Offering HIV screening to new patients in general practice on a routine basis increases testing rates and improves detection and earlier diagnosis, research co-led by Queen Mary University of London and UCL suggests.
HIV testing rates in general practice are low, despite testing being recommended in UK and international guidelines. Lack of testing leads to later HIV diagnosis, poorer clinical outcomes and higher care and treatment costs. It can also increase the chances of an individual passing on the virus.
A paper published in EClinicalMedicine today examines the impact of implementing HIV screening using one-off training for staff, reflecting 'real-world' conditions in 13 east London GP practices.
It compares outcomes with those recorded in the same team's earlier randomised control trial in which staff from 20 practices received initial training plus regular support. The initial trial, which ran between 2010 and 2012, found the approach increased both the number of HIV tests and the number of diagnoses. CD4 counts at diagnosis were high - suggesting that the infection was picked up when the immune system was still healthy.
The study team believes this new analysis is the first comparing results of 'real-world' implementation of nurse-led HIV screening in routine primary care with those of a trial, as well as with practices that received no intervention (the comparator group).
This analysis showed outcomes achieved from routine implementation were comparable to those achieved in the randomised control trial: increased HIV testing rates, resulting in more and earlier diagnoses. The rise in new diagnoses in both practice groups was higher than in a comparator group of ten practices that received no training or support.
All the practices were within the City and Hackney Clinical Commissioning Group area.
People diagnosed during the 'routine implementation' period had average CD4 scores at diagnosis of 425 cells/micro litre - higher than the 351 recorded during the initial trial period and the 327 recorded for newly-diagnosed patients of the comparator group of practices.
HIV testing was 55% higher in implementation practices than comparator practices, diagnosis rates were 106% higher and CD4 count at diagnosis was typically 35% up. The researchers caution that the wide range in confidence levels around data, mean the results on the latter two outcomes are suggestive but not conclusive.
Importantly, most of the new diagnoses were among people in groups at the highest risk of late diagnosis - heterosexuals, and black African and Caribbean adults. Both those groups are under-represented at sexual health services where they would be offered HIV testing - which can mean they are diagnosed later.
The 13 practices did not receive the regular support from the research team enjoyed by the trial practices so the team could study the impact when practices made screening part of their routine registration of new patients.
Study co-lead Dr Werner Leber, a GP and clinical lecturer in primary care at Queen Mary University of London, said the 'implementation phase' confirmed that practices could successfully integrate HIV screening - particularly of new patients - into business as usual.
Dr Leber said: "During our initial research study we found that offering HIV tests to new patients did pick up previously undiagnosed cases of HIV. The data collected outside the clinical trial environment and published today shows that the intervention is effective in routine care within modern GP practices."
The study was funded by the National Institute for Health Research through the NIHR Applied Research Collaboration (ARC) North Thames (formerly NIHR CLAHRC North Thames).
Study co-lead Dr Jasmina Panovska-Griffiths, a Senior Research Fellow and Lecturer at UCL, said: "Our study shows that implementation of nurse-led HIV screening in general practices can be delivered effectively, leading to increased HIV testing that may be associated with increased and earlier HIV diagnosis. It also appears that most of the new diagnoses are amongst people who are less likely to attend sexual health services where they would be offered HIV testing."
Professor Chris Griffiths, Director of the Institute of Population Health Sciences at Queen Mary, said: "General practices across London and in urban areas with higher HIV prevalence in the UK and beyond need urgently to implement HIV screening in routine care. Screening is a key tool which can help realise the goal of eradicating HIV."
Professor Rosalind Raine from UCL and Director of NIHR ARC North Thames, said: "We were delighted to be able to fund this research, which has important implications for people, populations and health care systems internationally. People, particularly those from at risk key populations, are likely to benefit from increased access to testing in a familiar primary care setting with links to prompt treatment and care for those testing positive."
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Notes to editors
Evaluating the impact of post-trial implementation of post-trial implementation of RHIVA nurse-led HIV screening on HIV testing, diagnosis and earlier diagnosis in general practice in London, UK Leber. W, Panovska-Griffiths J. et al DOI: 10.1016/j.eclinm.2019.11.022
After the embargo lifts the article will be available at: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(19)30234-2/fulltext
For more information please contact: Chris Mahony in the Queen Mary University of London press office at c.mahony@qmul.ac.uk or +44 (0)207 882 5315 or Rowan Walker in the UCL press office at rowan.walker@ucl.ac.uk or +44 (0) 20 3108 8515
About Queen Mary University of London
At Queen Mary University of London, we believe that a diversity of ideas helps us achieve the previously unthinkable.
In 1785, Sir William Blizard established England's first medical school, The London Hospital Medical College, to improve the health of east London's inhabitants. Together with St Bartholomew's Medical College, founded by John Abernethy in 1843 to help those living in the City of London, these two historic institutions are the bedrock of Barts and The London School of Medicine and Dentistry.
Today, Barts and The London continues to uphold this commitment to pioneering medical education and research. Being firmly embedded within our east London community, and with an approach that is driven by the specific health needs of our diverse population, is what makes Barts and The London truly distinctive.
Our local community offer to us a window to the world, ensuring that our ground-breaking research in cancer, cardiovascular and inflammatory diseases, and population health not only dramatically improves the outcomes for patients in London, but also has a far-reaching global impact.
This is just one of the many ways in which Queen Mary is continuing to push the boundaries of teaching, research and clinical practice, and helping us to achieve the previously unthinkable.
About the National Institute for Health Research
The National Institute for Health Research (NIHR) is the nation's largest funder of health and care research. The NIHR:
- Funds, supports and delivers high quality research that benefits the NHS, public health and social care
- Engages and involves patients, carers and the public in order to improve the reach, quality and impact of research
- Attracts, trains and supports the best researchers to tackle the complex health and care challenges of the future
- Invests in world-class infrastructure and a skilled delivery workforce to translate discoveries into improved treatments and services
- Partners with other public funders, charities and industry to maximise the value of research to patients and the economy.
The NIHR was established in 2006 to improve the health and wealth of the nation through research, and is funded by the Department of Health and Social Care. In addition to its national role, the NIHR supports applied health research for the direct and primary benefit of people in low- and middle-income countries, using UK aid from the UK government.
The NIHR Applied Research Collaboration (ARC) North Thames is a partnership of six leading universities (including Queen Mary and University College London), the NHS and councils across central/east London,
Bedfordshire, Essex and Hertfordshire). It also involves patients, communities, charities and industry who share a commitment to improving health and social care services and people's health.
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Our community of more than 41,500 students from 150 countries and over 12,500 staff pursues academic excellence, breaks boundaries and makes a positive impact on real world problems.
We are consistently ranked among the top 10 universities in the world and are one of only a handful of institutions rated as having the strongest academic reputation and the broadest research impact.
We have a progressive and integrated approach to our teaching and research - championing innovation, creativity and cross-disciplinary working. We teach our students how to think, not what to think, and see them as partners, collaborators and contributors.
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Journal
EClinicalMedicine