Professional Documents
Culture Documents
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!
Expanding)access:)HIV)testing)in)extended)settings!
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PHAST!review!of!the!Gilead!UK!and!Ireland!Fellowship!
Programme!2009–2011!HIV!testing!projects!
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Final)project)report!
February!2013
001/UK/13(01/MMAR/1018!!!!!!!February!2013! 1! !Final!Report!
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PHAST consultants provide evidence based, high quality, outcome-focused public health
services and support. Many have worked at high level in the NHS, the Department of
Health or in academia. PHAST also has experts in medicine, nursing, pharmacy, health
economics, ethics, ecology, psychology, sociology and law.
PHAST has delivered over 360 projects to a wide range of clients such as government
departments, Strategic Health Authorities, Primary Care Trusts, Royal Colleges and
Charities. Quality assurance and due diligence processes are in place to ensure all
associates work to the highest standard. PHAST is a Community Interest Company,
which is a type of social enterprise that is committed to using its surpluses and assets
for the public good. Social enterprises are social mission driven organisations which
trade in goods or services for a social purpose.i
David Murray BSc MSc FFPH - Director and Consultant in Public Health, PHAST
Project design and management, and author (david.murray@phast.org.uk)
Dr Catherine Brogan MBBS MSc FFPH - Chief Executive and Consultant in Public
Health, PHAST
Quality assurance
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Whereas!conventional!businesses!distribute!their!profit!among!shareholders,!in!social!enterprises!the!surplus!goes!towards!one!
or!more!social!aims!which!the!business!has.!PHAST!will!invest!any!surplus!into!development!of!new!products!and!working!with!
charities.!!In!line!with!this!PHAST!directors!and!shareholders!receive!no!dividends!for!their!work!in!managing!PHAST!CIC.!!PHAST!
CIC!is!also!regulated!by!the!CIC!Regulator,!based!at!Companies!House,!to!ensure!it!fulfils!its!Social!Enterprise!objectives!with!a!
mandatory!requirement!for!annual!audit.!!
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Contents)
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1.! SUMMARY FINDINGS AND CONCLUSIONS) 5!
1.1! INTRODUCTION! 5!
1.2! APPROACH! 5!
1.3! THE PROJECTS! 6!
1.4! OVERALL FINDINGS! 6!
1.5! CONCLUSIONS! 7!
2.! INTRODUCTION) 8!
2.1! GILEAD AND UK & IRELAND FELLOWSHIP PROGRAMME! 8!
2.2! HIV IN THE UK: OVERVIEW! 9!
2.3! TESTING POLICY! 10!
2.4! SUMMING-UP! 13!
3.! AIM AND OBJECTIVES) 14!
3.1! AIM! 14!
3.2! OBJECTIVES! 14!
4.! METHODS) 14!
4.1! CONCEPTUAL FRAMEWORK! 14!
4.2! DATA SOURCES! 14!
4.3! LIMITATIONS TO SCOPE! 15!
4.4! DATA COLLATION! 15!
4.5! ANALYSIS! 16!
5.! RESULTS AND FINDINGS) 17!
5.1! OVERVIEW OF REPORTING! 17!
5.2! FINDINGS – PROJECT CHARACTERISTICS! 19!
5.3! FINDINGS – PROJECT OUTCOMES: TESTING! 29!
5.4! FINDINGS – PROJECT OUTCOMES: NON-TESTING! 36!
6.! DISCUSSION) 36!
6.1! INTRODUCTION! 36!
6.2! IMPACT AND SAMPLE! 36!
6.3! LIMITATIONS! 37!
6.4! FEASIBILITY! 37!
6.5! ACCEPTABILITY! 38!
6.6! EFFECTIVENESS! 39!
6.7! COMMENTARY ON INDIVIDUAL SETTINGS AND PROJECTS! 39!
6.8! OVERVIEW! 40!
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7.! CONCLUSION) 41!
