The role of testing in HIV prevention

Abstract

Despite worldwide roll-out of antiretroviral therapy, HIV incidence has been stable for the past 10 years. Prevention strategies, such as treatment as prevention, safer sex, and more recently pre-exposure prophylaxis have been viewed as the mainstays of efforts to reduce incidence. But one essential part of the prevention armamentarium has, at times, been overlooked: accessible testing. The UK could be about to address this oversight as a draft quality standard document from the National Institute for Health and Care Excellence (NICE) recommends the introduction of routine HIV testing. NICE outlines six quality statements that encourage testing for HIV in different settings and populations, including patients in high-prevalence areas and in at-risk demographic groups who are admitted to hospitals, attending emergency departments, or visiting general practitioners. The NICE statement also recommends that people who are at risk take tests at least annually. The speed and ease of modern HIV testing might make people more inclined to accept routine testing. When a test for HIV was first introduced in 1985, no effective treatment was available, and a positive result was seen more as a death sentence than as a chance to prevent further disease. However, prognosis today is very different and, in the UK, a positive result from an HIV test can lead to far better health outcomes than living with undiagnosed infection. Routine testing is likely not only to increase the numbers of diagnosed infected patients and thereby decrease transmission, but also to reduce stigma around HIV testing and infection more generally. Crucially, to implement routine testing effectively, systems need to be put in place in parallel to ensure linkage to care, treatment, and adherence interventions for people identified as HIV positive and comprehensive prevention advice must be provided for those with negative results. Perhaps the next step for routine testing is availability for an even wider audience than that proposed by NICE. Normalisation of HIV testing might encourage more thought about risks in all people, helping to eliminate stigma as awareness spreads. Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: the Global Burden of Disease Study 2015Scale-up of ART and prevention of mother-to-child transmission has been one of the great successes of global health in the past two decades. However, in the past decade, progress in reducing new infections has been slow, development assistance for health devoted to HIV has stagnated, and resources for health in low-income countries have grown slowly. Achievement of the new ambitious goals for HIV enshrined in Sustainable Development Goal 3 and the 90-90-90 UNAIDS targets will be challenging, and will need continued efforts from governments and international agencies in the next 15 years to end AIDS by 2030. Full-Text PDF Open AccessNot just PrEP: other reasons for London's HIV declineThe reduction in HIV diagnoses in London in 2016 is attributed to pre-exposure prophylaxis (PrEP).1 We believe that the causes of the 42% decline seen at our clinic are likely to be multifactorial. 56 Dean Street diagnoses one in four of London's HIV cases, 50% of whom have incident infection (ie, within 4 months of infection). Because of this, and following the results of the START study,2 we actively recommend treatment at, or close to, diagnosis, reducing the risk of transmission in people who would otherwise be highly infectious. Full-Text PDF