The committee's discussion
Evidence statement numbers are given in square brackets and refer to the summaries of evidence contained within the reviews that were conducted to support the development of this guideline. For an explanation of the evidence statement numbering, see the evidence reviews section.
The committee discussed the recommendations and considerations in the 2 guidelines being updated (NICE guidelines PH33 and PH34), and considered the view of the experts in the review decision. The committee agreed that the previous recommendations were still pertinent but they needed some updating to better reflect current practice. The committee removed or amended parts of the recommendations that it agreed were outdated. For more information, see update information.
The committee concluded that many of the recommendations from the previous guidelines were aimed at a broader population than men who have sex with men, and black Africans. For the more specific recommendations, the committee agreed it would be appropriate to broaden them to apply to any population with a high rate of HIV. The committee recognised that men who have sex with men, and black Africans are still the most high-risk groups for HIV in the UK and this is reflected in the guideline (recommendation 1.2.6). An additional benefit of broadening the recommendations to apply to everyone with undiagnosed HIV is that it should help to normalise HIV testing so that it is not seen differently from any other blood test. For more information on the relevance of this guideline for other groups, see the equality impact assessment.
The committee discussed the distinction between testing and screening. It was reminded that recommending screening programmes is outside NICE's role. It was aware that HIV screening in antenatal settings is currently recommended by the UK National Screening Committee and has a very high uptake. It also discussed the differences between opt-in and opt-out approaches to testing, that is whether people are asked if they want an HIV test or they are told they will be tested for HIV unless they specifically ask not to be. It agreed that it was important to make sure people understand that HIV testing is voluntary and to give everyone the opportunity to opt out of a test.
The committee discussed that HIV testing may not always be routinely undertaken among people who have conditions that might indicate HIV infection. For this reason, it agreed that it is important for national guidelines to recommend HIV testing when diagnosing or treating conditions that may indicate HIV infection (see Guidance: HIV in indicator conditions HIV in Europe).
The committee agreed that the British HIV Association UK national guidelines for HIV testing 2008 are the most up-to-date HIV guidelines available in the UK and are also accredited by NICE, so they remain in the recommendations. The only exception relates to indicator conditions, for which more up-to-date guidance is available from 'Guidance: HIV in indicator conditions'. Although this guideline has not been accredited by NICE, the committee agreed it was a useful and authoritative source of information to give people who are offering HIV testing.
The committee discussed the meaning of 'high prevalence'. NICE guidelines PH33 and PH34 used the definition given by Public Health England of 2 in 1,000 people. However, as more people are being diagnosed with HIV and treated, and because they are living longer, the background prevalence of HIV is rising and the overall UK prevalence in 2014 was 1.9 per 1,000.
The committee was aware that during the development of this guideline, Public Health England carried out a new analysis of 2014 data on diagnosed HIV prevalence distribution in local authorities in England. Based on this analysis, groups and communities at high prevalence of diagnosed HIV can be defined as follows:
High prevalence: local authorities with a diagnosed HIV prevalence of between 2 and 5 per 1,000 people aged 15 to 59 years.
Extremely high prevalence: local authorities with a diagnosed HIV prevalence of 5 or more per 1,000 people aged 15 to 59 years.
When this is applied to national late HIV diagnosis data, it shows that two-thirds of late HIV diagnoses occur in high-prevalence and extremely-high-prevalence local authorities. This means that if this guideline is successfully applied in high- and extremely-high-prevalence areas, it could potentially affect two-thirds of late diagnoses nationally.
The committee agreed that the definitions of high prevalence and extremely high prevalence were useful, and it incorporated them into the recommendations. The committee also agreed it was important for areas to find out their diagnosed prevalence, as well as that of surrounding areas (recommendation 1.1.1). This allows them to adapt their strategy for HIV testing using the recommendations in this guideline. These data are available from Public Health England's sexual and reproductive health profiles. Additionally, the committee was aware that local data are often available to supplement national data from Public Health England, and that local data may be more up to date and provide more granular detail about local groups and populations with a high rate of HIV.
The committee did not make recommendations for all of the evidence statements. This was mainly because it did not believe, based on the evidence, that an intervention was effective; or it agreed that the intervention may not be applicable in the UK. For details of the evidence statements not used to make recommendations, see the evidence reviews section.
The discussion below explains how we made [new 2016] recommendations in:
section 1.2 Increasing opportunities for HIV testing.
The committee discussed the appropriateness of different settings for offering HIV testing. It noted the role the voluntary sector plays in HIV testing, particularly in terms of increasing its acceptability among some subpopulations. In terms of healthcare settings, it acknowledged that previous evidence for PH33 and PH34 had shown that both primary and secondary care were suitable settings to offer and recommend HIV tests. The committee did not feel it was appropriate to recommend promoting HIV testing in any particular setting more than others, so it made recommendations for all settings, using HIV prevalence to determine the intensity of interventions.
