HIV testing is crucial to ending new HIV transmissions in England by 2030. By increasing testing, we can stop HIV in its tracks and make sure more people can access life-saving HIV treatment. Yet, despite testing being cost effective and taking just minutes to do, access remains inconsistent.
In 2019, there were nearly 550,000 missed opportunities to test for HIV in specialist sexual health services, with over 252,000 incidents of an HIV test not even being offered.
Every missed opportunity to test someone for HIV is a failure to them, and to the goal of ending new transmissions.
We know stigma is often a key factor in declining an HIV test, this is well documented, particularly for Black African communities. We also know that while the majority of missed opportunities to test for HIV (64%) occurred among women and that HIV testing rates are lower in women compared to men. However, HIV testing rates are lower, and late diagnosis higher, amongst some groups of men, for example, heterosexual Black African men.
The impact of this is borne out in the stubbornly high number of people who continue to be diagnosed late, at 42%. If we don’t make headway, of the around 5,800 people living with the virus in the UK who don’t know their status, more than 2,400 won’t be diagnosed until they have had the condition for a few years. This isn’t just bad for their health, it means they could unknowingly pass HIV on.
Even in places where opt-out HIV testing should be standard, including A&E departments and GPs in areas of high HIV prevalence, it isn’t happening routinely.
But we also have a blueprint for what works.
Firstly, in maternity services, HIV testing has been mainstreamed with remarkable results. Opt-out testing is routine for pregnant women and there is now 99% testing coverage. Women who are diagnosed during pregnancy can start treatment, improving their health outcomes, and preventing vertical transmission (the rate is now less than 0.5% in the UK).
Secondly, in 2019 there were over 25,000 HIV self-sampling test kits returned via the national HIV self-sampling scheme which allows people to order online and test at home, with results sent in just a few days. Reactivity in self-sampling and community HIV testing was 0.5% compared to 0.2% in specialist sexual health services. Well designed, community-led, and culturally competent services can overcome some of the traditional barriers to HIV testing, such as stigma and low-risk perception.
Despite this, the availability of self-sampling and community testing remains a postcode lottery in England. This must change – everyone should have access to HIV testing that suits their needs.
We also need to look at new opportunities and technologies to increase HIV testing. The HIV Commission identifies 16 places the NHS should be doing the routine, opt-out testing. They are listed under a traffic light system. ‘Green’ indicates that normalised HIV testing is policy and practice, the aforementioned antenatal screening in maternity. ‘Amber’ indicates where there is direction to test but the application is not routine, and the ‘red’ where HIV testing provision is poor or non-existent. The table is currently far too red and this needs to change to meet the 2025 target for an 80% reduction in new transmissions and the 2030 goal for England to be the first country to end HIV transmissions.
Settings including termination clinics and gender identity clinics support those who face broader inequalities and marginalisation. While pharmacies are an ideal intermediate location, especially in rural areas where other services are not nearby or home sampling is not desirable.
All of this will require a culture shift on responsibility for HIV testing, embedding it in other settings. We know stigma can still be found in healthcare settings, which can erode trust and perpetuate poor mental health among people affected by HIV. That’s why training on HIV and sexual health should be mandatory for the entire healthcare workforce and staff across the NHS should feel confident offering and discussing HIV testing, something which is all too often not the case.
We talk a lot about the huge progress in HIV treatment and prevention tools, such as PrEP and PEP. However, we shouldn’t overlook the big advances there have been in HIV testing which now means people can get a result within minutes.
Gone are the days of going to a clinic in a darkened hospital basement and waiting weeks for the result. Testing for HIV is something to be proud of and means everyone can play their part in ending new cases of HIV. The Government has indicated it ‘completely sees the value’ of opt-out HIV testing, now it must turn these words into action.
