The attitude of doctors and healthcare administrative staff is a greater obstacle to extending HIV testing than that of patients, a study has found.

This paper set out to explore the attitudes of patients to being offered HIV testing in Cornwall where the prevalence is reported as 32 per 100,000 population. Patients attending six GP practices and selected hospital outpatient clinics, between November 2008 and January 2009, were enrolled in the study. They were given a short information sheet on HIV and asked to respond to a series of statements about HIV testing.

A total of 616 patients participated from various settings: 339 (55%) from primary care, 44 (7%) dermatology,

48 (8%) gastroenterology, 22 (4%) gynaecology, 52 (8%) neurology,

53 (9%) ophthalmology, 21 (3%) respiratory medicine and 37 (6%) unplanned pregnancy clinic. The ratio of men to women was 1:2.2, median age group 45-55 (range under 25 to over 75).

Significantly more people attending primary care were unwilling to be tested if presenting with a medical problem known to be related to HIV; however, the absolute number of people who responded negatively

to this statement in either setting was small.

Overall, 2.4% of the people surveyed were identified as being from a high-risk group for HIV. All of these respondents stated they would be willing to be tested if presenting with a condition associated with HIV.

The reasons people gave for declining HIV testing included: not feeling at risk (n=102), fears regarding insurance (n=27), concerns about confidentiality (n=23) and not wanting to know their status (n=2). In total, 94% of patients said they would be willing to have an HIV test if they presented with a problem associated with HIV; 71% were willing to be tested as part of their routine care. (The latter figure is similar to the proportion of patients accepting routine HIV testing in GUM clinics in Cornwall, 72%). And 72% said they would be willing for the test result to be included in their medical notes.

The reasons patients give for declining HIV testing are well known, especially concerns about insurance and confidentiality. It is also well established from other studies that those who are at high risk of HIV are less likely to accept testing.

However, the most interesting finding from this paper is the negative attitudes and resistance encountered from clinical and non-clinical staff in hospital settings.

The authors stated that two out of ten secondary care specialists approached declined to participate. One surgical specialty agreed and then withdrew when a consultant was asked a question about HIV from a patient that he felt unable to answer. One medical specialty declined to participate as the consultants said they knew when to offer HIV testing appropriately and did not want to upset their patient cohort.

In another specialty, the questionnaire return boxes repeatedly disappeared from a prominent position in the waiting room. One receptionist in another discipline appeared to have conscientious objections to the project.

Just under 30% of the estimated 77,400 people living with HIV in the UK are unaware of their diagnosis. Late diagnosis leaves patients at risk

of AIDS-defining illnesses and also contributes to almost a quarter of all deaths in HIV-positive adults.

Earlier diagnosis saves lives, which

is why the UK National Guidelines on HIV testing, published in 2008, recommend routinely offering an

HIV test to patients in certain clinical settings.

HIV testing should also be offered to all patients registering in general practice or admitted to hospital in areas where local prevalence exceeds 2 per 1,000 population - this includes all of London and most urban areas

of the UK.

This study was carried out in an area in the UK with relatively low HIV prevalence so the findings may not be transferable to urban areas with higher prevalence and, presumably, greater awareness. However, this is an assumption and the negative attitudes to HIV testing expressed by some individuals working in secondary care is extremely worrying.

It appears the public are broadly in favour, it's the medical profession that is the barrier to increasing testing.

Dr Richard Ma

• Drayton R, Keane F, Prentice E. Patients' attitudes towards increasing the offer of HIV testing in primary and secondary care. Int J STD & AIDS 2010;21:563-566