The majority of patients across all sociodemographic groups are happy to be offered HIV tests irrespective of the clinical setting, the HINTS study has found.

The study was set in four locations in London where diagnosed HIV prevalence exceeds 2 per 1,000: an emergency department (ED), an acute care unit (ACU), a dermatology outpatient clinic (OPD), and a large primary care centre (PC). In the first three settings, tests were offered by seconded local sexual health and permanent staff and a small number of non-clinical staff; only GPs were involved in the PC arm.

All staff received focused didactic and practical training in the provision of HIV testing.A questionnaire on attitudes and knowledge of HIV infection and testing was given to all clinical and support staff in each site.

HIV testing was offered to sequential patients, aged 16-65, accessing the healthcare settings for the first time over the testing period, who were not known to be HIV positive. Patients were also given questionnaires at intervals during the study.

Oral fluid-based HIV testing was employed in PC, ED and OPD arms using a fourth generation assay; fourth generation HIV serology was performed on serum samples for the ACU cohort.

A total of 146 staff completed the pre-study questionnaires: 91% from ED, ACU 76%, OPD 82% and PC 92%. Although staff in all departments were supportive of HIV testing, a smaller percentage were comfortable with offering HIV tests to patients themselves (ED 57%, ACU 42%, PC 75% and OPD 63%). Overall 72% of staff from all sites felt they would need further training before routinely offering HIV tests.

Of 6,194 patients offered HIV tests 4,105 (67%) accepted. Eight individuals were newly diagnosed and successfully transferred to care; two partners were diagnosed through partner notification. HIV positivity across sites was 1.9/1,000 persons (95% CI: 0.6 to 3.2/1,000). There were seven false reactive oral fluid screening tests (two in ED and five in PC) as confirmed by serological testing.

Uptake of HIV testing ranged from 62% in ED to 75% in PC. Male and younger patients were more likely to accept tests. Patients were more likely to accept tests offered by a medical student or doctor rather than a nurse or non-clinical tester.

There were 1,003 questionnaires returned from patients across all sites; compared with the total population of those offered HIV tests (6,194), these patients were more likely to be white (70% vs 57%) and to have accepted HIV testing (74% vs 67%). Only previous HIV testing behaviour was shown to be associated with test uptake: 49% of respondents had never had an HIV test before and this group was more likely to accept a test than those who had had one previously.

The majority (92%) of the 1,003 questionnaire respondents agreed that it was acceptable to be offered HIV testing in that setting; greater acceptability was associated with younger age, male sex and test uptake but not with ethnicity or clinical site. More than 90% of questionnaire respondents (including test acceptors and decliners) agreed with statements advocating expansion of HIV testing to non-specialist settings.

HIV testing seems to be acceptable to the majority of patients attending different clinical settings including general practice. This appears to be the case across all sociodemographic groups including men who have sex with men and minority ethnic groups. This assuages concerns that higher risk individuals may be less likely to accept an HIV test in non-specialist settings. Almost half those tested had not had an HIV test before.

NICE already recommends expansion of HIV testing beyond sexual health and antenatal clinics; one recommendation is to offer HIV testing to all general medical admissions and primary care registrants in areas where diagnosed prevalence of HIV exceeds 2 per 1,000 persons.

However, while the concept of expanded HIV testing appeared to be acceptable to staff, there seem to be barriers to implementation. Those cited included lack of time and being ill prepared to answer patient queries. A qualitative arm of this study addresses some of the barriers to HIV testing (see the following review).

 Dr Richard Ma

• Rayment M, Thornton A, Mandalia S et al on behalf of the HINTS Study Group. HIV Testing in Non-Traditional Settings – The HINTS study: a multi-centre observational study of feasibility and acceptability. PLoS ONE 7(6):e39530.doi:10.1371/journal.pone.0039530