APPENDIX 1 – DATABASE DATA-ENTRY PAGES) 43!
APPENDIX 2 – DATABASE DATA FIELD DEFINITIONS AND SOURCES) 47!
APPENDIX 3– PROJECT LOCATION CHARACTERISTICS) 52!
APPENDIX 4 – QUALITATIVE FEEDBACK FINDINGS) 53!
APPENDIX 5 – PROJECT OUTCOMES: NON-TESTING PROJECTS SUMMARY (N=6)
) 58!
APPENDIX 6 – REFERENCES) 60!
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1.2 Approach
• PHAST reviewed slide presentations, abstracts and posters of projects presented by
UKIFP grant-holders at three annual Best Practice Sharing Events (BPSE).
• In contrast to the studies reported on in the Health Protection Agency ‘Tim e t o Test ʼ
publication, which incorporated more systematic on-going data collection
arrangements, reporting of the UKIFP projects was limited to information presented
at annual BPSE. This is likely to contribute to some of the inconsistencies between
the reports.
• The adequacy and completeness of the available reporting from the BPSE
presentations varied substantially between projects. While this could be explained by
diversity and varied resourcing of projects, there was often incomplete or
inconsistent reporting of:
o The timing and duration of time data referred to.
o Testing criteria and service delivery model.
o Definitions and reporting of test eligibility, test offer, and accepting versus
actually conducting an HIV test.
o Type of HIV test used (Point of care bloodspot test, point of care saliva test,
serology).
o Clear definitions of screen-positive versus confirmed-positive or new
diagnoses.
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1.3 The Projects
• About 40% of projects were in inner London, with most of the rest in other larger
cities. Two-thirds were in highly deprived areas. Two ‘Tim e t o Test ʼ projects were
continued through the UKIFP.
• There was substantial diversity of settings, target populations, and testing
approaches/indications:
o 20 projects in hospital settings, mostly in A&E departments, with a few in
outpatient clinics or inpatient settings.
o 8 projects in primary care settings.
o 15 projects in community settings including: community health clinics, mental
health teams, home sampling, gay community events, and gay saunas.
o Projects targeted both general populations in high prevalence areas and high
risk groups.
o Projects adopted indications for testing for the provision of both population
screening and diagnostic testing in patients with clinical indicator conditions.
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1.5 Conclusions
• This report documents the outcomes of the largest collection of HIV testing projects
outside traditional settings in the UK, and complements the findings of ‘Tim e t o Test ʼ.
The reliability of overall conclusions from this summary review of 2009 and 2011
UKIFP projects, based on BPSE presentations, is substantially reduced by the
limitations of absence of standardised reporting formats across projects.
Furthermore, the methodological differences in review approaches mean the findings
of this report cannot be directly compared to ‘Tim e t o Test ʼ, but rather should be
seen as additional evidence.
• That said, the UKIFP HIV testing projects represent a rich and substantial sample of
experience in HIV testing outside traditional settings in the UK and several projects
have been published in peer reviewed journals. Further, the results from the
sustainability audit provides some encouraging evidence for sustainability of UKIFP
projects, evidence not available from ‘Tim e t o Test ʼ projects
• UKIFP projects enabled a substantial number of HIV tests and identification of screen
positives. Apart from potentially having saved individual lives, the findings make a
further helpful contribution to the UK knowledge base on what works and what does
not.
• Overall HIV test offer rates were low, similar to those reported in the ‘Tim e t o Test ʼ
report. This limits the impact of the initiatives, but the presentations provide too little
detail and analysis to enable an exploration of reasons for the low offer rates.
• Overall HIV test acceptance rates were also low, and substantially lower than
reported in ‘Tim e t o Test ʼ. Again, the reasons for this cannot not be established from
the available information.
• The UKIFP screen positive rates are substantially above the cost effectiveness
threshold suggested in the United States (1 new diagnosed case per 1000 tests). Due
to methodological differences and in the absence of consistent case definitions across
projects in BPSE presentations however results cannot be directly compared to the
‘Tim e t o Test ʼ report.
