New NICE guidance to increase HIV testing in black African communities in England
New NICE guidance aims to increase HIV testing to help reduce undiagnosed infection and prevent transmission among back African communities living in England.
HIV is still a serious problem in this country, with a large proportion of people unaware they are infected. It is a disease that affects all people in society; however, people of black African heritage are disproportionately affected by HIV. In 2009, over 2,000 black Africans were diagnosed with an HIV infection, representing one third of all new diagnoses in the UK1.
HIV can be successfully managed with antiretroviral therapies which suppress the virus and help prevent transmission; however, if someone is diagnosed late it's more likely that the virus will have already seriously damaged their immune system. Late diagnosis is one of the biggest contributing factors to illness and death for people with HIV.
Professor Mike Kelly, Director of the Centre for Public Health Excellence at NICE said: “For many people of black African heritage there is a fear that being diagnosed HIV positive will result in social exclusion or racism and prejudice from both inside and outside their community. As such there is often a reluctance to be tested which can significantly delay diagnosis. This new guidance from NICE aims to normalise HIV testing by ensuring it is routinely offered to all people who live in an area where there is a high prevalence of HIV, when registering with a new GP, on admission to hospital, or when having a blood test.”
Black African communities encompass diverse population groups from a range of countries. For the purpose of this guidance the term ‘black African' refers to people who identify themselves as black African - whether they are migrants from Africa, African descendants or African nationals. Recommendations include:
Involving communities and promoting testing
- Work in partnership with those running existing community activities to promote HIV testing and the benefits of early diagnosis and treatment, and to raise awareness of local services and how to access them. This includes addressing any misconceptions about HIV testing and treatment (for example, in relation to life expectancy following a positive diagnosis - or related to HIV treatment costs). It also includes reducing the stigma (real or perceived) associated with HIV testing and living with HIV, both among black Africans and health professionals.
Planning services - developing a strategy and commissioning services in areas of identified need
- Ensure HIV testing is available in a range of healthcare and community settings (for example, GP surgeries and community centres) based on the outcomes of a needs assessment. These should be accessible and acceptable to the target population, in terms of both geographical setting and service design (for example, in terms of appointment systems, opening hours and cultural sensitivity).
Reducing barriers to HIV testing for black African communities
- Ensure staff offering HIV tests emphasise that the tests are confidential. They should be able to direct those who are concerned about confidentiality to a genitourinary medicine clinic, where people do not have to give their real name.
Healthcare settings: offering and recommending an HIV test
- All health professionals should routinely offer and recommend an HIV test to people who are at risk of infection, in line with British HIV Association (BHIVA), et al. guidelines*2
- Health professionals should also routinely offer and recommend an HIV test to all patients attending: genitourinary medicine or sexual health clinics, antenatal services, termination of pregnancy services, drug dependency programmes and tuberculosis, hepatitis B, hepatitis C and lymphoma services.
- In areas where more than 2 in 1000 population have been diagnosed with HIV: primary care and general medical admissions professionals should consider offering and recommending an HIV test when registering and admitting new patients (this is in line with BHIVA guidelines) and all health practitioners should offer and recommend an HIV test to anyone who has a blood test (regardless of the reason).
HIV referral pathways
- Ensure people who test positive are seen by an HIV specialist at the earliest opportunity, preferably within 48 hours, certainly within 2 weeks of receiving the result (in line with British HIV Association guidelines). They should also be given information about the diagnosis and about local support groups.
- Encourage repeat testing after a negative result for those who are at risk of infection (for example, for those who have new or multiple partners).
- For people with positive and negative HIV test results, if appropriate, offer or provide information about further behavioural or health promotion interventions.
Joseph Ochieng, Terrence Higgins Trust's Programme Development Officer for African communities, said: “These guidelines are vital in encouraging people from black African communities to get tested easily while reducing the barriers to these health checks. If we're to reduce the high numbers of black African people who have HIV, but don't know it, and help prevent onward transmission of the infection, we need to reassure people that testing is a routine part of their healthcare, is confidential and plays a vital role in saving their lives and and the lives of their partners.
