
patients are asked if they have read and understand the AIDS leaflet.
In some centres a slightly longer interview at the stage of registration
may occur when a fuller discussion of the AIDS leaflet may be given.
Informed consent is then obtained by the blood donor, giving written
consent to say that they have understood that a battery of tests,
including that for HIV, will be performed on a blood sample.
Individuals are informed that should the test be abnormal they will
be notified in a confidential manner. If the result on the first test
is confirmed as positive, individuals are given a further appointment
with a trained HIV counsellor, frequently a physician with counselling
training, who would take a second sample for further confirmatory
testing and if necessary give further counselling if this result is
also positive. Referral for further follow up occurs with the patient’s
consent.
3c) Insurance
In certain circumstances an insurer may request an individual to
have an HIV test before agreeing to provide life insurance.
In this instance, individuals are notified in writing of the need
for an HIV test, the test procedure, asked to provide their written
consent to the test and to nominate a doctor (usually their general
practitioner) to take the blood sample and to receive the result (stages
4 and 5 of pre-test discussion). Pre-test discussion in stages 1,
2 and 3 will then be performed by the patient’s nominated doctor.
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ANNEX A
HIV PRE-TEST DISCUSSION QUESTIONNAIRE
Summary of Results
(Survey carried out in October 1994)
Overall Analysis
Of the total 80 questionnaires sent out, 46 were completed and returned.
Respondents fall into five categories: ante-natal clinics, drug dependency
clinics, general practice, GUM clinics and HIV specific clinics. Also
included are 12 clinics which did not offer any form of counselling, it
is not know which category these clinics fall in. The responses have been
divided into high and low prevalence areas. Overall, 34 clinics in high
and low prevalence areas offered pre-test counselling.
Staff Group & Place of Work
Pre-test counselling is mostly undertaken by Health Advisors at the
clinics, except at General Practices where all counselling is carried
out by GPs. At ante-natal clinics a combination of counsellors, Health
Advisors and midwives carry out the counselling sessions.
Training for Pre-test Counselling
The types of training most common amongst staff groups in the survey
were general counselling training and specific pre-test counselling training.
4 of the 7 GPs had some form of counselling training. Of the 14 Health
Advisors, 10 had general counselling training, the remaining 4 had specific
counselling training only. 3 Health Advisors had more than one form of
training.
Number of Patients Counselled in a One Week Period
Overall high prevalence areas saw approximately two thirds more patients
than low prevalence areas. GUM clinics in the survey saw an average of
15 patients per week in high prevalence areas and 9 patients a week in
low prevalence areas.
Table 1 Number of Patients Counselled in a One Week
Period
|
Clinic
|
Clinic Area
|
| |
High Prevalence
|
Low Prevalence
|
Total
|
|
Ante-natal
|
21
|
0
|
21
|
|
Drug Dependency
|
0
|
0
|
0
|
|
General Practice
|
3
|
0
|
3
|
|
GUM
|
134
|
76
|
210
|
|
HIV Specific
|
0
|
15
|
15
|
|
Total
|
158
|
91
|
249
|
Appointments
Of the 34 clinics in both high and low prevalence areas, 38% see patients
by appointment only, 15% see patients without requiring an appointment
and 47% see patients both with or without appointment.
Patient’s Reason for HIV Test
The survey shows that for patients who attended for their first pre-test
appointment, the main reason for ordering an HIV test was patient self
referral; in both high and low prevalence areas. However, at ante-natal
clinics the major reason for an HIV test was for screening purposes.
Table 2 Patient’s Reason for HIV Test
|
Clinical Type
|
Self Referral
|
Differential Diagnosis
|
Screening
|
Total
|
|
Ante-natal
|
2
|
1
|
18
|
21
|
|
Drug Dependency
|
0
|
0
|
0
|
0
|
|
General Practice
|
2
|
0
|
1
|
3
|
|
GUM
|
164
|
41
|
5
|
210
|
|
HIV
|
15
|
0
|
0
|
15
|
|
Total
|
183 73%
|
42 17%
|
24 10%
|
249 100%
|
Average Length of Counselling Session by Patient Risk Group
Overall, the average length of time spent on counselling sessions
with most patient groups was not less than 21 minutes. On average, heterosexual
males and females received the shortest counselling sessions, between
11-20 minutes.
Average Length of Counselling Session by Clinic Type
Drug Dependency clinics in the survey spent the longest average length
of time on counselling sessions (between 31-60 minutes), whilst GPs spent
the shortest (between 0-10 minutes).
Table 3 Average Length of Time Spent with Patient
by Clinic Type
|
Clinic Type
|
Average Time Spent
|
|
Ante-natal
|
11-20 mins
|
|
Drug Dependency
|
31-60 mins
|
|
General Practice
|
0-10 mins
|
|
GUM
|
21-30 mins
|
|
HIV
|
11-20 mins
|
GUM Clinics Response
Half the GUM clinics spend on average between 11-20 minutes on a counselling
session, whilst the other half spend between 21-30 minutes.