• Nonetheless, UKIFP’s HIV testing projects findings appear to lend some measure of
further support to the effectiveness of HIV testing in extended settings. A more
standardised approach to reporting and evaluation of projects of findings may have
significantly increased the utility and impact of UKIFP projects.
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2. Introduction
2.1 Gilead and UK & Ireland Fellowship Programme
Gilead Sciences is a biopharmaceutical company that discovers, develops and
commercialises innovative therapeutics in areas of unmet medical need, including HIV.
In 2009 Gilead Sciences established the United Kingdom and Ireland Fellowship
Programme (UKIFP). Full details are available on the UKIFP website
(http://www.ukifellowshipprogramme.com).
2. To find undiagnosed HIV patients in the UK and Ireland, across a wide variety of
clinical and non-clinical settings.
3. To use evidence generated from the programme to shape public health policy
(either at local or national level), or to generate new studies or joint ventures to
shape clinical care pathways.
A wide range of projects, diverse in term of approach, setting, tests, and
population/client group focus have been supported; and as a consequence the projects
offer a potentially rich contribution to the emerging evidence base on HIV testing in
extended settings.
Over three annual cycles (2009-2011) the UKIFP has invested a total of £1.6 million,
supporting 39 projects examining extended HIV testing (2009 n=9, 2010 n=19, 2011
n=11).
Gilead commissioned PHAST to undertake an independent review of the UKIFP’s HIV
testing project outcomes. The review aims to add learning above and beyond
consideration of project progress, delivery, continuity, and perceived achievements,
consistent with the aims of the UKIFP outlined above and in light of the wider policy
context.
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2.3 Testing policy
2.3.1 Screening and testing
Strictly speaking, the various ‘testing’ policies and guidelines discussed below mainly
concern ‘screening’ of populations at various levels and types of risk. The exceptions are
those focussing on clinical indicator conditions, which could be more accurately described
as ‘case finding’, or in some cases ‘diagnostic’ testing based on clear clinical symptoms.
2.3.2 Rationale
The rationale for wider HIV testing is driven by UK and international evidence of the:
• The individual health and survival benefits of earlier diagnosis and treatment
• The public health benefits of preventing onward transmission
• The economic benefits of reduced health and other care costs, and increased
wider economic productivity.
Source)(and)methods) Implementation)recommendations)
British!HIV!Association! • In!LAs/PCTs!with!high!prevalence!though!further!evaluation!of!
BHIVA)/British! feasibility!and!acceptability!required):!
Association!of!Sexual!
o All!people!registering!with!a!GP!
Health!and!HIV!BASHH)/!
British!Infection!Society! o All!medical!admissions!
BIS).!UK!National!HIV!
• Universal:!
Testing!Guidelines.!
200815! o Termination!of!pregnancy!services!
opinion!and!review!of! o Drug!dependency!programmes!
US!evidence!and! o Healthcare!services!for!those!diagnosed!with:!TB,!HBV,!HCV,!and!
guidelines)!! lymphoma!
Health!Protection! • Hospital!medical!admissions!in!high!prevalence!areas!as!a!priority)!
Agency.!Time!to!test.!
• General!practice!exact!model!of!delivery!unclear!and!needs!
20112!!
further!investigation!(!not!all!practices!undertake!new!patient!
Evaluation!of!9! checks)!
Department!of!Health!
R&D!pilot!projects)!
NICE!guideline:!Black! • High!prevalence!areas:!
African!communities!and!
16 o Primary!care!registrations!
others.!2011 !!
o General!medical!admissions!!
Evidence!review)!2011)!
o Anyone!having!a!blood!test!
NICE!guideline:!MSM.! • Primary!care!–!men:!
17
2011 ! o High!prevalence!areas!
