Missed opportunities for HIV testing--a costly oversight

Abstract

Objectives: In the UK, one-third of human immunodeficiency virus (HIV)-infected individuals are unaware of their diagnosis, and of those diagnosed a similar proportion have late stage disease. To address this National guidelines have been introduced promoting HIV testing across all medical specialities. We investigated HIV testing patterns in an inner London area with high local HIV prevalence, to identify missed opportunities for HIV testing and its consequences.

Methods: All human immunodeficiency virus (HIV) tests performed in 2008 at Guys and St Thomas' NHS Trust virology department were reviewed. Tests were stratified for location of request. Case-note review was carried out on all hospital HIV-positive diagnoses outside the genitourinary medicine (GUM) or screening settings to establish the circumstances surrounding the test, and missed opportunities for previous HIV testing.

Results: A total of 40,883 HIV tests were performed in 36,395 individuals. Three hundred and fifty-four (1%) tested positive. Excluding those from GUM or screening settings, 34 (2.8%) of the 1225 inpatients, 17 (0.3%) of the 5303 outpatients and 68 (1.12%) of the 5746 from primary care tested positive. Nineteen (41%) of 46 evaluable hospital diagnoses had presented to local healthcare services within the previous 12 months, 17 (37%) with an HIV indicator condition, but had not been tested. Of the 5303 outpatient tests conducted, 3148 (59%) were performed by either fertility or renal specialist teams. Other specialties conducted relatively few tests. The mean cost of admission for those diagnosed as an inpatient was £36,625 (range £331-223,000). The total cost for the 12 inpatients, who had presented to services in the preceding year but had not been tested was £439,500.

Conclusion: Despite large numbers of HIV tests as screening tests in GUM and antenatal settings, relatively few tests occurred elsewhere with profound costs. Missed opportunities to access this high-prevalence HIV population is concerning and urgent engagement of primary, secondary and tertiary healthcare systems to increase HIV testing and prevent late-stage diagnoses is underway.