Average Number of Pre-test Counselling Sessions
Overall, 28 out of 34 (82%) respondents reported the average number
of pre-test counselling sessions as one per patient and 6 out of 34 (18%)
reported an average of two sessions. All 17 GUM clinics in both high and
low prevalence areas responded with an average of one session of pre-test
counselling per patient. An average of 2 sessions per patient was reported
in 3 out of 5 Drug Dependency clinics and 2 out of 6 GPs.
Topics Covered at First Pre-test Appointment
Overall the topics of history and issues regarding the test itself
(excluding written consent and travel abroad), were covered by 80% or
more of respondents. Under the subject of education, safer sex issues
are also discussed by most (91%) clinics (Table 4).
Table 4 Topics Covered at First Pre-Test Appointment
| |
Area
|
|
Content
|
High
|
Low
|
Total
|
|
History
|
Sexual history
|
21
|
12
|
33
|
|
Drug use history
|
20
|
12
|
32
|
|
Patients risk perception
|
21
|
12
|
33
|
|
Condom use
|
19
|
11
|
30
|
|
Travel abroad
|
12
|
10
|
22
|
|
Education
|
Safer sex
|
19
|
12
|
31
|
|
Info about STD/Hepatitis
|
14
|
10
|
24
|
|
Safe drug use
|
13
|
11
|
24
|
|
Written info test procedure
|
11
|
2
|
13
|
|
Medical aspects HIV
|
15
|
6
|
21
|
|
Test
|
Test procedure
|
18
|
13
|
31
|
|
"Window period"
|
20
|
12
|
33
|
|
Significance negative result
|
21
|
12
|
33
|
|
Confidentiality
|
20
|
13
|
33
|
|
Positive result
|
21
|
12
|
33
|
|
Who to share result with
|
18
|
11
|
29
|
|
Partner notification
|
10
|
9
|
19
|
|
Verbal consent to test
|
16
|
11
|
27
|
|
Written consent to test
|
7
|
2
|
9
|
|
Issues about
|
Employment issues
|
14
|
9
|
23
|
|
HIV testing
|
Discrimination negative test
|
12
|
10
|
22
|
|
Discrimination positive test
|
15
|
12
|
27
|
|
Early medical treatment
|
13
|
6
|
19
|
|
Reducing onward transmission
|
13
|
8
|
21
|
|
Reassurance if negative
|
13
|
7
|
20
|
|
Special Q’s
|
Termination of pregnancy
|
15
|
5
|
20
|
|
pregnant women
|
Prophylactic treatments mother
|
11
|
4
|
15
|
|
Breast feeding
|
14
|
5
|
19
|
|
Drug treatment
|
11
|
4
|
15
|
|
Mode of delivery
|
10
|
5
|
15
|
| |
|
Maximum possible total = 34
|
Topics covered by between 60-80% of clinics include; travel abroad, medical
aspects of HIV, partner notification, employment issues, discrimination
against those testing negative and reducing onward transmission.
Topics which feature lowest in the first pre-test appointment are written
information on test procedure and written consent to the test.
A breakdown of topics covered by clinic type and area shows that clinics
in low prevalence areas are less likely to cover written information on
test procedure and written consent to the test, than high prevalence areas.
All ante-natal clinics cover topics relevant to pregnant women.
Average Length of Time between Counselling Session and
Test Procedure
62% of clinics carry out the pre-test counselling session on the same
day as the test procedure, where as 21% take between 7 to 10 days.
Of the 17 GUM clinics, 66% in high prevalence areas carry out the counselling
session on the same day as the test procedure, whilst the figure for low
prevalence areas in 87%. 3 out of 5 drug dependency clinics all in high
prevalence areas take between 7 to 10 days, whilst the other 2 clinics,
which take between 1 to 3 days, are in low prevalence areas.
Location of Blood Sampling
85% of clinics replied that sampling was carried out on the same site
as the pre-test counselling, whereas only 15% carried out sampling elsewhere.
Average Length of Time between Counselling Session and Test Procedure
by Location of Blood Sampling
All ante-natal clinics taking part in the survey carry out blood sampling
on the same location as pre-test counselling. All but one of the clinics
taking more than 5 days between counselling and test procedure did so
despite carrying out sampling on site (Table 5).
Table 5 Average Length of Time by Location of Blood
Sampling
|
Average Length of Time
|
|
Clinical Type
|
Location
|
Same Day
|
1-3 Days
|
3-5 Days
|
7-10 Day
|
Total
|
|
Ante-natal
|
On site
|
3
|
1
|
0
|
1
|
5
|
|
Off site
|
0
|
0
|
0
|
0
|
0
|
|
DDC
|
On site
|
1
|
0
|
1
|
2
|
4
|
|
Off site
|
0
|
0
|
0
|
1
|
1
|
|
GP
|
On site
|
3
|
0
|
0
|
2
|
5
|
|
Off site
|
0
|
0
|
1
|
0
|
1
|
|
GUM
|
On site
|
10
|
3
|
0
|
1
|
14
|
|
Off site
|
3
|
0
|
0
|
0
|
3
|
|
HIV
|
On site
|
1
|
0
|
0
|
0
|
1
|
|
Off site
|
0
|
0
|
0
|
0
|
0
|
|
Total
|
|
21
|
4
|
2
|
7
|
34
|
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ANNEX B
POST-TEST COUNSELLING
It is beyond the remit of this guidance to discuss post-test counselling
in detail. Post-test counselling should be available for both those diagnosed
as HIV negative and those diagnosed positive. The main features of post-test
counselling are outlined below.