The committee noted that there is pressure on healthcare professionals' time during appointments. Some kinds of HIV tests might take too long – for example, a GP would not be able to perform point-of-care testing (POCT) during a 10-minute appointment in addition to the main consultation. However, another healthcare practitioner in the practice, for example a practice nurse, might be able to offer this test.
The committee considered that the uptake of HIV testing was generally high when testing was offered but that staff are often reluctant to offer and recommend a test. The committee felt it was particularly important that practitioners who are reluctant to offer tests more widely should know about this.
The committee discussed criteria for offering testing in secondary care, emergency care and GP surgeries based on the identified HIV prevalence of the area (recommendations 1.1.5 to 1.1.10). It agreed that further opportunities to maximise HIV testing should be pursued in areas with a high prevalence of HIV. This could include testing someone who has not previously been diagnosed with HIV when they are having blood tests on admission to hospital, or when they register with a GP practice (recommendations 1.1.6 and 1.1.9). In high- and extremely-high-prevalence areas, having a blood test for another reason provides an opportunity for an HIV test with little resource impact (just the cost of the test). The committee also agreed that when new patients register with a GP surgery their overall health is assessed and this is an efficient opportunity to promote HIV testing.
The committee felt it was important not to miss opportunities to offer testing opportunistically in areas of extremely high prevalence (recommendations 1.1.7 and 1.1.10). This could include offering testing to everyone who has not previously been diagnosed with HIV, when they are admitted to hospital, or to people attending GP appointments. However, the committee also noted the importance of using clinical judgement before offering an opportunistic test in general practice (recommendation 1.1.10). For example, a GP might decide not to offer a test during a consultation if the person is distressed or upset or has recently been tested.
On balance, recognising the practical implications of introducing opportunistic testing in GP practices as well as the potential resource impact, the committee made a weaker 'consider' recommendation for GP surgeries (recommendation 1.1.10). This means that the recommendations place a stronger onus on hospitals to deliver testing in extremely-high-prevalence areas, compared with GP surgeries. The committee agreed this was justifiable because testing in acute settings is likely to be cheaper than in GP surgeries, and most people being admitted to hospital have blood taken for other reasons (recommendations 1.1.6 and 1.1.7).
The committee also discussed the effectiveness of offering testing to people who present to health services with conditions that might indicate HIV. The effectiveness of this depends to some extent on the accuracy of the list of indicator conditions used. The committee agreed that defining a list of indicator conditions was outside the scope of this guideline. However, it agreed that HIV in indicator conditions from HIV in Europe was sufficiently evidence-based to inform recommendations 1.1.5 and 1.1.8 and to be a useful supplement to the guideline.
The committee noted stakeholder comments about the importance of testing in prisons. Little evidence was identified on the effectiveness of interventions to provide HIV testing in custodial settings, although 2 studies looked at the timing of HIV tests in prisons [ES14]. Despite the lack of evidence, the committee agreed that prisons were a high-prevalence environment for HIV and other blood-borne viruses and that health services in prisons would be expected to recommend testing to people in line with the approach used in GP surgeries. It was also clear that the committee had a duty to promote equality through its guidelines, and a recommendation for people in prison would support this.
The committee saw evidence to suggest that uptake of HIV testing was higher if tests were offered within 24 hours of reception into prison [ES14]. It was aware of national guidance from Public Health England on improving testing rates for blood-borne viruses in prisons and other secure settings, which indicates that testing should happen within 72 hours of reception, and inferred that, if combined with other tests for blood-borne viruses, HIV testing would have a lower cost impact. It was mindful that there is a NICE guideline on physical health of people in prison. On balance, it felt that the evidence was strong enough to recommend that HIV testing should be recommended at prison reception.
The committee discussed the range of settings where HIV testing could be offered, especially less invasive tests. It noted the importance of offering testing to people in places they would normally go, but was also aware that there could be a potential stigma associated with this (for example, because they might not want to be seen by other members of their community). The committee discussed faith settings as an example of a setting where HIV testing could be offered. However, it acknowledged that not all faith settings would be appropriate or faith groups willing to participate.
The committee discussed the distinction between self-sampling and self-testing. No evidence was found on self-testing so it did not include this in the recommendations.
The committee discussed self-sampling and agreed that although there was limited evidence currently, it showed great promise, especially as a way to engage people who are less likely to present at services. However, given the paucity of the evidence, the committee decided that it was only able to make a 'consider' recommendation (making decisions using NICE guidelines explains how we use words to show the strength, or certainty, of our recommendations).
The committee recognised that not all community settings are appropriate for providing self-sampling kits and agreed it was important to consult stakeholders when setting up self-sampling services. The committee agreed there were likely to be economies of scale and that some local authorities might get better value for money by commissioning online self-sampling services such as the one currently provided by Public Health England [ES17].