Appendix 1: The HIV Testing Traffic Light
| Service | Current Policy and Guidance | Responsibility | Implementation | To Reach 2030 Goal |
| Maternity services / antenatal screening | Offered to all women on opt- out basis as part of the Infectious diseases in pregnancy screening (IDPS) programme. | Funded nationally by NHS England through Section 7A agreement. | 99% testing coverage. Transformative results, almost eliminating vertical transmission and dramatically increasing the proportion of women diagnosed. | Continue current practice. Identify factors in success and learning for increasing uptake elsewhere. |
| Sexual health services (SHS) | NICE 2016 guidance – all should be offered on attendance. BASHH, BHIVA and BIA guidelines 2020 – universal testing on an opt-out basis. | Local authorities through devolved public health grant. | In 2019, only 65% testing coverage across SHS attendees. Almost half (43%) of those not tested were not offered a test. | Implementation nof opt-out HIV testing to all SHS attendees. |
| Prisons | NICE guidance on HIV testing and physical health of people in prison, both 2016 – all people should be offered an HIV test on an opt-out basis. | Joint commitment by NHS England, add National Offender Management Service (NOMS) and PHE through their Partnership Agreement on healthcare in prisons. | Mixed implementation. In 2018 77% were offered a test with only 44% uptake. Testing practice is unlikely to be truly opt-out when it is in place. Test positivity rates are higher than other settings (1.2%). | Renewed efforts to implement true opt-out testing for people entering prison in England. |
| A&Es in areas of high or extremely high local HIV prevalence | NICE Guidance 2016 – all should be offered on admission and in routine blood tests. BASHH, BHIVA and BIA 2020 guidance – all patients accessing should be offered a test and recommends an opt-out approach. BASHH, BHIVA and BIA 2020 guidance – testing should be done in secondary care when clinically indicated. BASHH, BHIVA and BIA 2020 guidance – testing should be done in secondary care when clinically indicated. | Unclear responsibility with some local authorities funding through the public health grant. Some STPs/ ICSs have implemented across admissions during COVID- 19. CCG funded when clinically indicated. | Not routinely implemented across the country. Difficult to collect data on testing in this setting due to differential data collection/reporting mechanisms. Challenges around both funding and implementation at a local level. | Implement opt-out HIV testing for all emergency and secondary care admissions and/or when bloods taken, starting in high and extremely high prevalence areas. All people presenting with HIV indicator conditions should be offered an HIV test. |
| Hospitals in areas of high or extremely high local HIV prevalence | As above | As above | As above | As above |
| GP surgeries in areas of high or extremely high local HIV prevalence | 2016 NICE guidelines – all should be offered a test on admission. BASHH, BHIVA and BIA 2020 guidance – all patients accessing should be offered a test and recommends an opt-out approach. BASHH, BHIVA and BIA 2020 guidance – testing should be done when clinically indicated. | Unclear responsibility – Some local initiatives funded through the local authority public health grant. Funded by Social Impact Bond in Lambeth, Southwark and Lewisham. CCG funded when clinically indicated. | Poor implementation though has been done on an ad hoc basis. Difficult to collect data on testing in this setting due to differential data collection/reporting mechanisms. Key to increasing testing to those less likely to access an STI clinic – women, Black communities and other ethnic minorities and those living outsid cities and big towns. Challenges around funding responsibility and nervousness amongst GPs around offering HIV tests have been barriers. | Implement opt-out testing for all new registrants at GP surgeries. All people presenting with HIV indicator conditions should be offered an HIV test. |
| During cervical screening | As above | As above | No current guidance but is an opportunity to reach women living with HIV who have not been pregnant or acquired HIV post-pregnancy. | Offered to women and people with a cervix as part of the service. |
| A&E in areas of low or medium local HIV prevalence | NICE guidance 2016 – recommends testing on admission for key populations, those reporting possible risk or when clinically indicated. | Unclear responsibility. CCG funded when clinically indicated. | Not routine. High levels of late diagnosis (common in lower prevalence areas) and look back data indicate that people are also being missed who present with indicator conditions. Difficult to collect data on testing in this setting due to differential data collection/reporting mechanisms. Sometimes available to purchase in pharmacies. An intermediate location for those, especially in towns and rural areas, where other services are not near or taking a home sample/test alone is not desirable. Would help make pharmacies a place to access PrEP. | HIV testing should be routine on an opt-out basis for anyone receiving a blood test and on admission. All people presenting with HIV indicator conditions should be offered an HIV test. |
| Pharmacies | NICE guidance 2016 – recommends community testing in pharmacies in areas of high or extremely high prevalence. No system of charge back for the pharmacist to undertake this work. | Sometimes available to purchase in pharmacies. An intermediate location for those, especially in towns and rural areas, where other services are not near or taking a home sample/test alone is not desirable. Would help make pharmacies a place to access PrEP. | Free HIV tests should be accessible through pharmacies and POCT should be offered where practicable. | |
| Termination clinics | NICE guidelines 2016 recommend testing on first attendance and repeat testing. BASHH, BHIVA and BIA guidance 2020 – all patients accessing should be offered a test and recommends an opt-out approach. | Unclear responsibility. | Not routinely implemented. This will also be necessary for this setting to become a place to access PrEP. | Opt-out HIV testing should be routine. |
| Addiction and substance misuse services | NICE guidance 2016 – routine HIV testing in ‘drug dependency services’. BASHH, BHIVA and BIA guidance 2020 – all should be offered a test and recommends an opt-out approach. | Local authorities through the public health grant. | Unclear but commissioning framework doesn’t support routine testing in these settings. Some done as part of broader BBV testing initiatives. PHE reports high level of missed opportunities to diagnose people living with HIV who inject drugs. | HIV testing (as part of BBV testing) should be routinely provided on an opt-out basis for those accessing addiction and substance misuse services. |