HIV

Background information

Testing

Treatment

Prevention and control

Patient information (English only)

Patient information (English and other languages)

Other useful resources

References

Background information

• Globally, there were an estimated 34.2 million people living with HIV (Human Immunodeficiency Virus) in 2011 [1].
• East and Southern Africa remains the area most heavily affected by the HIV epidemic. Out of the total number of people living with HIV worldwide in 2009, 34% resided in ten countries of Southern Africa [1]. 
• In 2011, there were 6,280 people (4,470 men and 1,810 women) newly diagnosed with HIV in the UK, of whom an estimated 48% (2,990) acquired their infection through heterosexual contact and 48% (3,010) through sex between men [2]. 
• Of the estimated 2,990 newly diagnosed persons in 2011 infected heterosexually, 57% were black African [2].
• By the end of 2011, there were an estimated 96,000 (95% credible interval 90,800-102,500) people living with HIV (both diagnosed and undiagnosed), equivalent to a crude rate of 1.5 people per 1,000 population (all ages) in the UK (2.1 per 1,000 men and 1.0 per 1,000 women) [2]. Approximately a quarter (24%, 22,600) of HIV-infected people were estimated to be unaware of their infection.
• A new method to assign probable country of infection suggests that 52% (1,560/2,990) of all heterosexuals diagnosed in 2011 acquired their infection in the UK, up from 27% (1,100/4,090) in 2002 [2]. This is indicative of increasing transmission within the UK and highlights the need for further prevention efforts, particularly among black African communities.
• New diagnoses are difficult to interpret in isolation, but considered alongside data on recently acquired infections and incidence estimates, it is evident that transmission of HIV among men who have sex with men is ongoing in the UK, and remains substantial [2]. For some men who have sex with men migration may partly be a way to better accommodate their sexuality.  This demonstrates the need for sexual health promotion among non-UK born people at risk of HIV in the UK.
• HIV disrupts normal immune function by infecting and destroying cells which are vital in co-ordinating an immune response (specifically CD4+ T cells). This makes the body increasingly susceptible to opportunistic infections.
• When an HIV-infected person presents with particular indicator diseases they are said to have progressed to AIDS (Acquired Immune Deficiency Syndrome).
• Without appropriate highly-active antiretroviral therapy (HAART), HIV infection usually progresses to AIDS in an average of ten years, although this time period is highly variable.
• With HAART, good health can be maintained for many years and the development of major opportunistic infections avoided. 
• HIV can be passed on through infected blood, semen, vaginal fluids or breast milk. The most common routes of transmission are:
  • sexual transmission
  • sharing or use of contaminated equipment during injecting drug use, tattooing and body piercing 
  • mother to child transmission during birth or breastfeeding
  • needlestick or other sharps injuries 
  • receipt of infected blood or blood products (e.g. clotting factors) in countries where screening does not take place or is inadequate (all blood and blood products are now screened in the UK)

For further background information please see the HPA HIV webpages. 

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Testing

Sample required for diagnosis: Clotted blood (2-6ml)

In 2008 the British HIV Association published new UK National Guidelines for HIV Testing [external link]. The following text is based on the report and updated with the 2011 NICE guidelines for expanded testing among the black African community [external link] and among men who have sex with men [external link].

Who should be offered a test?

Where the diagnosed HIV prevalence in the local population exceeds 2 in 1000 population an HIV test should be offered and recommended to:

1. all men and women newly registering in general practice regardless of country of origin
2. all general medical admissions
3. anyone having blood tests (regardless of reason) in primary or secondary care

HIV testing should be also routinely offered and recommended to the following patients (irrespective of the prevalence of HIV in the local population):

