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  • Guideline Summary
  • NGC:011124
  • 2016 Dec 1

HIV testing: increasing uptake among people who may have undiagnosed HIV (Joint NICE and Public Health England guideline).

National Institute for Health and Care Excellence (NICE), Public Health England. HIV testing: increasing uptake among people who may have undiagnosed HIV (joint NICE and Public Health England guideline). London (UK): National Institute for Health and Care Excellence (NICE); 2016 Dec 1. 62 p. (NICE guideline; no. 60). 

View the original guideline documentation External Web Site Policy

This is the current release of the guideline.

This guideline meets NGC's 2013 (revised) inclusion criteria.

Major Recommendations

Note from the National Guideline Clearinghouse (NGC): See the "Availability of Companion Documents" field for the supporting Evidence Reviews 1a and 1b, 1c, and 2.

Recommendations are marked:

  • [new 2016] if the evidence has been reviewed and the recommendation has been added
  • [2011] if the evidence has not been reviewed since 2011
  • [2011, amended 2016] if the evidence has not been reviewed but either:
    • Changes have been made to the recommendation wording that change the meaning or
    • National Institute for Health and Care Excellence (NICE) has made editorial changes to the original wording to clarify the action to be taken

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation) and is defined at the end of the "Major Recommendations" field. See the original guideline document for definitions of terms used in this guideline.

Offering and Recommending Human Immunodeficiency Virus (HIV) Testing in Different Settings

Local Prevalence

Offer and recommend HIV testing based on local prevalence and how it affects different groups and communities. Use Public Health England's sexual and reproductive health profiles and local data to establish:

  • Local HIV prevalence, including whether an area has high prevalence or extremely high prevalence
  • Rates of HIV in different groups and communities [new 2016]

Specialist Sexual Health Services (Including Genitourinary Medicine)

Offer and recommend an HIV test to everyone who attends for testing or treatment. [2011, amended 2016]

Ensure both fourth-generation serological testing and point-of-care testing (POCT) are available. [2011, amended 2016]

Secondary and Emergency Care

Routinely offer and recommend an HIV test to everyone attending their first appointment (followed by repeat testing in line with the recommendation under "Repeat Testing" below) at drug dependency programmes, termination of pregnancy services (Note: Antenatal HIV testing is covered by the UK National Screening Committee and is outside the remit of this guideline), and services providing treatment for:

  • Hepatitis B
  • Hepatitis C
  • Lymphoma
  • Tuberculosis [2011, amended 2016]

In all areas, offer and recommend HIV testing on admission to hospital, including emergency departments, to everyone who has not previously been diagnosed with HIV and who:

  • Has symptoms that may indicate HIV or HIV is part of the differential diagnosis (for example, infectious mononucleosis-like syndrome), in line with HIV in Europe's 'HIV in indicator conditions' External Web Site Policy
  • Is known to be from a country or group with a high rate of HIV infection (see "Local Prevalence" above)
  • If male, discloses that he has sex with men, or is known to have sex with men, and has not had an HIV test in the previous year
  • Is a trans woman who has sex with men and has not had an HIV test in the previous year
  • Reports sexual contact (either abroad or in the UK) with someone from a country with a high rate of HIV
  • Discloses high-risk sexual practices, for example the practice known as 'chemsex'
  • Is diagnosed with, or requests testing for, a sexually transmitted infection
  • Reports a history of injecting drug use
  • Discloses that they are the sexual partner of someone known to be HIV positive, or of someone at high risk of HIV (for example, female sexual contacts of men who have sex with men) [2011, amended 2016]

In areas of high and extremely high prevalence, also offer and recommend HIV testing on admission to hospital, including emergency departments, to everyone who has not previously been diagnosed with HIV and who is undergoing blood tests for another reason. [new 2016]

Additionally, in areas of extremely high prevalence, offer and recommend HIV testing on admission to hospital, including emergency departments, to everyone who has not previously been diagnosed with HIV. [new 2016]

General Practitioner (GP) Surgeries

In all areas, offer and recommend HIV testing to everyone who has not previously been diagnosed with HIV and who:

