Authors' response

Dr Smith raises an important issue concerning the implementation of HIV testing strategies.1 Recent guidance from NICE echoes that of the 2008 UK guidelines, and recommends that men and women known to be from a country of high HIV prevalence should routinely be offered and recommended an HIV test from healthcare professionals in primary and secondary care.2 NICE acknowledge, however, that there is a lack of evidence of the effectiveness of different interventions to increase uptake of testing.

Approaches include simply increasing the routine offer of a test at a time when individuals attend primary care services or, alternatively, directly contacting registered patients inviting them to attend for a test. Recent research has shown there is high level of acceptability by patients, including black Africans, of being routinely offered a test when attending various health services including primary care and that this approach is associated with high uptake of testing.3 Frequently, the barrier here lies with the reluctance of healthcare professionals to offer a test rather than reluctance by patients to accept a test when the offer is seen as part of routine care.

The acceptability of contacting patients directly has not been established and there is an absence of published research evaluating this approach. The concern is that such an intervention would lead to increased stigmatisation among the targeted group with low uptake levels of testing. In a survey of black Africans newly diagnosed with HIV, a high proportion (76%) reported seeing their GP within the 12 months prior to diagnosis, and of those attending the issue of HIV testing was raised in only 17%.4 This suggests that increasing the routine offer and uptake of testing at the point of access to health services may result in a significant number being diagnosed earlier and that this may be a more effective case finding approach than other screening interventions.

Reducing the barriers to and increasing the uptake of testing in primary care is an important first step and we would encourage Dr Smith and his colleagues to undertake this as outlined in the NICE guidance. We would also welcome and encourage the evaluation of other approaches to increasing the uptake of HIV testing in primary care, including systematically contacting those from the target populations, to assess their acceptability and effectiveness.

• © British Journal of General Practice, January 2011