Can we do more with HIV testing?

Abstract

In 2015 an estimated 0.8% of adults aged 15–49 years worldwide are living with HIV infection, although the rates have been variable between countries and regions (www.who.int/gho/hiv/en/). Rates in Europe have been estimated to be around 0.4%. The diagnosed HIV prevalence rate in London in 2015 was 5.8 per 1000 residents aged 15–59 years ( https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/594779/London_HIV_Spotlight_2015_data.pdf), but the rates were much higher (~27%) in Black African populations than in the White population (~5%). A number of initiatives were introduced in Europe over the last decade to help with the early diagnosis of HIV in people unaware of their HIV infection. One such initiative was ‘indicator condition-guided HIV testing’, which recommended the routine offer of HIV testing at the first diagnosis of an indicator disease such as cervical dysplasia, and was based on the prevalence rates or assumed rates of >0.1% of HIV infection (Lazarus et al. HIV Medicine 2013;14:445–8). Using population-based register linked data, Carlander et al. show the prevalence rates of undiagnosed HIV to be 0.3% in migrant women with cervical intraepithelial neoplasia grade 2+ (CIN2+) diagnoses, and argue that HIV testing should be performed in migrant women with CIN2+ disease and with unknown HIV status. Most will agree with this conclusion, but many will go beyond. Their data also show the rate of undiagnosed HIV to be 0.08% in migrant women without CIN2+ diagnosis, and some of the migrant subgroups without CIN2+ exceeded 0.1% prevalence. A more equitable approach will be to offer HIV testing to all migrant women with any cervical abnormality or to those referred for colposcopy. One may argue that in places with population HIV prevalence rates of >0.1%, as in London, HIV testing should be made available to all those who present with cervical dysplasia. Immune suppression leads to adverse outcomes of treatment of CIN2+ disease. The data presented by Carlander et al. is notable for a second reason. The median CD4 nadir measurements in their cohort was in the range of 25–310 cells/μL amongst women with CIN2+ diagnoses, and 122–260 cells/μL in all other women without CIN2+ diagnoses. Late presentation (CD4 < 350 cells/μL) in HIV is associated with increased morbidity and mortality. Initiating HIV antiretroviral treatment when CD4 measurements are >500 cells/μL leads to a reduction in serious health events and deaths when compared with starting HIV treatment at CD4 counts of 350 cells/μL or below (The INSIGHT START Study Group N Engl J Med 2015;373:795–807). Offering HIV testing to all women will help to prevent late presentations. A number of factors such as the duration of undiagnosed HIV, its transmissibility to others, and healthcare costs of late diagnosis need consideration against the costs of testing. We now have several types of HIV tests that can enable better access to testing. In immune-suppressed women, HPV-related multizonal anogenital neoplasia and cancers are more common, and may continue to manifest long after cervical disease. The earlier the diagnosis and treatment of HIV, the better are the chances of prevention of malignant disease in the lower anogenital tract. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.