  • Has symptoms that may indicate HIV or HIV is part of the differential diagnosis (for example, infectious mononucleosis-like syndrome), in line with HIV in Europe's 'HIV in indicator conditions External Web Site Policy'
  • Is known to be from a country or group with a high rate of HIV infection
  • If male, discloses that they have sex with men, or is known to have sex with men, and has not had an HIV test in the previous year
  • Is a trans woman who has sex with men and has not had an HIV test in the previous year
  • Reports sexual contact (either abroad or in the UK) with someone from a country with a high rate of HIV
  • Discloses high-risk sexual practices, for example the practice known as 'chemsex'
  • Is diagnosed with, or requests testing for, a sexually transmitted infection
  • Reports a history of injecting drug use
  • Discloses that they are the sexual partner of someone known to be HIV positive, or of someone at high risk of HIV (for example, female sexual contacts of men who have sex with men) [2011, amended 2016]

In areas of high and extremely high prevalence, also offer and recommend HIV testing to everyone who has not previously been diagnosed with HIV and who:

  • Registers with the practice or
  • Is undergoing blood tests for another reason and has not had an HIV test in the previous year [new 2016]

Additionally, in areas of extremely high prevalence, consider HIV testing opportunistically at each consultation (whether bloods are being taken for another reason or not), based on clinical judgement. [new 2016]

Offer and recommend repeat testing to the people described in this section in line with "Repeat Testing" section below. [new 2016]

If a venous blood sample is declined, offer a less invasive form of specimen collection, such as a mouth swab or finger-prick. [2011, amended 2016]

Prisons

At reception, recommend HIV testing to everyone who has not previously been diagnosed with HIV. For more information see the NGC summary of the NICE guideline Physical health of people in prison. [new 2016]

Community Settings

Providers of community testing services (including outreach and detached services) should set up testing services in:

  • Areas with a high prevalence or extremely high prevalence of HIV, using venues such as pharmacies or voluntary sector premises (for example, those of faith groups)
  • Venues where there may be high-risk sexual behaviour, for example public sex environments, or where people at high risk may gather, such as nightclubs, saunas and festivals [2011, amended 2016]

Recognise that not all community settings are appropriate for providing testing services, for example, because tests should be undertaken in a secluded or private area (in line with British HIV Association guidelines External Web Site Policy). [2011, amended 2016]

Ensure that people who decline or are unable to consent to a test are offered information about other local testing services, including self-sampling. See making decisions using NICE guidelines External Web Site Policy for more information about consent. [2011, amended 2016]

Ensure that lay testers delivering tests are competent to do so and have access to clinical advice and supervision. [2011, amended 2016]

Increasing Opportunities for HIV Testing

Point-of-Care Testing

Offer point-of-care testing (POCT) in situations where it would be difficult to give people their results, for example, if they are unwilling to leave contact details. [new 2016]

Explain to people at the time of their test about the specificity and sensitivity of the POCT being used and that confirmatory serological testing will be needed if the test is reactive. [2011, amended 2016]

Self-sampling

Consider providing self-sampling kits to people in groups and communities with a high rate of HIV (see "Local Prevalence" above). [new 2016]

Ensure that people know how to get their own self-sampling kits, for example, by providing details of Web sites to order them from. [new 2016]

Repeat Testing

When giving results to people who have tested negative but who may have been exposed to HIV recently, recommend that they have another test once they are past the window period. [2011, amended 2016]

Recommend annual testing to people in groups or communities with a high rate of HIV, and more frequently if they are at high risk of exposure (in line with Public Health England's HIV in the UK: situation report 2015 External Web Site Policy). For example:

  • Men who have sex with men should have HIV and sexually transmitted infection tests at least annually, and every 3 months if they are having unprotected sex with new or casual partners
  • Black African men and women should have an HIV test and regular HIV and sexually transmitted infection tests if having unprotected sex with new or casual partners [2011, amended 2016]

Consider the following interventions to promote repeat testing:

  • Call–recall methods using letters or other media, such as text messages or email, to remind people to return for annual testing.
  • Electronic reminders in health records systems to prompt healthcare professionals to identify the need for testing during appointments and offer it if needed. [new 2016]

People Who Decline a Test

If people choose not to take up the immediate offer of a test, tell them about nearby testing services and how to get self-sampling kits. [2011, amended 2016]

Partners of People Who Test Positive

Partners of people who test positive should receive a prompt offer and recommendation of an HIV test through partner notification procedures. [new 2016]

Promoting Awareness and Uptake of HIV Testing

Content

Materials and interventions for promoting awareness and increasing the uptake of HIV testing should be designed in line with NICE's guidelines on behaviour change: general approaches External Web Site Policy and behaviour change: individual approaches External Web Site Policy and patient experience in adult NHS services External Web Site Policy. [new 2016]