The topics and the timing of the discussion (which should be performed
in person) will depend on the patients’ reactions to their positive result.
The aims of post-test counselling are to:
- Address immediate concerns and provide support for those who are positive.
- Provide information on the prevention of HIV transmission for both
those who are diagnosed as HIV positive and those HIV negative.
If the individual is diagnosed as HIV positive the counsellor should:
- Address the patient’s immediate reactions.
- Refer for specialist management, including treatment where appropriate.
- Give details of support services.
- Offer follow up appointments and ongoing support which may include
addressing issues concerned with legal matters and support for carers
and partners.
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ANNEX C
THE HIV ANTIBODY TEST
Test Sites
Those who wish to have an HIV antibody test should be able to do so
with the minimum of inconvenience. In the United Kingdom testing for HIV
antibodies is available at GUM and other specialist clinics, open-access
same-day test clinics, general practitioners and a few private clinics.
Injecting drug users may be offered testing in drug dependence clinics.
In higher prevalence districts, a policy is encouraged of offering named
voluntary HIV antibody tests to all women attending for ante-natal care*.
*Since these guidelines were written, policy with respect to antenatal
testing has changed. All women in England are now offered and recommended
an HIV test as part of their antenatal care, not just those in high prevalence
areas.
An HIV test may also be part of diagnostic investigations.
Test procedure
The diagnosis of HIV infection is most commonly based on the detection
of specific antibodies to HIV.
The test for HIV antibodies is a sensitive one and sera that are negative
on testing are not usually tested further. Sera that do react are retested
twice and/or with other confirmatory tests.
Negative results
A negative test indicates that HIV antibodies have not been detected.
This means that either the patient is not infected or, rarely, in the
"window period" between HIIV infection and detectable antibody
production. This period is usually less than three months although exceptionally
it may be longer.
If through a recent possible exposure, a patient could be in the window
period they should be advised to undergo a repeat test in three to six
months’ time.
Positive results
A confirmed positive result may extremely rarely be a false positive.
If a patient’s result is thought likely to be a false positive, the patient
should be retested.
Indeterminate results
When confirmatory testing fails to establish that a reactive sample
is negative or positive, the result may be said to be indeterminate. The
laboratory may then seek a follow up specimen or do direct tests for the
virus as well as for the antibody to it.
Consent to testing
Informed consent has three requirements:
- The individual must be competent to consent.
- The individual should understand the purposes, risks, harms and benefits
of being tested and those of not being tested.
- The individual must consent voluntarily.
Confidentiality
All medical staff have a legal duty to maintain the confidentiality
of personal health information. Additional confidentiality is provided
by Section 2 of the NHS Venereal Disease Regulations 1974.
"Every Regional Health Authority and every Area Health Authority
shall take all necessary steps to secure that any information capable
of identifying an individual obtained by officers of the Authority with
respect to persons examined or treated for any sexually transmitted disease
shall not be disclosed except:
a) for the purpose of communicating that information to a medical
practitioner, or to a person employed under the direction of a medical
practitioner in connection with the treatment of persons suffering from
such disease or the prevention of the spread, thereof, and
b) for the purpose of such treatment or prevention".
Where the NHS Venereal Diseases Regulations 1974 and National Health
Service Trusts (Venereal Diseases) Directions 1991 do not apply, the usual
duty of confidentiality applies.
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REFERENCES
- Introduction of a test for HTLVIII Antibody. CMO(85)12 Department
of Health and Social Security 1985.
- HIV infection and AIDS. Ethical Considerations for the Medical
Profession; Second Edition; BMA Foundation for AIDS 1992.
- Guidelines for offering Voluntary Named HIV Antibody Testing to
women receiving Ante-natal Care. PL\CO(94)3 Department of Health
1994; Welsh Office PSM(94)12.
- Guidance on establishing additional sites for HIV Antibody Testing.
PL\CO(94)3 Department of Health 1994; Welsh Office PSM(94)12.
- HIV and AIDS: The Issues. A Teaching Pack for Doctors. Department
of Health 1992.
- HIV and AIDS: Issues in Primary Care. Educational Pack for General
Practitioners. Department of Health 1994.
- Caring for people with sexually transmitted diseases including
HIV disease. English National Board for Nursing, Midwifery and Health
Visiting 1994.
Similar guidance was issued by the Health Departments of Scotland, Wales
and Northern Ireland and copies of the relevant publications can be
obtained from these departments.
- The National Health Service (Venereal Diseases) Regulations 1974
HMSO.
- National Health Service Trusts (Venereal Diseases) Directions 1991
HMSO.
Document published: March 1996
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