The committee noted the importance of timely partner tracing and notification, not only for the purposes of offering an HIV test, but if the sexual contact was recent then providing post-exposure prophylaxis promptly could reduce the risk of infection.
The committee discussed the frequency of HIV testing and agreed that repeat testing should be promoted to people in higher-risk groups. It discussed evidence for the effectiveness of different systems to promote repeat testing, such as call–recall methods and electronic reminders. The committee agreed that systems like these should be implemented wherever possible. It noted that the evidence suggested that electronic reminders that cannot be dismissed without completing a query box were more effective than reminders that could be clicked off. However the evidence was not sufficient to support this as a recommendation and overall the committee agreed it would be too onerous [ES18].
The committee noted that late diagnosis of HIV is substantially more costly than early diagnosis, because of the costs of inpatient admission and treatment. The committee was aware that prompt diagnosis of HIV would be cost saving per person, and there could be further cost savings through averting transmission (recommendation 1.2.9). The committee agreed that HIV testing is most cost effective when the cost per positive test is lowest. The committee noted that the cost of an HIV test is incurred for each person tested and therefore the cost per positive test result decreases when either the cost of the HIV test decreases, or the HIV prevalence in a population increases.
The committee noted that the review of cost effectiveness identified mixed evidence as to whether it is more cost effective to test everyone for HIV, or to target certain groups. The studies identified considered the general population in the UK or the US and compared various strategies for testing everyone or only those who disclosed risk factors that identified them as a higher-risk group. Differences in populations, strategies, inputs, cost perspectives and model structure presented difficulties in comparing and interpreting the results. The committee was limited in how it could use this evidence in making recommendations.
The committee discussed that the additional cost of testing for HIV for a person already undergoing blood tests was likely to be low. The committee felt that in an areas of high and extremely high prevalence, offering HIV testing to everyone undergoing blood tests for another reason would be cost effective, because of the low incremental cost and high HIV prevalence (recommendations 1.1.6, 1.1.9).
The committee discussed that HIV testing for everyone admitted to hospital would incur an additional cost, but that this would be cost effective in areas of extremely high prevalence (recommendation 1.1.7) given the likelihood of bloods being taken for other reasons.
The committee discussed that HIV testing for everyone attending a GP surgery would incur an additional cost, but that opportunistic testing would be cost effective in areas of extremely high prevalence (recommendation 1.1.10).
In other settings or areas of lower prevalence, the committee felt that targeting specific groups was more likely to be cost effective: that is, it would result in the lowest cost per positive test (recommendations 1.1.5, 1.1.8, 1.2.6).
The committee noted an analysis of pilot projects for HIV testing in hospitals, primary care and community settings and for self-sampling, which found variation in cost per positive test. It concluded that no single setting was likely to offer the greatest value for money. The committee recommended setting up community testing in high- and extremely high-prevalence areas in addition to testing in hospitals and primary care (recommendation 1.1.14). The same analysis found that the cost per test of self-sampling was comparable to the cost per test in other settings, and so could represent a cost effective method of diagnosing HIV (recommendations 1.1.16, 1.2.3, 1.2.4, 1.2.8).
When discussing testing in GP surgeries and emergency departments (section 1.1), the committee discussed the resource impact of the recommendations. It felt that making testing routine for all attendees in GP surgeries and emergency settings could have a substantial resource impact and could only be justified in areas of extremely high prevalence. However, the committee agreed that opportunistic testing for everyone having a blood test in these settings in extremely-high- and high-prevalence areas represents best practice, although it was mindful of the resource implications. The committee also considered the potential resource impact of self-sampling. An expert told the committee that self-sampling was likely to cost the same as traditional testing approaches involving healthcare professionals. It may also be an effective approach in harder to reach subgroups at risk, and could have potential to reduce late diagnosis in these groups. This could reduce the health and social care costs associated with late diagnosis [EP2].
The committee discussed further the role that primary care professionals (particularly GPs) could have in opportunistically offering and recommending HIV testing to a subpopulation of people at risk who are difficult to reach through methods described in recommendations 1.1.8 and 1.1.9. It discussed promoting opportunistic testing at every consultation in extremely-high-prevalence areas as a way of promoting testing to this subpopulation. The committee agreed that HIV testing for everyone attending a GP surgery would incur an additional cost. The proportion of HIV tests conducted in GP surgeries was estimated to be 3.8%. The committee reasoned that if 3.8% of all people aged 15 to 59 in areas of extremely high prevalence who do not have an HIV diagnosis had an HIV test in their GP surgery, the estimated cost would be between £2 million and £4 million depending on the cost used for GP time and laboratory costs. The committee noted that, given current HIV testing practice, this was a highly unlikely scenario and therefore the resource impact of the recommendation is likely to be much smaller. Notwithstanding, given the annual treatment costs for HIV, the life expectancy of somebody living with HIV and the potential reduction in transmission due to treatment, the committee agreed that opportunistic GP testing was good value.