Provide promotional material tailored to the needs of local communities. It should:

  • Provide information about HIV infection and transmission, the benefits of HIV testing and the availability of treatment
  • Emphasise that early diagnosis is not only a route into treatment and a way to avoid complications and reduce serious illness in the future, but also reduces onward transmission
  • Detail how and where to access local HIV testing services, including services offering POCT and self-sampling, and sexual health clinics
  • Dispel common misconceptions about HIV diagnosis and treatment
  • Present testing as a responsible act by focusing on trigger points, such as the beginning of a new relationship or change of sexual partner, or on the benefits of knowing one's HIV status
  • Address the needs of non-English-speaking groups, for example, through translated and culturally sensitive information. [2011, amended 2016]

Ensure interventions to increase the uptake of HIV testing are hosted by, or advertised at, venues that encourage or facilitate sex (such as some saunas, Web sites, or geospatial apps that allow people to find sexual partners in their proximity). This should be in addition to general community-based HIV health promotion. [2011, amended 2016]

Promote HIV testing when delivering sexual health promotion and HIV prevention interventions. This can be carried out in person (using printed publications such as leaflets, booklets and posters) or through electronic media. [2011]

Ensure health promotion material aims to reduce the stigma associated with HIV testing and living with HIV, both among communities and among healthcare professionals. [2011, amended 2016]

Ensure health promotion material provides up-to-date information on the different kinds of HIV tests available. It should also highlight the significantly reduced window period resulting from the introduction of newer tests such as fourth-generation serological testing. [2011, amended 2016]

Methods of Raising Awareness

Use or modify existing resources, for example TV screens in GP surgeries, to help raise awareness of where HIV testing (including self-sampling) is available (for content see the recommendations under "Content" above). [new 2016]

Consider a range of approaches to promote HIV testing, including:

  • Local media campaigns
  • Digital media, such as educational videos
  • Social media, such as online social networking, dating and geospatial apps
  • Printed materials, such as information leaflets [new 2016]

Reducing Barriers to HIV Testing

Advertise HIV testing in settings that offer it (for example, using posters in GP surgeries) and make people aware that healthcare professionals welcome the opportunity to discuss HIV testing. [new 2016]

Staff offering HIV tests should:

  • Emphasise that the tests are confidential. If people remain concerned about confidentiality, explain that they can visit a sexual health clinic anonymously.
  • Be able to discuss HIV symptoms and the implications of a positive or a negative test.
  • Be familiar with existing referral pathways so that people who test positive receive prompt and appropriate support.
  • Provide appropriate information to people who test negative, including details of where to get free condoms and how to access local behavioural and preventive interventions.
  • Recognise and be sensitive to the cultural issues facing different groups (for example, some groups or communities may be less used to preventive health services and advice, or may fear isolation and social exclusion if they test positive for HIV).
  • Be able to challenge stigmas and dispel misconceptions surrounding HIV and HIV testing and be sensitive to people's needs.
  • Be able to recognise the symptoms that may signify primary HIV infection or illnesses that often coexist with HIV. In such cases, they should be able to offer and recommend an HIV test. [2011, amended 2016]

Ensure practitioners delivering HIV tests (including those delivering outreach POCT) have clear referral pathways available for people with both positive and negative test results, including to sexual health services, behavioural and health promotion services, HIV services and confirmatory serological testing, if needed. These pathways should ensure the following:

  • People who test positive are seen by an HIV specialist preferably within 48 hours, certainly within 2 weeks of receiving the result (in line with UK national guidelines for HIV testing 2008 External Web Site Policy). They should also be given information about their diagnosis and local support groups.
  • Practitioners in the voluntary or statutory sector can refer people from HIV prevention and health promotion services into services that offer HIV testing and vice versa. [2011, amended 2016]

Definitions

Strength of Recommendations

Some recommendations can be made with more certainty than others, depending on the quality of the underpinning evidence. The Committee makes a recommendation based on the trade-off between the benefits and harms of a system, process or an intervention, taking into account the quality of the underpinning evidence. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

Interventions That Must (or Must Not) Be Used

The Committee usually uses 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally the Committee uses 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions That Should (or Should Not) Be Used – a 'Strong' Recommendation

The Committee uses 'offer' (and similar words such as 'refer' or 'advise') when confident that, for the vast majority of people, a system, process or an intervention will do more good than harm, and be cost effective. Similar forms of words (for example, 'Do not offer…') are used when the Committee is confident that an intervention will not be of benefit for most people.

