Opportunistic testing

The ideal time for diagnosing HIV is before our patient progresses to symptoms - the chances for early diagnosis are higher and so the potential health benefits greater.

To support this we need to offer HIV tests to people who do not have any symptoms of HIV but who might be at risk. How, realistically, can this be done in a practice?

There are two strategies.

HIV screening is one approach that is appropriate for high prevalence areas for HIV. Examples of screening include offering a test to all newly registered patients or all women seeking contraception or an abortion. For more information on this see the fourth, and final, section of Update yourself.

Opportunistic testing for HIV of those at risk is the strategy we explore in this section. It depends on sexual history-taking. Clinicians should be aware of the benefits of diagnosing HIV early, and should be able to:

- introduce the topic of HIV with patients in a way that makes no assumptions

- take a sexual history and ask other relevant questions to assess risk

Knowledge of risk groups and of risk behaviours helps us to offer HIV tests to those at higher risk.

The advantages of routine sexual history-taking

No clinician in primary care would take a sexual history every time they see every patient. However those who are comfortable with sexual history-taking and ready to use their skill find it invaluable in a whole range of aspects of clinical care, even aside from picking up opportunities to test someone at risk for HIV.

Conducting a careful sexual health risk assessment will help you to:

- raise patient awareness and understanding (and this forms the basis for sexual health promotion)

- assess asymptomatic patients for risk of additional infections (eg Hepatitis B and C or Chlamydia) that may need to be tested for

- avoid misjudgments and wrong assumptions (which patient needs time spent in discussion of sexual health – and which doesn’t!).

- formulate differential diagnosis in the symptomatic patient (could that patient with persistent diarrhoea or shingles have HIV?)

- make clinical decisions (such as choice of contraceptive method, use of pH paper to assess vaginal discharge)

- clarify why a screening test (eg HIV, chlamydia, or viral hepatitis) has been declined – has the patient got good reasons? Or poor ones?

To learn more about how to take a sexual history and assess risk see resources.

Risk groups for HIV

We should be aware of which groups of people have a higher than average risk of having HIV.

People from high prevalence countries. Countries with the highest prevalence of HIV are in sub-Saharan Africa. Some Eastern European countries, the Caribbean and some parts of South East Asia also have relatively high prevalence. You can find out more about global and specific country prevalence by visiting UNAIDS or WHO.

Enquiring about country of origin is valuable for a range of reasons, for example it will help identify whether there is a need for viral hepatitis testing.
Men who have sex wtih men are, as a group, at higher risk of having HIV (although individuals may be at no, or low, risk).

People who have ever injected drugs
are also at higher risk, although viral hepatitis is a much more substantial risk in the UK.

Some risk groups may be apparent without conducting a sexual health and HIV risk assessment for example people from a high prevalence country, or those attending for methadone.
However some risk groups only become apparent when we discuss sexual health and conduct an HIV risk assessment, for example men who have ever had sex with another man. Or someone who once or twice injected drugs in the past. Or someone who has had sex with someone from a country with a high prevalence of HIV.
If we do establish that someone is in a risk group, and wish to raise the subject of HIV, it is best not to make assumptions about the risk of the individual patient.  For example, someone attending a methadone clinic may never have injected drugs and may have had a negative HIV test 6 months ago without risks since. Or a middle-aged patient from a country with a high prevalence of HIV may never have had sex or injected drugs. For strategies for raising the subject of sexual health or HIV when the patient may not be expecting it, see resources.

Risk behaviours for HIV

Risk behaviours for HIV include:

- Unprotected penetrative sexual intercourse

- Unsafe injecting practices

- Multiple sexual partners
Combinations of one or more risk group with one or more risk behaviour are the most concerning. However it’s best to have a very low threshold for offering HIV tests – if in doubt, test.

  Afua, 39 - a patient's view
I remember well when I first met my new GP after I moved to the area - it must have been nearly 10 years ago now. I was asking for more of my contraceptive pill. I remember that after she had asked me a few things about my work and so on, she asked where I came from – she must have spotted my accent. When I told her I was from Ghana she surprised me. She said something about how there were quite a few infections that were commoner in other countries than here in the UK, and so they were offering hepatitis and HIV tests as a matter of routine – had I ever had tests for those conditions? Had I ever wondered if I might be at risk?

I must have looked a bit doubtful because she went on to explain the benefits of knowing about these infections if you had them. I declined at the time but thought about it quite a bit – I had had a couple of boyfriends in Ghana before I came to the UK. Then later I asked her for the tests and we agreed to test for HIV and hepatitis. As I hadn’t had any kids at that point she suggested it would be worth checking my rubella immunity and check for sickle too.

I was of course shocked to find I had HIV, but I adjusted and my health has stayed excellent even though I am now on medication. A new partner and two children later – things are good! My GP is just retiring – I will miss her, we agree we have a special bond.

Return to Update yourself or view the next section HIV screening

Did you know...

Human Immunodeficiency Virus, HIV, was identified by two different research groups in 1983.

Antiretrovirals were initially used singly however it quickly became apparent that this led to resistance and so now they are used in combinations of 3 or more.