The Ministry of Health has accepted recommendations from its AIDS Medical and Technical Advisory Committee (AMTAC) with respect to the ‘normalisation’ of medical HIV testing.
These recommendations are broadly supported by professional bodies and the New Zealand AIDS Foundation.
The original HIV testing guidelines
The original Ministry of Health guidelines for HIV testing of adults were established in 1987. At that time testing was performed in the context of:
- acknowledged high-risk behaviour for transmission of HIV
- lack of effective treatments for HIV
- recognition of the need to promote safe behaviours as the primary means of preventing HIV transmission.
The guidelines emphasised the value of both pre and post test counselling, and whilst defining issues that needed to be addressed at some stage during the counselling process, recommended that testing proceeded in the context of a significant counselling component. The need for special ‘pre testing counselling’ has been perceived by some as a barrier to testing, and possibly inhibiting some clinicians from conducting a test when they think that an HIV test may be of value.
Benefits of HIV testing
AMTAC considers that the continued increase in 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. Infected individuals can benefit from combination antiretroviral therapy and prophylaxis against opportunistic infections. The appropriate use of the former has had a dramatic effect on morbidity and mortality from HIV, although for some it can have significant side effects. AMTAC further recognises that HIV testing is becoming part of ‘routine’ medical care, for example, routinely offering HIV screening as part of standard antenatal care.
Consequently, AMTAC believes that testing should move from the current position of being ‘exceptional’ to becoming 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 around HIV testing where such testing is being performed in a medical context.
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.
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), including 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.
Conducting HIV tests
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. For example, a Ministry of Health brochure, Preventing HIV Infection, is freely available from local public health units.
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 US Guidelines from the Morbidity Mortality Weekly Report (MMWR) “Revised Recommendations for HIV Testing of Adults, Adolescents and Pregnant Women in Healthcare Settings”, MMWR September 22 2006 Vol 55 No. RR–14.