Interventions That Could Be Used

The Committee uses 'consider' when confident that a system, process or an intervention will do more good than harm for most people, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the person's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the person.

Clinical Algorithm(s)

A National Institute for Health and Care Excellence (NICE) interactive flowchart titled "HIV testing and prevention" is provided on the NICE Web site External Web Site Policy.

Disease/Condition(s)

Human immunodeficiency virus (HIV) infection

Guideline Category

Counseling

Diagnosis

Evaluation

Prevention

Risk Assessment

Clinical Specialty

Emergency Medicine

Family Practice

Infectious Diseases

Internal Medicine

Obstetrics and Gynecology

Preventive Medicine

Urology

Intended Users

Advanced Practice Nurses

Allied Health Personnel

Health Care Providers

Nurses

Other

Patients

Physician Assistants

Physicians

Public Health Departments

Social Workers

Substance Use Disorders Treatment Providers

Guideline Objective(s)

  • To increase the uptake of human immunodeficiency virus (HIV) testing in primary and secondary care, specialist sexual health services and the community
  • To describe how to plan and deliver services that are tailored to the local prevalence of HIV, promote awareness of HIV testing and increase opportunities to offer testing to people who may have undiagnosed HIV

Target Population

All individuals who have not previously been diagnosed with human immunodeficiency virus (HIV) and who:

  • Have symptoms that may indicate HIV or HIV is part of the differential diagnosis
  • Are known to be from a country or group with a high rate of HIV infection
  • If male, disclose that they have sex with men, or are known to have sex with men
  • Are trans women who have sex with men
  • Report sexual contact (either abroad or in the UK) with someone from a country with a high rate of HIV
  • Disclose high-risk sexual practices, for example, the practice known as 'chemsex'
  • Are diagnosed with, or request testing for, a sexually transmitted infection
  • Report a history of injecting drug use
  • Disclose that they are the sexual partner of someone known to be HIV positive, or of someone at high risk of HIV

Interventions and Practices Considered

  1. Offering and recommending human immunodeficiency virus (HIV) testing in different settings
  2. Increasing opportunities for HIV testing
  3. Promoting awareness and uptake of HIV testing
  4. Reducing barriers to HIV testing

Major Outcomes Considered

  • Human immunodeficiency virus (HIV) knowledge
  • HIV test uptake/acceptance
  • HIV testing rate
  • Number of HIV tests performed
  • Return for test results
  • Sexual risk reduction
  • HIV positivity
  • Cost-effectiveness

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Note from the National Guideline Clearinghouse (NGC) and the National Institute for Health and Care Excellence (NICE): Evidence reviews were conducted to support the update of NICE's guidelines on human immunodeficiency virus (HIV) testing in black Africans and HIV testing in men who have sex with men (MSM) (PH33 and PH34) and focused on the effectiveness of interventions which increase awareness of the benefits of, the opportunity for and uptake of HIV testing. The reviews also examined new evidence relating to interventions aimed at improving the uptake of HIV testing among all people who may have undiagnosed HIV. The evidence reviews for PH33 and PH34 were also considered as part of the overall evidence base. See the "Availability of Companion Documents" field for the supporting Evidence Reviews 1a and 1b, 1c, and 2.

Methods

These reviews were conducted according to the methods guidance set out in 'Developing NICE guidelines: the manual' (October 2014) (see the "Availability of Companion Documents" field).

Review Question

Review Question (RQ) 1: What are the most effective and cost-effective ways to increase the uptake of HIV testing to reduce undiagnosed HIV among people who may have been exposed to it?

  • RQ 1a: What interventions to increase awareness of the benefits of HIV testing and details of local testing services among the general public and healthcare workers are the most effective?
  • RQ 1b: What interventions to increase opportunity for, and uptake of, HIV testing are the most effective?
  • RQ 1c (Separate review) What interventions that increase awareness of the benefits of HIV testing and details of local testing services among the general public and healthcare workers; or increase opportunity for, and uptake of, HIV testing are cost effective?
  • RQ2: What factors help or hinder the uptake of HIV testing among people who may have undiagnosed HIV, and how can the barriers be overcome?

Searching and Screening

A single systematic search of relevant databases and Web sites was conducted from 1996 (the start date for the searches for PH33 and PH34) to May 2015 to identify relevant evidence for this review (see Appendix 5 in Evidence Review 1a and 1b for search strategy).