Evidence!review)! o Areas!with!large!MSM!community!
o MSM!
o CICs!
• Secondary!and!emergency!care!admissions!(!men:!
o High!prevalence!areas!
o MSM!
o CICs!
• MSM!community!out(reach!using!POCT!!
House!of!Lords!Select! • Beginning!in!high!prevalence!areas:!
Government!response!to! • Confirmed!support!for!the!recommendations!of!the!House!of!
House!of!Lords!Select! Lords!select!committee.!
Committee!report.!
201119! • Requested!the!National!Screening!Committee!to!consider!the!
evidence!on!extended!testing!in!areas!of!high!prevalence.!
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• Extended!HIV!testing!to!be!covered!in!the!forthcoming!
national!sexual!health!strategy.!
HPA.!Commissioning! Provides!implementation!evidence(base!to!support!commissioners!in!
Expanded!HIV!Testing!in! expanding! routine! HIV! testing! in! general! medical! admissions! and!
High!Prevalence!Areas.! primary!care!in!high!prevalence!areas.!
2012!11!
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DH.!Public!Health! Indicators!of!essential!actions!taken!to!protect!the!public’s!health,!
Outcomes!Framework.! includes:!‘the!proportion!of!persons!presenting!with!HIV!at!a!late!
201220! stage!of!infection!CD4<350)’!
Halve It Coalition
• Halve the proportion of people diagnosed late with HIV (CD4 count <350mm3) by
2015.
• Halve the proportion of people living with undiagnosed HIV by 2015.
Its membership includes the following organisations: African Health Policy Network
(AHPN), All-Party Parliamentary Group on HIV and AIDS, British Association for Sexual
Health and HIV (BASHH), British HIV Association (BHIVA), Gilead Sciences Ltd, HIV
Pharmacy Association, Medical Foundation for AIDS and Sexual Health, National AIDS
Trust (NAT), National HIV Nurses Association, Royal College of General Practitioners –
Sex, Drugs and HIV Group, and Terrence Higgins Trust. Please see
http://www.halveit.org.uk/ for more information.
3.1 Aim
Provide an independent expert review and advice on analysis and communication of the
findings of the UKIFP HIV testing projects (2009-2011) to contribute to the UK evidence
base of HIV testing outside specialist settings.
3.2 Objectives
1. Undertake the collation and independent expert review of the available findings of the
Gilead UKIFP HIV testing projects (2009-2011), in particular in relation to the following
testing outcomes:
2. Advise Gilead on the appropriate external communication and use of the findings as
evidence.
4. Methods
4.1 Conceptual framework
To deliver the stated aims and objectives, the project has been conceptualised, designed
and delivered as a retrospective evaluation of the outcomes reported by projects within
the programme.
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Outcome) Measures)(and)definitions)
Impact! • Volume!of!tests!offered!No!of!tests!offered)!
• Volume!of!tests!delivered!No!of!tests!undertaken)!
Feasibility! • Screening!test!offer!rate!%!of!population!eligible!offered!test)!
• Review!of!staff/volunteer!qualitative!survey!results!
Acceptability! • Screening!test!uptake!rate!%!of!population!offered!test!in!which!test!
conducted)!
• Review!of!participant!qualitative!survey!results!
Effectiveness! • Screen!positive!rate!%!of!screen!positive!tests!results!in!population!
receiving!test)!
• Confirmed!positive!case!rate!%!of!confirmed!positive!cases!in!
population!receiving!screening!test)!
• New!confirmed!positive!case!rate!%!of!confirmed!and!new!positive!
cases!in!population!receiving!screening!test)!
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Programme) Summary)
Year)
2009! Implemented!and!reported!
2010! Some!delayed!implementation!
Some!longer!duration!projects!
Some!reporting!from!all!projects!
2011! Many!implemented!relatively!recently!
Some!interim!process!reporting!not!outcomes)!
