Recommendations for HIV testing of adults in healthcare settings

The continued diagnoses of cases of HIV infection in New Zealand means that there is a need to encourage more widespread and frequent testing of persons with risk behaviours.

There are both individual and public health benefits of early diagnosis of HIV infection. People with HIV can live relatively normal lives with drug treatment. Treatment and care for people with HIV is of a high standard.

Testing should be part of ‘normal’ medical practice, similar to testing for other treatable conditions, but without any relaxation of the need for consent and confidentiality.

It is important to note that these recommendations are not intended to modify current recommendations concerning HIV testing and counselling of persons at high risk of HIV who are being tested in the non-clinical setting, for example, community based testing at the New Zealand AIDS Foundation or drug treatment clinics.

The following recommendations aim to promote more frequent HIV testing and to ‘normalise’ the protocols where testing is being performed in a medical context.

HIV testing is recommended for:

• all persons with a history of unprotected sexual exposure that could result in HIV transmission (vaginal or anal sex without using a condom), especially men who have sex with men
• all persons with a history of injecting drug use that involves the sharing of drug injecting equipment, needles, syringes, spoons, filters etc
• all persons seeking assessment for sexually transmitted infections
• all pregnant women
• all persons with recently diagnosed tuberculosis infection
• persons with sexual contacts from countries where transmission of HIV infection is common, (for example and not limited to, Africa, Thailand or other Asian countries, Eastern Europe)
• prospective partners in a new sexual relationship
• any person whose blood or body fluids is the source of an occupational exposure for a healthcare provider.

It is further recommended that persons likely to be at high risk for HIV infection should be screened for HIV at least annually.

Persons who are known to have a high frequency of risk behaviours for HIV transmission should be advised of the need for periodic retesting (six-monthly) and offered prevention counselling as appropriate to their circumstances.

 It is recommended that:

• Testing should remain voluntary and only undertaken with the patient’s knowledge, consent and understanding that an HIV test is recommended.
• Oral informed consent must be obtained before the test is performed. Document in the patient’s medical notes that oral informed consent was obtained.
• The clinician requesting the test should continue to discuss the patient’s risk behaviour that has led to the recommendation for testing (eg, unprotected sexual exposure) and engage in a brief dialogue as to how such risk behaviour could be managed in the future
• The clinician requesting the HIV antibody test should discuss with the person how the results of the tests are to be provided and, written information on HIV should be available.

HealthEd have published a checklist for HIV testing, including pre-test discussion and post-test discussion: Voluntary Counselling and Testing for Diagnosis of HIV Infection.

1. HIV positive results should continue to be communicated confidentially by means of direct (ie, face-to-face) personal contact between the testing clinician and patient, in a supportive clinical environment, and not conveyed over a phone. Appropriate advice should be obtained from an HIV treatment specialist or clinical microbiologist regarding ongoing assessment and management of the patient.

2. Negative results do not need to be provided face-to-face, and in many situations can be delivered by phone or other agreed means.

3. Positive or negative HIV results should be documented in the patient’s confidential medical record, and should be readily available to other healthcare providers involved in the patient’s clinical management.

4. When HIV infection is diagnosed, healthcare providers should make strenuous efforts to encourage and assist infected persons to disclose their HIV status to their spouses, current sexual partners, previous sexual partners within the last 6–12 months, and that all of these sexual partners should be offered testing for HIV infection.

5. All people in New Zealand have a legal duty not to endanger the life, health or safety of others. In law this means that HIV infected people must take ‘reasonable steps’ to avoid transmitting HIV. Where the need to modify risky behaviour has been clearly identified, the clinician should be prepared to explore strategies for change with the patient or alternatively refer the patient to another agency, for example sexual health clinic or the New Zealand AIDS Foundation Clinic, that have specific skills in this regard. Such referral should not be an impediment to proceeding with the test.

These recommendations are in accord with Centers for Disease Control and Prevention Guidelines: “Revised Recommendations for HIV Testing of Adults, Adolescents and Pregnant Women in Healthcare Settings”, MMWR September 22 2006 Vol 55 No. RR–14.