18 th Annual Conference of the

British HIV Association (BHIVA)

Miss Emma Rezel

London School of Hygiene and Tropical
Medicine

18-20 April 2012, The International Convention Centre, Birmingham

 4th generation Ag/Ab HIV testing:
47% of clinics contradict current
guidelines

Rezel, E.1, Walker, C.2 and Collins, S.3

1 London School of Hygiene and Tropical Medicine

2 Marie Stopes International
3 HIV i-Base
 Current guidelines
BHIVA / BASHH / BIS guidelines recommend 4th generation
(antigen/antibody) tests since 2008.
In 2010 BASHH issued a statement on the window period for testing:
“[4th generation tests] will detect the great majority of individuals who have
been infected with HIV at one month (4 weeks) after specific exposure”.
Patients ... should not be made to wait 3 months (12 weeks) before testing.
They should be offered a 4th generation laboratory HIV test and advised
that a negative result at 4 weeks post exposure is very reassuring/highly
likely to exclude HIV infection.
An additional HIV test should be offered to all persons at 3 months (12 weeks)
to definitively exclude HIV infection. Patients at lower risk may opt to wait
until 3 months to avoid the need for HIV testing twice.

BASHH (March 2010).

 i-Base information services
• HIV i-Base is a community HIV treatment
information and advocacy organisation
• Services include a treatment information phoneline
an email and online Q&A service
• Mainly HIV treatment but some testing
• Information is based on latest guidelines & research
• Emphasis on self empowerment for any aspect
of an individuals health
 Awareness & understanding of the
BASHH statement
• During 2011 the phoneline had an increase in
calls about HIV testing indicating very varied
experiences, many from distressed callers.
• Some clinics refused to test until 3 months.
• Some clinics did not know the tests that were
used at their centre.
• Some clinics provided people testing with
information that was different to the
guidelines.
 Quality of access to testing
• From a service-user perspective, are guidelines
for national HIV testing being met by clinics
during prefatory phone contact?
• What and how is information provided to a
worried service-user who is uncertain about
attending a clinic for HIV testing?
• What implications do these finding have on
access to testing in the UK when currently 1 in 4
positive people are unaware of their status?
 Aims
1. To identify what information is provided to the
public by sexual health services regarding HIV
testing procedures and guidance.
2. To qualify the standard of both the information
provided to the simulated service-user and the
manner in which the service-user was handled.
3. To establish how closely sexual health services
adhere to recent guidelines, specifically relating
to fourth generation testing.
 Methods
• Design
– A simulated service-user rang clinics with a simple standard case. As
an open access service, this was designed to minimise impact on clinic
work load (<5 minutes).
– The design was to capture the breadth of experiences (good and bad)
and not to identify individual good and bad clinics.
• Population
– A sample of 112 clinics were randomly selected from the 340 clinics
listed on the BASHH website.
• Instrument
– A semi-structured questionnaire.
• Analysis
– A thematic analysis of the questionnaire.
– A rating system to score clinic responses.
– Differences in mean rating scores between clinics in London and
outside of London and differences in mean rating scores between
different staff respondents were tested for using an unpaired t test.
Results 1 – “Is it a 3rd or 4th generation
test?”
4th generation with detail 24%
4th generation 16%
Gave some indication test was
4th generation 6%
3rd generation 4%
Both 3rd and 4th 2%
PCR test 1%
Inaccurate or unclear response 8%
Didn’t know 31%
Didn’t answer 8%
 Results 2 – “How accurate are the results/
when should I come in to get tested?”
Come in straight away for accurate test-
time of exposure in terms of accuracy not discussed 5%
Worthwhile at 4 weeks but not conclusive,
repeat test at 12 weeks 11%
Very accurate at 4 weeks 13%
Worthwhile testing at 6 – 8 weeks but not
conclusive until 12 weeks 6%
Very accurate at 6 – 8 weeks 9%
Very/only accurate at 12 weeks 36%
Dependent on other factors 6%
Unsure/unclear response/accuracy
and timing not explicit 8%
Didn’t answer 6%
 Sensitivity of responses
Most sensitive calls Least sensitive calls
41% of clinics were sensitive and 13% were alarmist, insensitive or
non-judgemental and put inaccurate:
patient at ease: "We don't understand it all so I doubt
“There’s no need to be anxious. A nurse you will either.”
will answer all your questions if you go “If you don’t know much about him,
in for an appointment.” why did you have unprotected sex with
“Even if he was positive, it depends on him?”
various factors, like, if he’s on “We only see positive tests amongst
treatment and if there’s blood-to-blood heterosexuals who have sex with
transmission. HIV is hard to catch so someone from Africa.”
don't worry” "If you're not prepared for a positive
result, don't come in for a test."
96% of these clinics encouraged clinic 95% of these clinics failed to mention
attendance in some way confidentiality or discrete service.
 Conclusions
• Most clinics provided a thorough response for questions that
required non-technical knowledge.
• Standards of information dropped for simple technical details,
especially when the call was not taken by a health professionals.
• When nurses, doctors or health advisors took calls there was a
statistically significant improvement in quality of responses
compared to receptionist staff.
• Only 17% of clinics adhered to the BASHH statement on HIV
window periods very closely.
• Training all staff who take calls from the public on basics of 4th
generation testing, the window period and current guidelines
would improve services.
 In summary
• People should be able to access tests based on current
guidelines. This includes early testing to avoid anxiety
and to seek appropriate health care.
• Inaccurate or conflicting information may be a barrier to
an individual testing and retesting in the future
• Standardising training in line with current guidelines was
identified as an area for improvement in approximately
half the clinics surveyed.
 i-Base responses

• New i-Base Guide to HIV

testing and risk of sexual
transmission
(free print and online)
• Phoneline:
0808 800 6013
• Online Q&A:
www.i-Base.info
 Thank you
HIV i-Base
Charlotte Walker and Simon Collins
(co authors)

UK-CAB
Memory Sachikonye

The London School of Hygiene &

Tropical Medicine