The discussion below explains how we made [new 2016] recommendations in:
There was some evidence of effectiveness for media campaigns, educational videos, online social networking and information leaflets in raising awareness of HIV testing. The committee agreed that different methods of awareness raising are effective for different groups and that a range of methods should be recommended [ES1, ES2,ES6, ES7, ES8, ES9, ES10].
The committee discussed the evidence from 1 study on the effectiveness of motivational interviewing for increasing uptake of HIV testing [ES4]. The committee felt that there was not enough evidence from the study to recommend this as an intervention but that referring to NICE's guidelines on behaviour change would cover this type of approach (recommendation 1.3.1).
The committee noted that evidence suggested computerised interviews and risk assessments were unlikely to be effective at increasing uptake of HIV testing in people who may have undiagnosed HIV. However, it did not think the evidence was strong enough to recommend that they should not be used. [ES3].
There was evidence suggesting that financial incentives are effective at increasing uptake of HIV testing [ES21]. However, the committee noted a lack of evidence from UK healthcare settings. Without stronger evidence of effectiveness in the UK, the potentially significant resource impact of the intervention could not be justified.
The committee noted that awareness raising was a core element of any health promotion and it deemed the resource impact of the new recommendations to be minimal. The intention behind the new recommendations was to bring the principles in line with current technologies and modes of delivery of messages.
Details of the evidence discussed are in evidence reviews, reports and papers from experts in the area.
The evidence statements are short summaries of evidence. Each statement has a short code indicating which document the evidence has come from.
Evidence statement number E1.1 indicates that the linked statement is numbered 1.1 in review 1 for PH33, 'Review of effectiveness and cost effectiveness: increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among black African communities living in England'. Q1 indicates that the linked statement is numbered 1 in review 2 for PH33, 'Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among black African communities living in England – barriers to HIV testing'. ES1 indicates that the linked statement is numbered 1 in the review for PH34 'Preventing and reducing HIV transmission among men who have sex with men'.
The expert report 'Time to test for HIV: expanded healthcare and community HIV testing in England. Interim report' was also used to inform the original recommendations in PH33 and PH34.
ES1a.1 indicates that the linked statement is numbered 1 in review 1a for this guideline. ES1b.1 indicates that the linked statement is numbered 1 in review 1b for this guideline. ES1c.1 indicates that the linked statement is numbered 1 in review 1c for this guideline. ES2.1 indicates that the linked statement is numbered 1 in review 2 for this guideline. EP1 indicates that expert paper 'Targeted testing based on indicator conditions' is linked to a recommendation. EP2 indicates that expert paper 'HIV testing in the UK and summary of current UK practice' is linked to a recommendation.
If a recommendation is not directly taken from the evidence statements, but is inferred from the evidence, this is indicated by IDE (inference derived from the evidence).
2011: E3.2, ES3, ES13 2016: ES1a.1, ES1a.2, ES1a.6, ES1a.7, ES1a.8, ES1a.9, ES1a.10
2011: E3.2, ES3, ES13 2016: ES1a.1, ES1a.2, ES1a.6, ES1a.7, ES1a.8, ES1a.9, ES1a.10
The committee's assessment of the evidence on HIV testing identified a number of gaps. These gaps are set out below.
1. Interventions to increase awareness of the benefits of HIV testing and details of local testing services among people who have not been diagnosed with HIV, particularly:
one-to-one and group-based information provision
opportunistic information provision
use of social media
mass media campaigns.
2. Interventions to increase awareness of the indicators for, and the benefits of, HIV testing among practitioners who should offer testing or refer people for testing.
3. Increasing the range of settings where tests can be carried out, particularly in community and outreach settings.
4. Changes in service delivery to increase the uptake of HIV testing, for example, increasing the number of tests offered; changing opening times and appointment systems; and changing confidentiality policies.
5. The impact of lay testers recommending or offering an HIV test.
6. The effectiveness of self-testing for HIV and self-sampling for an HIV test.
7. Interventions to assess whether indicator condition-targeted testing is effective compared with routine testing.
8. Interventions to increase uptake of HIV testing among people who have an illness that may indicate HIV infection.
9. Attitudes towards HIV testing among people who may have undiagnosed HIV, and service providers (that is, whether or not there is any stigma associated with HIV tests).
10. Barriers to HIV testing for people who may have undiagnosed HIV (for example, people who do not speak English as a first language) and service providers.
11. Appropriate settings for delivering HIV testing, for example custodial settings or faith settings.
12. Appropriate definition of 'high prevalence' in the UK context, especially in terms of cost effectiveness.
(Source committee discussion)