The protocols External Web Site Policy outline the methods for the review, including the search protocols and methods for data screening, quality assessment and synthesis.

All references from the database searches were screened on title and abstract against the criteria set out in the protocols. A random sample of 10% of titles and abstracts was screened by two reviewers independently, with differences resolved by discussion. Agreement at this stage was 93.4%. Full-text screening was carried out by two reviewers independently on 10% of papers. Agreement at this stage was 100%. Reasons for exclusion at full paper stage were recorded (see Appendix 4 in Evidence Review 1a and 1b).

Any studies which were included in the reviews for PH33 and PH34 have been excluded from evidence reviews 1a & 1b and 1c because the reviews for PH33 and 34 formed part of the evidence base for the new guideline. There may be some studies which were excluded by PH33 and PH34 which have been included in these reviews, for example, those covering the more general population or other at-risk groups.

Number of Source Documents

  • Review 1a: 14 studies were included.
  • Review 1b: 33 studies were included.
  • Review 1c: 12 studies were included.
  • Review 2: 6 studies were included.

See Figure 1 in the evidence reviews (see the "Availability of Companion Documents" field) for a flowchart of the literature through the reviews.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Final Study Quality Score

++ All or most of the checklist criteria have been fulfilled, and where they have not been fulfilled the conclusions are very unlikely to alter.

+ Some of the checklist criteria have been fulfilled, and where they have not been fulfilled, or are not adequately described, the conclusions are unlikely to alter.

Few or no checklist criteria have been fulfilled and the conclusions are likely or very likely to alter.

The tool used to assess the quality of studies is included in Appendix 3 of Evidence Review 1a and1b.

Methods Used to Analyze the Evidence

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Note from the National Guideline Clearinghouse (NGC) and the National Institute for Health and Care Excellence (NICE): Evidence reviews were conducted to support the update of NICE's guidelines on human immunodeficiency virus (HIV) testing in black Africans and HIV testing in men who have sex with men (MSM) (PH33 and PH34) and focused on the effectiveness of interventions which increase awareness of the benefits of, the opportunity for and uptake of HIV testing. The reviews also examined new evidence relating to interventions aimed at improving the uptake of HIV testing among all people who may have undiagnosed HIV. The evidence reviews for PH33 and PH34 were also considered as part of the overall evidence base. See the "Availability of Companion Documents" field for the supporting Evidence Reviews 1a and 1b, 1c, and 2.

Quality Assessment and Data Extraction

Each included study was data extracted by one reviewer, with all data checked in detail by a second reviewer. Any differences were resolved by discussion.

Included studies were rated individually to indicate their quality, based on assessment using a checklist. Each included study was assessed by one reviewer and checked by another. Any differences in quality grading were resolved by discussion. The tool used to assess the quality of studies is included in Appendix 3 and a summary of the quality assessment results of all included studies is included in Appendix 2 (see the Evidence Reviews 1a and 1b, 1c, and 2).

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

In September 2014 it was agreed that the National Institute for Health and Care Excellency (NICE)’s guidelines on human immunodeficiency virus (HIV) testing in black Africans and HIV testing in men who have sex with men (MSM) (PH33 and PH34) should be partially updated and combined into one piece of guidance to take account of new evidence relating to indicator conditions, changes in the law relating to home testing and self-sampling, and to reflect changes in commissioning responsibilities for HIV testing. It was agreed that the partial update would combine the recommendations in PH33 and PH34 into generic recommendations and, where appropriate, make specific recommendations for high risk population groups and home testing and sampling.

The evidence reviews were conducted to support the update of PH33 and PH34 and focused on the effectiveness of interventions which increase awareness of the benefits of, the opportunity for and uptake of HIV testing. The reviews also examined new evidence relating to interventions aimed at improving the uptake of HIV testing among all people who may have undiagnosed HIV. The evidence reviews for PH33 and PH34 were also considered as part of the overall evidence base.

The reviews were conducted according to the methods guidance set out in 'Developing NICE guidelines: the manual' (October 2014) (see the "Availability of Companion Documents field).

The Committee's Discussion

Updating the Previous Guidelines

The update committee discussed the recommendations and considerations in the 2 guidelines being updated (NICE guidelines PH33 and PH34), and considered the view of the experts in the review decision. The committee agreed that the previous recommendations were still pertinent but they needed some updating to better reflect current practice. The committee removed or amended parts of the recommendations that it agreed were outdated.

