Time to move towards opt-out testing for HIV in the UK

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Abstract
Strategies for testingHIV tests are usually done as part of diagnosis—in patients with signs or symptoms suggestive of HIV disease— or to screen for infection in people without symptoms. Most screening is done at the patient's request or because a healthcare worker judges a patient to be at increased risk for HIV infection and seeks consent for testing. One way to increase knowledge of HIV infection status is to use an opt-out approach to testing. This approach, which is also voluntary, considers HIV testing to be a standard part of medical care for particular patient populations. The populations are defined by variables that serve as surrogates for HIV prevalence or risk of HIV infection—for example, age, geographical area, country of origin, and healthcare setting. No judgment is made about an individual patient's risk of infection. Patients are given information about HIV, how the test will be carried out, and are tested unless they specifically decline. Extensive pretest counselling is not required. Instead, counselling resources are focused on people found to be infected or on risk reduction strategies for those who test negative. Precedents of this model exist in several areas such as testing all NHS healthcare workers for hepatitis B virus.New testing technologies make expanded testing easier. Point of care rapid tests can provide preliminary results during a single patient encounter.5 Rapid tests modified to use oral fluid samples obviate the need for either venepuncture or finger prick blood analysis.In the US, the Centers for Disease Control and Prevention have revised their screening guidelines to make voluntary opt-out HIV testing a standard of care for people aged 13-64 years attending health care (box).3 The guidelines apply to all settings unless the prevalence of undiagnosed HIV infection is known to be <0.1%. The World Health Organization and the Joint UN Programme on HIV/AIDS recently published guidelines recommending provider initiated, opt-out screening in concentrated and low level epidemics at sexually transmitted infection services, health services for populations at most risk, and antenatal, childbirth, and postpartum services.6HIV screening guidelines for the United States3 Opt-out HIV screening is recommended for patients in all healthcare settings People at high risk for HIV infection should be screened for HIV at least annually Separate written consent for HIV testing is not required; general consent for medical care should be considered sufficient to encompass consent for HIV testing Prevention counselling should not be required with HIV diagnostic testing or as part of HIV screening programmes in healthcare settings The UK currently uses opt-out testing for patients attending genitourinary medicine clinics and for pregnant women attending antenatal care.7 8 The British HIV Association (BHIVA) states that, “a potentially important mechanism for limiting the HIV epidemic is the widespread use of HIV testing in a variety of clinical settings,” but provides no specific guidance on how the testing should be done.9 However, there is no recommendation for use of opt-out testing in other healthcare settings.