Status) Number) %)
Implementation!initiated!but! 3! 7%!
not!yet!reported!outcomes!
Not!yet!implemented! 2! 4%!
Almost 90% of projects were implemented to some degree and other, and had reported
some findings. Consequently at project level, the review is based on a high level of
completeness of data. Methodological design, completeness and adequacy of data within
individual projects are examined in following sections.
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diagnosed) Tests)
HIV)
Grant) Project) Grant)
Host)Organisation) Setting) prevalence)
Holder(s) Type) Year)
per)1000)
population)
in)host)LA)
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HIV)
Grant)
Host)Organisation) Grant)Holder(s) Setting) Project)Type) prevalence)
Year)
per)1000)
population)in)
host)LA)
NA!=!Not!Applicable,!NR!=!Not!Recorded!
diagnosed) Tests)
Project)Number)
HIV)
Grant) Grant)
Host)Organisation) Setting) Project)Type) prevalence)
Holder(s) Year)
per)1000)
population)
in)host)LA)
NA!=!Not!Applicable,!NR!=!Not!Recorded!
* Project)7:)Despite)UKIFPʼs)contribution)to)this)large)service)initiative,)it)would)not)be)appropriate)to)attribute)
its)impact)to)UKIFP)&)data)has)been)excluded)from)the)analyses)
)
5.2.2 Project location characteristics
Project locations were analysed in terms of region, London Boroughs, Office for National
Statistics (ONS) area classification, Index of Multiple Deprivation score and diagnosed
HIV prevalence for the host area.
The findings are summarised below and fuller details are available in Appendix 3.
)
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Region
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ONS Ar ea Classificat ion
The overwhelming majority of projects were located in areas classified by ONS as Cities
and Services (40%) and London Central (38%).
Diagnosed HI V pr ev alence
As shown in Tables A, B and C earlier, the majority of projects (80%) were in local
authority areas with levels of diagnosed HIV prevalence classified by the Health
Protection Agency (HPA) as ‘high’ (>2/1000).
!
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)) N) %) )) N) %) )) N) %)
A&E! 4! 10.3%! NA! !(! !(!
AAU/MAU/EAU! 5! 12.8%! NA! !(! !(!
Mental!Health! 1! 4.0%!
Inpatient!Other! 2! 5.1%!
Other/Oncology! 1! 4.0%!
Hospital! 19! 48.7%!
Colposcopy! 3! 12.0%!
GUM!clinic! 1! 4.0%!
Outpatient! 8! 20.5%!
Other!! 3! 12.0%!
TOP! 1! 4.0%!
New!Patients! 3! 8.0%! NA! !(! !(!
Primary!Care! 5! 12.8%!
Other! 2! 5.0%! NA! !(! !(!
Clinic! 4! 16.0%!
Healthcare! 5! 12.8%!
CMHT! 1! 4.0%!
Community! Events)! 2! 8.0%!
15! 38.5%!
settings! Home! 2! 8.0%!
Non(healthcare! 10! 25.6%!
Out(reach! 3! 12.0%!
Venues)! 3! 12.0%!
Totals! 39! !! !! 39! !! !! 25! !!
The majority of projects (48.7%) focussed on the general population in a high risk
geographic area. A substantial proportion of projects (23.1%) focussed on multiple high
prevalence or high risk groups, including MSM, black African communities, and prisoners.
Other projects focussed exclusively on particular high risk groups: MSM (10.3%) and
black African communities (5.1%). A small proportion of projects (7.7%) also focussed
on testing patients with clinical indicator conditions, and could be considered as ‘case
finding’ or ‘diagnostic’ testing, rather than true population screening.
!
Unfortunately many projects did not report test type or provided incomplete details, and
consequently 25.6% of project test types were categorised as ‘not reported’ and 20.5%
‘POCT: Unspecified’.
In projects reporting fuller details, 20.5% employed POCT: blood spot, 12.8% POCT:
saliva, and 12.8% serology tests.