The committee concluded that many of the recommendations from the previous guidelines were aimed at a broader population than men who have sex with men, and black Africans. For the more specific recommendations, the committee agreed it would be appropriate to broaden them to apply to any population with a high rate of HIV. The committee recognised that men who have sex with men, and black Africans are still the most high-risk groups for HIV in the UK and this is reflected in the guideline. An additional benefit of broadening the recommendations to apply to everyone with undiagnosed HIV is that it should help to normalise HIV testing so that it is not seen differently from any other blood test. For more information on the relevance of this guideline for other groups, see the equality impact assessment in the original guideline document.

HIV Testing and HIV Screening

The committee discussed the distinction between testing and screening. It was reminded that recommending screening programmes is outside NICE's role. It was aware that HIV screening in antenatal settings is currently recommended by the UK National Screening Committee and has a very high uptake. It also discussed the differences between opt-in and opt-out approaches to testing, that is whether people are asked if they want an HIV test or they are told they will be tested for HIV unless they specifically ask not to be. It agreed that it was important to make sure people understand that HIV testing is voluntary and to give everyone the opportunity to opt out of a test.

The committee discussed that HIV testing may not always be routinely undertaken among people who have conditions that might indicate HIV infection. For this reason, it agreed that it is important for national guidelines to recommend HIV testing when diagnosing or treating conditions that may indicate HIV infection (see Guidance: HIV in indicator conditions HIV in Europe External Web Site Policy).

Other Guidelines

The committee agreed that the British HIV Association UK national guidelines for HIV testing 2008 External Web Site Policy are the most up-to-date HIV guidelines available in the UK and are also accredited by NICE, so they remain in the recommendations. The only exception relates to indicator conditions, for which more up-to-date guidance is available from 'Guidance: HIV in indicator conditions'. Although this guideline has not been accredited by NICE, the committee agreed it was a useful and authoritative source of information to give people who are offering HIV testing.

Refer to the original guideline document for a discussion of prevalence rates and definitions were incorporated into the guidelines.

Evidence Statements Not Used to Make Recommendations

The committee did not make recommendations for all of the evidence statements. This was mainly because it did not believe, based on the evidence, that an intervention was effective; or it agreed that the intervention may not be applicable in the UK. For details of the evidence statements not used to make recommendations, see the evidence reviews section in the original guideline document.

Rating Scheme for the Strength of the Recommendations

Strength of Recommendations

Some recommendations can be made with more certainty than others, depending on the quality of the underpinning evidence. The Committee makes a recommendation based on the trade-off between the benefits and harms of a system, process or an intervention, taking into account the quality of the underpinning evidence. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

Interventions That Must (or Must Not) Be Used

The Committee usually uses 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally the Committee uses 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions That Should (or Should Not) Be Used – a 'Strong' Recommendation

The Committee uses 'offer' (and similar words such as 'refer' or 'advise') when confident that, for the vast majority of people, a system, process or an intervention will do more good than harm, and be cost effective. Similar forms of words (for example, 'Do not offer…') are used when the Committee is confident that an intervention will not be of benefit for most people.

Interventions That Could Be Used

The Committee uses 'consider' when confident that a system, process or an intervention will do more good than harm for most people, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the person's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the person.

Cost Analysis

Refer to the "Evidence of Cost-effectiveness" and "Resource Impact and Implementation Issues" sections in the original guideline document, as well as Evidence Review 1c (see the "Availability of Companion Documents" field) for cost analysis information.

Method of Guideline Validation

Not stated

Description of Method of Guideline Validation

Not applicable

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

The evidence statements in the original guideline document provide short summaries of evidence. Each statement has a short code indicating which supporting document the evidence has come from.

Potential Benefits

Improving the acceptability of human immunodeficiency (HIV) testing and increasing the uptake of HIV testing will reduce the pool of undiagnosed infection, improve outcomes for those affected (because of earlier diagnosis) and reduce onward transmission, particularly in some high-risk populations.

Potential Harms

  • Point-of-care tests (POCT) or 'rapid' tests have reduced specificity and sensitivity compared with fourth-generation laboratory tests. This means there will be false positives, particularly in areas with lower human immunodeficiency virus (HIV) prevalence, and all positive results need to be confirmed by serological tests.
  • Some groups or communities may be less used to preventive health services and advice, or may fear isolation and social exclusion if they test positive for HIV.

