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Every missed HIV diagnosis is a failure of care

Letter from Professor Chloe Orkin, chair of the British HIV Association (BHIVA)

Every HIV diagnosis that is overlooked or missed by any doctor is a failure of clinical care. People whose HIV is diagnosed late have frequently been seen by a doctor prior to their diagnosis without an HIV test being offered.

Nobody dies from being offended, but by overstating the ‘ethical issue’ of offending patients when offering HIV testing, as in your recent article entitled Four ethical issues to consider before offering HIV tests to your patients risks HIV infections being missed or diagnosed too late.

This oversight means that people fail to receive the treatment and care they need which in turn leading to unnecessary illness and in some cases death. HIV testing is important in preventing onward transmission as people who are diagnosed and treated are no longer infectious to other people. NHS Trusts are reporting missed HIV diagnoses as serious untoward incidents and performing root cause analysis on each one. Surely missing a diagnosis of HIV is a greater medico-legal risk to the medical profession than offending someone by offering a test. This article risks reinforcing the HIV associated stigma that we have spent 30 years fighting.

The recent recommendations by NICE and Public Health England to expand GPs remit in offering HIV testing are based on robust evidence that shows an urgent need to increase the awareness and uptake of HIV testing in England. The advice will also help make HIV testing a routine investigation and – we hope – help reduce the stigma that allows HIV to flourish.

HIV currently infects 17 more people each day in England, many of whom will remain unaware of their infection precisely due to the stigma which still clings to this undiscriminating and life-threatening condition. We don’t have a vaccine or a magic bullet, but we could potentially stop nearly all transmission of HIV, nearly all new infections, purely by diagnosing people earlier and putting them on treatment (and by using PrEP), but we are signally failing to do this. More extensive testing, without wasting too much time on risk assessments (which are too often wrong) is the key part of this. This testing cannot be done just in GUM clinics, where there is very little extra capacity, so MUST be done in other settings – particularly in primary care. Without this increased testing, we will never change the epidemiology of HIV in the UK, and every year there will be another 6,000 new diagnoses.

We believe that GPs are perfectly capable of negotiating complexity in all areas of their practice as well as understanding the critical importance of HIV testing. Let’s not reduce the impact of the NICE guidelines that clinicians are expected to follow to deliver best outcomes within safe, competent practice by adding our preconceptions.


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Readers' comments (8)

  • Amen

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  • It’s disappointing – and a missed opportunity – that a practising GP was not invited to write this article about the ethics and medicolegal issues of HIV testing in the general practice setting.

    The undiagnosed proportion of those with HIV in England has fallen steadily over the years from 1 in 3 to a new low of 1 in 8. This fall represents the efforts of many, including many in general practice who normalised HIV testing years ago.

    We must not regress to the darkest days of HIV stigma, as Chloe Orkin, Chair of BHIVA, has pointed out in her comprehensive response. The article undermines the efforts of those of us working hard to bring further increases in HIV testing for a last push to eliminate late diagnosis of HIV in the UK and to minimise new infections through the benefits of bringing treatment to all.

    We fully support Professor Orkin and would be very happy to contribute an alternative article focusing on the health risks to patients and ‘ethicolegal’ risks of failing to diagnose this highly treatable infection.

    Philippa Matthews FRCGP
    Clinical Lead for Sexual and Reproductive Health and HIV
    Royal College of General Practitioners

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  • Dear Philippa, please see this recent article from Dr RIchard Ma:

  • Very interesting article

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  • David Banner

    The title of this article is chilling. "Failure of care" suggests medical negligence, with all that that implies. If the sore throat I saw last month turns out to be an HIV patient should I be sued??
    I'm all in favour of increasing diagnosis, but not with the dark threat of medico-legal hell.

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  • The article states that HIV testing MUST be done elsewhere "particularly in primary care " because "there is very little extra capacity" in GUM clinics....... Sorry, but most GPs I know are already at breaking point.....WE have no capacity for any additional work either. GPs are "perfectly placed" to do just about everything.....but I am fed up being the dumping ground for everyone.

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  • I feel that I may be one of the fortunate GP who was invited to a few national international conferences/seminars several years ago. Then and even now I believe in routine testing of the HV if we have tackle the whole issue of preventing this condition spreading any further. Let us be honest and serious about it but off course we have to respect clients privacy and exercise confidentiality -it is mandatory

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  • Healthy Cynic

    You really need to clarify what you are saying. Is it
    1. all patients should have HIV tests (in which case this is a public health issue that requires a national programme), or
    2. GPs should be vigilant and offer HIV test as part of work-up in patients thought to be at risk due to lifestyle/presentation.
    If it is the latter, why don't you say that, rather than imply that all GPs are lazy and incompetent.
    Is your chair funded by the Daily M

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  • Healthy Cynic

    ..Daily Mail?

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