An educational outreach programme promoting opt-out rapid HIV testing of new practice registrants led to increased rates of HIV diagnosis but there was no significant difference in the proportion having low CD4 counts at diagnosis.

The study was based in Hackney, an area of London with a diagnosed HIV prevalence of 8 per 1,000. Practices were randomised into two groups.

The intervention group received a practice-based outreach educational programme with follow-up training, integrated rapid HIV testing into the registration health check, provided free rapid HIV tests and were paid £10 per test completed.

The control practices provided usual care which included HIV testing by serology opportunistically or at the patient’s request. Hackney practices were incentivised to perform serological testing for HIV as part of sexual health checks and opportunistically when clinically indicated.

A pragmatic, cluster-randomised control trial design was used to see if the multifaceted educational outreach programme promoting rapid HIV testing in general practice would lead to increased and early detection of HIV.

The primary outcome was mean CD4 count of newly diagnosed patients; secondary outcomes were rate of new HIV diagnoses, percentage of patients with CD4 counts < 350 and percentage of patients with CD4 counts < 200. Women newly diagnosed through the UK Antenatal HIV Screening Programme were also included.

Overall 40 out of 45 practices agreed to take part. Three practices in the intervention group withdrew during the study but all provided complete study data which were included in the intention-to-treat analysis. Practice and population characteristics and the numbers of new registrants were similar at baseline.

The intervention group offered 11,187 rapid HIV tests and 4,978 (45%) were accepted by new registrants. Of these, 14 were reactive on rapid testing, including 11 that were confirmed HIV positive by serology and three confirmed HIV negative. Intervention practices also identified an additional 18 diagnoses through opportunistic serology compared with ten in the control practices.

Overall, intervention practices identified 32 new HIV-positive patients, whereas control practices identified 14 new cases.

CD4 count was available for 30 of 32 newly diagnosed patients from intervention practices and all of the 14 patients in control practices.

Mean CD4 count was not significantly different between the two groups (356 vs 270, adjusted difference in square root transformed CD4 count 3.1 (95% CI: -1.2 to 7.4; P = 0.16).

Mean CD4 count was significantly different when antenatal screening was excluded 6.4 (95% CI: 1.2 to 11.6; P = 0.017) and when patients who were diagnosed with HIV but defaulted from care were included, the adjusted difference was 4.1 (95% CI: 0.0 to 8.1; P = 0.049).

The HIV diagnosis rate was 0.30 (95% CI: 0.11 to 0.85) per 10,000 patients per year in the intervention group and 0.07 (95% CI: 0.02 to 0.20) in the control group.

Nearly three quarters (73%) of patients in control practices had a CD4 count < 350 compared with just over half (55%) in intervention practices; the risk ratio was 0.75 (95% CI: 0.53 to 1.07). Just under half (46%) of patients from control practices had a CD4 count < 200 compared with 28% in intervention practices; risk ratio 0.60 (95% CI: 0.32 to 1.13).

Although the intervention led to increased rates of HIV diagnosis it did not produce significant differences in the proportion having low CD4 counts at diagnosis. It is worth noting that despite a combination of educational outreach and financial incentives, the number of HIV diagnoses was lower than expected.

Reducing the prevalence of undiagnosed HIV remains a challenge for the UK. Almost a quarter of the 107, 800 people with HIV are undiagnosed and 42% are diagnosed late (CD4 count < 350) and 24% very late (CD4 count < 200).

Earlier diagnosis can reduce morbidities related to low CD4 counts as well as risk of onward transmission.

NICE has already endorsed expansion of HIV testing especially in areas with high diagnosed prevalence of HIV (> 2 per 1,000). Pilot studies have demonstrated acceptability and feasibility of HIV testing in primary care but expanded testing has not been widely adopted in this setting.

Financial incentives and educational strategies are not the panacea to behaviour change in healthcare professionals especially in terms of health promotion and disease prevention. The jury is still out regarding the most effective strategy to encourage HIV testing in primary care. Perhaps we need to understand the motivation for primary care teams to deliver HIV testing.

Dr Richard Ma