Qualifying Statements

  • The recommendations in this guideline represent the view of the National Institute for Health and Care Excellence (NICE), arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
  • Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

Description of Implementation Strategy

Putting This Guideline into Practice

The National Institute for Health and Care Excellence (NICE) has produced tools and resources External Web Site Policy to help put this guideline into practice (see also the "Availability of Companion Documents" field).

Some issues were highlighted that might need specific thought when implementing the recommendations. These were raised during the development of this guideline and are:

  • The need to address misconceptions about HIV testing and treatment, for example:
    • The cost of HIV treatment
    • Life expectancy following a positive diagnosis (particular emphasis is needed on the benefits of early diagnosis for outcomes including life expectancy)
  • The need to reduce the stigma (real or perceived) associated with HIV testing and living with HIV, both among communities with a high or extremely high prevalence of HIV and among healthcare professionals.
  • The need to take local patterns of HIV into account when planning how to deliver services. Services should be tailored to the needs of the population, including whether an area has high prevalence or extremely high prevalence of HIV.

Putting recommendations into practice can take time. How long may vary from guideline to guideline, and depends on how much change in practice or services is needed. Implementing change is most effective when aligned with local priorities.

Changes should be implemented as soon as possible, unless there is a good reason for not doing so (for example, if it would be better value for money if a package of recommendations were all implemented at once).

Different organisations may need different approaches to implementation, depending on their size and function. Sometimes individual practitioners may be able to respond to recommendations to improve their practice more quickly than large organisations.

Here are some pointers to help organisations put NICE guidelines into practice:

  1. Raise awareness through routine communication channels, such as email or newsletters, regular meetings, internal staff briefings and other communications with all relevant partner organisations. Identify things staff can include in their own practice straight away.
  2. Identify a lead with an interest in the topic to champion the guideline and motivate others to support its use and make service changes, and to find out any significant issues locally.
  3. Carry out a baseline assessment against the recommendations to find out whether there are gaps in current service provision.
  4. Think about what data you need to measure improvement and plan how you will collect it. You may want to work with other health and social care organisations and specialist groups to compare current practice with the recommendations. This may also help identify local issues that will slow or prevent implementation.
  5. Develop an action plan, with the steps needed to put the guideline into practice, and make sure it is ready as soon as possible. Big, complex changes may take longer to implement, but some may be quick and easy to do. An action plan will help in both cases.
  6. For very big changes include milestones and a business case, which will set out additional costs, savings and possible areas for disinvestment. A small project group could develop the action plan. The group might include the guideline champion, a senior organisational sponsor, staff involved in the associated services, finance and information professionals.
  7. Implement the action plan with oversight from the lead and the project group. Big projects may also need project management support.
  8. Review and monitor how well the guideline is being implemented through the project group. Share progress with those involved in making improvements, as well as relevant boards and local partners.

NICE provides a comprehensive programme of support and resources to maximise uptake and use of evidence and guidance. See the into practice External Web Site Policy pages for more information.

Also see Leng G, Moore V, Abraham S, editors (2014) Achieving high quality care – practical experience from NICE. Chichester: Wiley.

Implementation Tools

Clinical Algorithm

Mobile Device Resources

Resources

For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Patient-centeredness

Bibliographic Source(s)

National Institute for Health and Care Excellence (NICE), Public Health England. HIV testing: increasing uptake among people who may have undiagnosed HIV (joint NICE and Public Health England guideline). London (UK): National Institute for Health and Care Excellence (NICE); 2016 Dec 1. 62 p. (NICE guideline; no. 60). 

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2016 Dec 1

Guideline Developer(s)

National Institute for Health and Care Excellence (NICE) - National Government Agency [Non-U.S.]

Public Health England - Professional Association

Source(s) of Funding

National Institute for Health and Care Excellence (NICE)

Guideline Committee

Public Health Advisory Committee A/HIV testing

Composition of Group That Authored the Guideline

Committee Chair: Susan Jebb, Professor of Diet and Population Health, Department of Primary Care Health Sciences

Committee Vice-chair: Chris Packham, Associate Medical Director, Nottinghamshire Healthcare NHS Trust

