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Expanding HIV testing in England: targeting high prevalence areas
V. Delpech, T. Chadborn
Health Protection Agency, London, United Kingdom
Background: Over 25000 people remained undiagnosed and one third of those diagnosed have a CD4 count < 200/mm3 in England. HIV testing is primarily performed among STI patients and pregnant women. To reduce late diagnosis and onward transmission, new guidelines (2008) recommend expanding testing in specific healthcare settings based on targeted geographical areas. We provide the rationale and epidemiological evidence for expanding HIV testing across England.
Methods: Based on the assumptions that 1) diagnosed prevalence is a good indicator of the undiagnosed prevalence (ratio 2:1) and 2) HIV testing is cost effective where prevalence >1/1000 people tested, we calculated rates of diagnosed HIV prevalence and identified areas >2/1000 population (15-59 years) across England using data from 2007 Survey of Prevalent HIV Infection Diagnoses (SOPHID) and population estimates.
Results: The overall diagnosed prevalence (15-59 years) was 0.16%. It exceeded 0.2% in 34/152 (22%) Primary Care Organisations (PCOs), of which 25 were in London. These PCOs covered 19% of the English population and 57% of HIV diagnosed persons (15-59) in England. Sixteen PCOs in London had a diagnosed prevalence >0.4% including the PCO with the highest prevalence (1.2%). Five PCOs outside London with a prevalence >0.2% threshold historically have had relatively high rates and four PCOs that have experienced more recent increases. These findings have been driven by, but not exclusively, high rates of diagnoses among men who have sex with men and black Africans in these PCOs.
Conclusions: At least one in five local health authority should consider offering universal testing to persons (15-59) registering in general practice or admitted for medical care. In other parts of England, universal offer should remain in traditional settings and among patients with clinical indicators or at risk. The acceptability and feasibility of expanding HIV testing will require thorough evaluation to inform future policies and guidelines.
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