1. all men and women known to be from a country of high HIV prevalence [external link] (>1%*)
2. all men and women who report sexual contact abroad or in the UK with individuals from countries of high HIV prevalence [external link].*
3. all pregnant women
4. all patients presenting for healthcare where HIV, including primary HIV infection, enters the differential diagnosis (table of indicator diseases [external link] [UK National Guidelines for HIV Testing 2008, page 7] and primary HIV infection [external link] [UK National Guidelines for HIV Testing 2008, page 13]). Typical symptoms of primary HIV infection include a combination of any of:
   1. fever
   2. rash (maculopapular)
   3. myalgia
   4. pharyngitis
   5. headache/aseptic meningitis.
5. all patients diagnosed with a sexually transmitted infection
6. all sexual partners of men and women known to be HIV positive
7. all men who have disclosed sexual contact with other men
8. all female sexual contacts of men who have sex with men
9. all patients reporting a history of injecting drug use
10. all those who may be at risk of exposure to the virus. For example, this may be as a result of having a new sexual partner or may be because they have previously tested negative during the 'window period'
11. all men who have not previously been diagnosed HIV positive and who:
    1. register in a practice in an area with a large community of men who have sex with men
    2. are known to have sex with men and have not had an HIV test in the previous year
    3. are known to have sex with men and disclose that they have changed sexual partner or disclose high risk sexual practices
    4. request screening for a sexually transmitted infection.

*see country pages

Who can test?

It should be within the competence of any doctor, midwife, nurse or trained healthcare worker to obtain consent for and conduct an HIV test.

Pre-test discussion

The primary purpose of pre-test discussion is to establish informed consent for HIV testing. Lengthy pre-test HIV counselling is not a requirement, unless a patient requests or needs this. The essential elements that the pre-test discussion should cover are:

• the benefits of testing to the individual
• details of how the result will be given

Some patients may need additional help to make a decision, for example, because English is not their first language. It is essential to ensure that these patients have understood what is proposed, and why. It is also important to establish that the patient understands what a positive and a negative result mean in terms of infection with HIV as some patients could interpret 'positive' as good news.

Post-test discussion for individuals who test HIV positive

As is good clinical practice for any situation where bad news is being conveyed, the result should be given face to face in a confidential environment and in a clear and direct manner. If a patient's first language is not English, consideration should be given to utilisation of an appropriate confidential interpretation service. If a positive result is being given by a non-genito-urinary medicine/HIV specialist, it is essential, prior to giving the result, to have clarified knowledge of local specialist services and have established a clear pathway for onward referral.

It is recommended that any individual testing HIV positive for the first time is seen by a specialist (HIV clinician, specialist nurse, sexual health advisor or voluntary sector counsellor) at the earliest possible opportunity, preferably within 48 hours and certainly within two weeks of receiving the result.

For full guidance see UK national guidelines for HIV testing [external link] and the 2011 NICE guidance on expansion of HIV testing:

Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among black African communities living in England [external link]

Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among men who have sex with men [external link]

Also useful:

HIV for non-HIV specialists: diagnosing the undiagnosed [external link]

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Treatment

In the UK, HIV is generally managed by secondary care HIV physicians (usually genito-urinary medicine or infectious disease specialists depending on local arrangements).

Care pathways encourage the early commencement of combination anti-retroviral therapy.

• Guidelines for the treatment of HIV-1 positive adults with antiretroviral therapy 2012 [external link]

The role of the primary care practitioner is to encourage people at risk to be tested and to promptly refer those found to be positive. People living with HIV may also require primary care support through their long term treatment and the GP may need to liaise closely with the secondary care team in prescribing for non-HIV related conditions. Guidelines are available for the immunisation of HIV infected adults [external link].

Other useful clinical guidelines: 

• Guidelines for the management of HIV infection in pregnant women 2012 [external link] 
• Management of sexual and reproductive health (SRH) of people living with HIV infection [external link] (2008)
• HIV associated malignancies [external link] (2008)

For other guidelines please refer to the websites of the British HIV Association [external link] and the British Association of Sexual Health and HIV [external link].

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Prevention and control

Prevention of the spread of HIV infection relies on sexual health promotion, testing and treatment of at risk groups for HIV, and testing and treatment for other STIs. Screening for HIV should be offered to all pregnant women to reduce the rate of mother to child transmission and HIV positive mothers should be counselled about breast feeding. The primary care practitioner has an important role to play in all these aspects.

