How GPs should approach HIV testing
Letter from Dr Richard Ma, north London
Pulse recently published an article written by a medicolegal advisor to warn GPs to consider some ‘ethical issues’ before offering HIV tests to patients. While the article might be well-intentioned, framing HIV testing in this way might discourage some primary care professionals from offering HIV testing in some clinically appropriate situations which might, ironically, result in patients being harmed from missed opportunities or late diagnosis of HIV.
Here are my thoughts on how GPs should approach HIV testing:
1. It is possible to offer testing sensitively. The offer of a test might offend if it is unexpected or if the motive was not explained; men who have sex with men (MSM) and Black Africans are identified as high risk groups by NICE guidelines, so they might be offered HIV testing more often than other groups. While repeated offer of a test during unrelated consultations might cause annoyance, it should be explained as part of a range of investigations when clinically appropriate, particularly if patient attends with clinical indicator conditions for HIV. Recent NICE guidelines that promote HIV testing in areas with high diagnosed prevalence of HIV (greater than 2 per 1000) might avoid such issues, particularly if this is promoted in the surgery and all new registrants are offered HIV tests regardless of sexuality or ethnicity, in order to make it as routine as an NHS Health Check for example.
2. There appears to be mixed messages about needing ‘informed consent’. While it is correct that a lengthy pre-test counselling is not necessary, insisting on taking time for informed consent sounds contradictory. Individual clinicians and patients should be able to judge for themselves if they wished to discuss further, particularly if they felt ambivalent about benefits of testing or concerned about the risks. Many other tests we offer in general practice have lifelong implications cancer screening, diabetes testing and even pregnancy testing; highlighting HIV testing in this manner might perpetuate discriminatory attitudes further as well as discourage clinicians from offering it.
3. The issue of protecting confidentiality is complex. Whether or not an individual chooses to disclose their status to their friends, family, workplace and GP is a very personal decision, especially if they felt this might be sensitive issue within their community. There are ways to record HIV status (such as using a non-specific Read code) without appearing to be colluding and perpetuating the stigma that people already feel. HIV physicians already encourage patients to disclose their status to their GPs and other clinicians to ensure they get the right care and also because it is good clinical practice to do so.
4. While appreciating this is an infectious and transmissible disease, we need to emphasise the risk of HIV transmission when someone has been on antiretroviral treatment with sustained undetectable viral load for more than six months is minimal. National guidelines no longer recommend post exposure prophylaxis for HIV after sexual exposure in this circumstance. Use of language such as ’may expose others to risk of death’ sounds slightly excessive and hysterical and might even criminalise people with HIV.
5. People with HIV have their rights protected under the Equality Act 2010. We need to encourage people to report what might be discriminatory practices purely based on someone’s HIV status– such as refusing to register HIV patients, refusing certain medical procedures, disproportionate use of protection for procedures (such as double gloves if there is no exposure to bodily fluids).
I am pleased Pulse has encouraged some lively discussions about HIV testing in general practice. We can help people feel more comfortable about disclosure by helping to make HIV a less stigmatised disease. There is nothing shameful about asking for an HIV test, or having HIV diagnosis. If we really want to eradicate discrimination of people with HIV and make their lives better, it should start with us as clinicians -we should stop discussing HIV in hushed voices, in fear and in secret.