Making the case for routine HIV screening
'Getting to Zero'. That is the vision of the near future in the 2011 World AIDS Day Report from UNAIDS: zero new HIV infections; zero discrimination; and zero AIDS-related deaths. 
It is a vision that has become all the more realisable in the past year. 2011 has seen significant progress in HIV treatment and prevention. Almost half of eligible individuals in low- and middle-income countries are now accessing antiretroviral therapy.
The number of new infections globally in 2011 was 21% lower than in 1997 at the peak of the HIV epidemic, and AIDS-related deaths have decreased by 21% since 2005. Clear evidence is emerging of the benefits of antiretroviral therapy as a prevention tool: a recent RCT has shown a 96% risk reduction in onward transmission of HIV through the use of antiretroviral therapy. 
Indeed, in countries with successful treatment distribution programmes, the number of new infections is falling. Beyond the benefits to the public health, the benefits of therapy for the individual are now clear, with evidence that HIV-infected persons accessing therapy in a timely fashion are living near-normal life spans. 
But what so of the situation in the UK? Treatment is freely available, but is limited to those who know their HIV sero-status. The HIV epidemic in the UK continues to grow, and the fraction of undiagnosed HIV remains frustratingly constant.
The number of people living with HIV in the UK is estimated to be 91 500 in 2010.  There were an estimated 6660 new HIV diagnoses in the last year alone. In men who have sex with men, there were 3000 new diagnoses – the highest ever annual figure recorded in this risk group.
An estimated one in four of all individuals with HIV infection remain unaware of their sero-status. Of those newly diagnosed, half were diagnosed with CD4 counts below 350 cells/?l, the current threshold for the initiation of antiretroviral therapy. Of the 680 people with HIV who died in 2010, two thirds had been diagnosed late.
Time and again, evidence emerges of missed opportunities in the timely diagnosis of HIV. In the British HIV Association audit of more than one thousand new HIV diagnoses made in 2010, 25% were perceived to have had a missed opportunity for the diagnosis of HIV infection earlier in the natural history of the disease.
A key strategy in tackling our problems is to increase access to HIV testing in the UK, outwith the traditional settings of sexual health clinics and antenatal care. For five years, a paradigm shift in the way we offer HIV testing has been urged by health leaders and specialist societies, and clear guidance has been issued, including instruction from NICE encouraging screening in the primary care setting. [6-9]
Unfortunately, there has been a translational delay in the implementation of this guidance. We need to target groups at increased risk of HIV infection, and we need to offer tests to those presenting with the myriad of HIV 'indicator conditions' that span the whole spectrum of clinical specialities.
In areas of high HIV prevalence, we need to consider implementing large scale, routine, screening programs in both primary and secondary care to diagnose the undiagnosed in our population, and thereafter transfer individuals living with HIV to specialist care.
High prevalence areas are defined as those with a local diagnosed HIV prevalence of more than two per thousand population. More than thirty-seven PCTs, spanning the breadth of the country, fulfil this criterion. An increasing evidence base shows that all of these approaches are feasible, efficacious, cost effective, and most importantly, highly acceptable to our patients.
The largest barrier rests with us, the healthcare providers: our own HIV testing prejudices need to be broken down. We need to engage commissioners to develop services and strategies to tackle HIV infection in our community.
A key strength of the pilot studies to date has been the close cooperation between Sexual Health services and local primary and secondary care providers. We would urge you to work with your local Sexual Health colleagues. They will be keen to work with you to provide education, support, clinical expertise and guidance to keep this issue high on your local health agenda.
Please engage with us, and Getting to Zero may be a feasible and very real vision here on our own doorstep.
From Dr Michael Rayment, SpR and Dr Rachael Jones, consultant
West London Centre for Sexual Health, Charing Cross Hospital
 Joint United Nations Programme on HIV and AIDS, 2011 World AIDS Day Report; November 2011. Available from: http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/JC2216_WorldAIDSday_report_2011_en.pdf[accessed 29th November 2011]
 Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. N Engl J Med 2011; 365:493-505
 May M, Gompels M, Delpech V, et al. Impact of late diagnosis and treatment on life expectancy in people with HIV-1: UK Collaborative HIV Cohort (UK CHIC) Study. BMJ 2011; 343:d6016
 Health Protection Agency. HIV in the United Kingdom 2011 Report, Health Protection Agency; November 2011. Available from: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317131685847[accessed 29th November 2011]
 British HIV Association, Survey of HIV testing policy and practice, and audit of new patients when first seen post-diagnosis, British HIV Association; April 2011. Available from:
http://www.bhiva.org/documents/ClinicalAudit/FindingsandReports/HIVdiagnosisWebVersion.ppt[accessed 29th November 2011]
 Improving the detection and diagnosis of HIV in non-HIV specialties, including primary care, 2007. Available from: http://www.info.doh.gov.uk/doh/embroadcast.nsf/vwDiscussionAll/EE0FA479BAA64A1B80257355003DFB47[accessed 29th November 2011]
 British Association for Sexual Health and HIV (BASHH), the British HIV Association (BHIVA) and the British Infection Society (BIS) Guidelines for HIV Testing. British HIV Association; 2008. Available from: http://www.bhiva.org/HIVTesting2008.aspx[accessed 29th November 2011]
 National Institute for Health and Clinical Excellence. Increasing the uptake of HIV testing among men who have sex with men (Guidance: PH34). London: National Institute for Health and Clinical Excellence; 2011
 National Institute for Health and Clinical Excellence. Increasing the uptake of HIV testing among Black Africans in England(Guidance: PH33). London: National Institute for Health and Clinical Excellence; 2011
 Health Protection Agency. Time to test for HIV: Expanded healthcare and community HIV testing in England. Health Protection Agency; 2010. Available from: http://www.hpa.org.uk/Publications/InfectiousDiseases/HIVAndSTIs/1011TimetotestHIVtesting/[accessed 29th November 2011