"Black African communities are diverse, from a range of countries, with different cultural and social beliefs, so these guidelines rightly show that, if HIV prevention strategies are to work, they must be tailored to local people's needs."
Professor Jane Anderson Consultant Physician, Homerton University Hospital NHS Foundation Trust: "For people with HIV to get the best from the available treatments they need to be aware of their infection and get into care in time. A late diagnosis for people who are HIV positive can have a huge impact on their chances of leading a long and healthy life and can potentially increase the number of people exposed. Up to 40% of new HIV diagnoses among people of black African heritage in the UK can be classified as late and this needs to change. It's also very important that people who are not infected know that they are HIV negative. Making HIV testing a routine is crucial to achieve these outcomes."
Dr Matt Kearney General Practitioner, Runcorn; Primary Care Adviser, Department of Health: “In areas where levels of HIV are high, testing needs to be offered routinely when registering new patients in GP practices, regardless of ethnic background or sexual orientation. This system is already in place in many practices, but not all. With around a quarter of people with HIV in this country unaware that they are infected, we need to ensure that people know that testing is simple, fast, reliable, accurate and confidential.”
Dr Keith Radcliffe, President of the British Association for Sexual Health and HIV said: “The later people are diagnosed with HIV, the more difficult and expensive it is to treat them, the poorer their outcome may be, and the more likely they are to have transmitted the infection. We know that Black Africans are disproportionately affected by HIV, so we are delighted that this guidance, which is based on an overwhelming body of evidence, demonstrates the urgent need to move away from targeted testing, to a system of routine testing for all those at risk of contracting HIV, and we hope that all local health authorities, and healthcare professionals work hard in implementing this guidance.”
Dr Clare Gerada, Chair of the Royal College of General Practitioners said: “HIV can be successfully managed in ways that can improve quality of life and reduce complications and transmission of infection. It is important therefore that all health professionals do everything possible to encourage testing amongst high risk groups. The RCGP welcomes the new NICE guidelines and we are sure that GPs will help patients come forward for testing.”
Notes to Editors
About the guidance
1. The guidance will be available on the NICE website from 23 March, 2011.
2. The Health Protection Agency will publish data on the number of new HIV diagnoses in the UK on 23 March 2011.
3. Black African communities are disproportionately infected with HIV in England which is why the Department of Health asked NICE to produce guidance on how to increase the uptake of testing in this population.
4. This is one of two pieces of complementary NICE guidance on how to increase the uptake of HIV testing. The other guidance focuses on men who have sex with men and is available from the NICE website. People with an interest in increasing the uptake of HIV testing among both groups should refer to both pieces of guidance.
5. *British HIV Association (BHIVA), el al. guidelines3 state that all health professionals should routinely offer and recommend an HIV test to:
- men and women known to be from a country of high HIV prevalence4
- men and women who report sexual contact abroad or in the UK with someone from a country of high HIV prevalence
- patients who have symptoms that may indicate HIV or where HIV is part of the differential diagnosis (see the BHIVA guidelines for a list of indicator diseases)
- patients diagnosed with a sexually transmitted infection
- the sexual partners of men and women known to be HIV positive
- men who have disclosed that they have sexual contact with other men
- the female sexual contacts of men who have sex with men
- patients reporting a history of injecting drug use.
The BHIVA, et al. guidelines also state that an HIV test should be offered to patients attending genitor-urinary medicine or sexual health clinics, antenatal services, termination of pregnancy services, drug dependency programmes, and services for tuberculosis, hepatitis B and C, and lymphoma.
In areas where more than 2 in 1000 people have been diagnosed with HIV, the BHIVA guidelines recommend that professionals should consider offering and recommending an HIV test when registering and admitting new patients.
6. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health
7. NICE produces guidance in three areas of health:
- public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
- health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
- clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.
8. NICE produces standards for patient care:
- quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
- Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients
NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the bestpatient care through NHS Evidence.
2 British HIV Association, British Association of Sexual Health and HIV, British Infection Society (2008) UK national guidelines for HIV testing 2008. London: British HIV Association.
3 British HIV Association, British Association of Sexual Health and HIV, British Infection Society (2008) UK national guidelines for HIV testing 2008. London: British HIV Association.
This page was last updated: 05 August 2011