Staff perceptions about the time needed to carry out HIV testing and to manage the results appear to be the main barriers to expanding testing to non-traditional settings, the qualitative arm of the HINTS study has found. Many healthcare staff also had preconceptions about patients’ attitudes to testing which were not borne out when patients were asked their views.

Focus groups were conducted in the pre- and post-testing phases. Four themes emerged from the focus group discussions: stigma of HIV; targeted versus routine testing; special skills and operational issues.

Some staff felt that HIV has been exceptionalised as a condition, perpetuated by having HIV testing in special settings.

In the pre-testing groups, staff expressed concerns that their offer of HIV testing was an inference about the patient’s behaviour and would lead to negative reactions. Staff across different sites were surprised that patients were happy to be tested and the anticipated stigma was not realised.

The pre-testing focus groups also felt the provision of routine HIV testing in non-specialist settings would be useful in reduction of HIV-related stigma among patients and normalisation of the condition among healthcare professionals; this was substantiated in the post-testing phase where staff reported that ‘the more it [HIV testing] is done, the more acceptable [it becomes].’

Opinions on the merits of targeted versus routine testing varied in the pre-testing groups; from placing emphasis on risk assessment

of individuals and testing high-risk individuals to routine testing as a means of diagnosing those who may not otherwise present to specialist services. There were also concerns that a targeted approach perpetuated stigma. There was a change in attitudes in the post-testing groups from using it as a diagnostic tool to viewing it as a useful public health intervention. Staff were also encouraged that new diagnoses were made as a result of the study and that they had been successfully transferred to HIV care.

There was a widely held belief that HIV testing required a specialist skill set, a view probably explained by historical exceptionalisation of HIV testing and care. Staff were divided into those who took a pragmatic approach of keeping pre-test discussion brief and focused, while others thought this was a complex process and were concerned about their ability to answer patients’ queries adequately, particularly around epidemiology and immediate management beyond diagnosis. However, post-testing focus groups acknowledged many of these anxieties were unfounded.

Lack of time was cited in all departments as a barrier to HIV

testing especially in the emergency department. Raising this issue in an unrelated consultation was also felt to be a distraction. GPs reported that testing did add time to their consultations but it was much less than they had expected.

The near-patient test, such as oral fluid sampling used in this study, was viewed more favourably than serology testing which was thought to be a disincentive.

The only concern regarding confidentiality was in the acute settings where consultations may take place in open areas and patients are often accompanied by friends or family.

There were concerns regarding management of results in all settings, particularly delivering a reactive test result; this was thought to require specialist staff.

There appeared to be support for normalisation of HIV testing especially in non-specialist settings. The main barriers to HIV testing were the time needed to conduct testing and management of results.

However, the interesting finding for me was some of the perceptions of healthcare staff towards HIV testing, particularly about how willing the public were to accept the test and the anxieties about answering questions relating to testing that were not realised. It seems to me part of the barrier to expansion of HIV testing might be the attitudes and perceptions of healthcare professionals to testing; this needs to be addressed if the aim of reducing late diagnosis of HIV is to be realised.

Dr Richard Ma