Committee Core Members/Members: Toby Prevost, Professor of Medical Statistics and Clinical Trials, Imperial College London; Lucy Yardley, Professor of Health Psychology, University of Southampton; Mireia Jofre-Bonet (Attended PHAC meetings 1 & 2 – was a committee member until June 2016), Professor, City University (London); Raymond Jankowski, National Lead for Healthcare Public Health, Public Health England; Suzanne Jones, Consultant in Public Health; Christine Liddell, Professor of Psychology, Ulster University; Jennifer Roberts (Attended PHAC meeting 1 – was a committee member until February 2016), Professor of Economics, University of Sheffield; Joyce Rothschild, Education Consultant; Chris Owen, Programme Manager, UCL Partners; Ian Basnett, Public Health Director, Barts Health; Ray Canham (Committee member from April 2016), Lay core member

Topic Expert Members: Philippa James, GP Partner, Cornbrook Medical Practice; Ann Sullivan, Consultant Physician HIV/GUM, Chelsea and Westminster Hospital NHS Foundation Trust; Robbie Currie, Sexual Health Programme Lead, London Borough of Bexley; Tina Maddocks (Attended PHAC meeting 1 – was a committee member until February 2016), HIV Outreach Specialist Nurse, Stockport Foundation Trust; Valerie Delpech, Head of HIV national surveillance, Public Health England; Ross Boseley, Lay topic expert member

Financial Disclosures/Conflicts of Interest

Details of Conflicts of Interest Policy is available on National Institute for Health and Care Excellence (NICE) website External Web Site Policy.

Declarations of all Public Health Advisory Committee members are available on the NICE Web site External Web Site Policy.

Guideline Status

This is the current release of the guideline.

This guideline meets NGC's 2013 (revised) inclusion criteria.

Guideline Availability

Available from the National Institute for Health and Care Excellence (NICE) Web site External Web Site Policy. Also available for download in ePub or eBook formats from the NICE Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Evidence Review 1a and ab. HIV testing: increasing uptake among people who may have undiagnosed HIV. Evidence review on: the most effective ways to increase the uptake of HIV testing to reduce undiagnosed HIV among people who may have been exposed to it. London (UK): National Institute for Health and Care Excellence (NICE); 2015 Dec. 141 p. Available from the National Institute for Health and Care Excellence (NICE) Web site External Web Site Policy.
  • Evidence Review 1c. HIV testing: increasing uptake among people who may have undiagnosed HIV. Evidence review on: the most cost effective ways to increase the uptake of HIV testing to reduce undiagnosed HIV among people who may have been exposed to it. London (UK): National Institute for Health and Care Excellence (NICE); 2015 Feb. 48 p. Available from the NICE Web site. External Web Site Policy
  • Evidence Review 2. HIV testing: increasing uptake among people who may have undiagnosed HIV. Evidence review on: factors which help or hinder HIV testing among people who may have undiagnosed HIV. London (UK): National Institute for Health and Care Excellence (NICE); 2015 Dec. 29 p. Available from the NICE Web site. External Web Site Policy
  • HIV testing: increasing uptake among people who may have undiagnosed HIV (Joint NICE and Public Health England guideline). Baseline assessment tool. London (UK): National Institute for Health and Care Excellence; 2016 Dec. (NICE guideline; no. 60). Available from the NICE Web site External Web Site Policy.
  • HIV testing: increasing uptake among people who may have undiagnosed HIV (Joint NICE and Public Health England guideline). Resource impact report. London (UK): National Institute for Health and Care Excellence; 2016 Dec. 12 p. (NICE guideline; no. 60). Available from the NICE Web site External Web Site Policy.
  • HIV testing: increasing uptake among people who may have undiagnosed HIV (Joint NICE and Public Health England guideline). Resource impact template. London (UK): National Institute for Health and Care Excellence; 2016 Dec. (NICE guideline; no. 60). Available from the NICE Web site External Web Site Policy.
  • Developing NICE guidelines: the manual. London (UK): National Institute for Health and Care Excellence (NICE); 2014 Oct. Available from the NICE Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on March 1, 2017.

The National Institute for Health and Care Excellence (NICE) has granted the National Guideline Clearinghouse (NGC) permission to include summaries of their clinical guidelines with the intention of disseminating and facilitating the implementation of that guidance. NICE has not yet verified this content to confirm that it accurately reflects that original NICE guidance and therefore no guarantees are given by NICE in this regard. All NICE clinical guidelines are prepared in relation to the National Health Service in England and Wales. NICE has not been involved in the development or adaptation of NICE guidance for use in any other country. The full versions of all NICE guidance can be found at www.nice.org.uk External Web Site Policy.

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