• NICE recommendations on one to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV, and to reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups [external link]
• NHS Infectious Diseases in Pregnancy Screening Programme [external link]
• Department of Health recommendations on HIV and breast feeding [external link]
• Department of Health recommendations on HIV post-exposure prophylaxis [external link]

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Patient information (English only)

Patient UK leaflet HIV and AIDS information [external link]

National Travel Health Network and Centre (NaTHNaC) STI leaflet for travellers - reducing your risk [external link]

Terrence Higgins Trust (THT) publications [external link]

The African Eye Trust [external link] HIV treatment questions and answers sheets

Do it Right [external link] information on sexual health for Africans living in England

Mambo - the healthier lifestyle magazine for Africans - useful resources [external link]

Your story, your script: helping people make decisions about HIV treatment [external link] printable resources

Positively Women magazine [external link] written and edited by women living with HIV

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Patient information (English and other languages)

NAM patient information booklets [external link] are available online to download.  For access to hardcopies of these resources, primary care practioners can register with NAM's free booklet scheme by calling +44 (0)20 7840 005 or emailing info@nam.org.uk.  The NAM website provides resources in Arabic, Czech, Dutch, French, German, Hebrew, Italian, Norwegian, Polish, Portuguese, Romanian, Russian, Somali, Spanish, Swedish, Thai and Turkish.

Antenatal screening for HIV [external link] (Department of Health information leaflet). Available in English, Arabic, Gujarati, Punjabi, Somali, Swahili, Turkish.

NAZ Project London [external link] free resources

HIV & AIDS information for female sex workers [external link] and STI, AIDS and Hepatitis B information for transgender sex workers [external link] in a range of languages is available from TAMPEP (European Network for HIV/STI Prevention and Health Promotion among Migrant Sex Workers)

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Other useful resources

HIV: diagnosis and care in general practice [external link] training video from HPA migrant health event 12 November 2012

HPA HIV and STI useful links

Avert [external link] local HIV/AIDS services available in the UK

African Health Policy Network [external link] an umbrella organisation of mostly African-led community based organisations that enables Africans to speak with a collective and representative voice on sexual and public health matters, with a mission to advance the health and well being of Africans living in the UK.

British Association for Sexual Health and HIV [external link] (BASHH) - a professional representative body for those practising sexual health including the management of STIs and HIV in the UK

British HIV Association [external link] (BHIVA) - a UK based professional association representing professionals in HIV care

NAT (National AIDS Trust) [external link] - the UK's leading HIV policy charity dedicated to transforming the UK's response to HIV

National African HIV Prevention Programme (NAHIP) [external link] - funded by the Department of Health, NAHIP works with predominantly African-led organisations to deliver HIV prevention interventions

Terrence Higgins Trust [external link] (THT) - the largest HIV and sexual health charity in the UK

The Medical Foundation for AIDS & Sexual Health [external link] a UK based charity which works with policy-makers and health professionals, supported by the British Medical Association

Black Health Agency services [external link] including an African AIDS Helpline and HIV support project

NaTHNaC HIV and sexually transmitted infections information for health professionals [external link]

HIV for non-HIV specialists, Diagnosing the undiagnosed [external link]. A practical guide for healthcare professionals in secondary care to support improved detection and diagnosis of HIV in the UK, by Dr Rachel Baggaley. Published by the Medical Foundation for AIDS & Sexual Health (MedFASH)

HIVinsight [external link] E-tutorials for nurses, an online educational initiative which has been developed by the National HIV Nursing Association (NHIVNA)

Sexual health, asylum seekers and refugees: a handbook for people working with refugees and asylum seekers in England [external link], by Ruth Wilson, Marsha Sanders and Hidegard Dumper. Published by the Family Planning Association.

The African Eye Trust [external link] provides HIV treatment information to African communities, including an HIV treatments magazine 'The African Eye Voice' for African communities in the UK. 

Mambo - the healthier lifestyle magazine for Africans, HIV section [external link]

TAMPEP [external link] European Network for HIV/STI Prevention and Health Promotion among Migrant Sex Workers

AIDS & Mobility Master Toolkit [external link] - a collection of core training materials and relevant additional information from the fields of HIV prevention and migrant health for anyone interested in learning about or implementing a transcultural HIV and AIDS mediator project.

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References

1. UNAIDS (regions and countries) [external link]
2. Health Protection Agency. HIV in the United Kingdom: 2012 Report. London: Health Protection Services, Colindale. November 2012.

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