No!tests!conducted! 5! 12.8%!
No!screen!positive!tests! 4! 10.3%!
Around 60% of projects did not report the true total population eligible for testing in
their model of delivery, and 41% did not report the number of tests they were able to
offer. Lower proportions of missing data were apparent in reporting of the actual
numbers of tests conducted (13%) and in numbers of screen positive test results (10%).
In the case of data on the numbers of confirmed positive tests and new diagnoses, a
high proportion of projects failed to provide these data or it was unclear what true result
represented a classification as a ‘positive test’ results in their project findings.
Consequently, attempts to analyse these variables were abandoned, and screen-positive
test results adopted as the main measure of project effectiveness.
Similarly, limitations of completeness of data at setting sub-sample levels 2 and 3 meant
that it was not feasible to reliably undertake testing outcome analyses at these levels.
Consequently this was limited to level 1 sub-sample settings: hospital, primary care, and
community settings.
Because of missing data, the tables below include unadjusted and adjusted totals and
sub-totals. Unadjusted figures include all available data. Adjusted figures included only
data from projects where both necessary parameters are available for key outcome
rate/% calculations shown. Sample sizes for unadjusted (n) and adjusted (N) figures are
also show.
)
)
Number)of)Positive)Screening)
Number)of)Tests)Conducted)
Number)of)Tests)Conducted)
%)Screened)Positive)
Subproject)Number)
Eligible)Population)
Number)Offered)
Number)Offered)
Project)Number)
Rate)per)1000)
%)Offered)
%)Uptake)
Tests)
Host)Organisation) Setting)
2! !! Royal!Victoria!Infirmary,!Newcastle! AAU/MAU/EA 3753! 478! 12.7%! 478! 396! 82.8%! 396! 2! 0.5%! 5.1!
U!
3! !! University!College!London!Hospital! AAU/MAU/EA 587! 238! 40.5%! 238! 107! 45.0%! 107! 2! 1.9%! 18.7!
U!
4! I! Royal!Liverpool!Hospital,!Liverpool! Outpatient:!!!!!!! NR! NR! !! NR! 405! !! 405! 12! 3.0%! 29.6!
GUM!Clinic!
10! !! Royal!Free!Hospital,!London! Outpatient:!!!!!!! NR! 202! !! 202! 170! 84.2%! 170! 2! 1.2%! 11.8!
TOP!
11! !! Homerton!University!Hospital,!!!! Outpatient:!!!!! NR! 1243! !! 1243! 430! 34.6%! 430! 0! 0.0%! 0!!
London! Other!
18! I! Newham!University!Hospital,!!!!!! A&E! NR! 91! !! 91! 91! 100%! 91! 6! 6.6%! 65.9!
London!
18! ii! The!Royal!London!Hospital! AAU/MAU/EA 1866! NR! !! NR! 289! !! 289! 2! 0.7%! 6.9!
U!
21! I! Chelsea!&!Westminster!Hospital,!!!!!!!! A&E! 21750! 2271! 10.4%! 2271! 1358! 59.8%! 1358! 5! 0.4%! 3.7!
London!
21! ii! St!Mary’s!Hospital,!London! A&E! 15569! NR! !! NR! 465! !! 465! 4! 0.9%! 8.6!
21! iii! Charing!Cross!Hospital,!London! A&E! !NR! NR!! !! NR!! NR! !! NR!! NR! ! !!
24! !! St!George’s!Hospital,!London! Outpatient:!!!!!! 1078! 794! 73.7%! 794! 105! 13.2%! 105! 0! 0.0%! 0!!
Colposcopy!
25! !! Homerton!University!Hospital,!!!! Outpatient:!!!!! 687! 687! 100%! 687! 518! 75.4%! 518! 1! 0.2%! 1.9!
London! Colposcopy!
32! ii! Homerton!University!Hospital,! Inpatient:!!!!!!!!!!! NR! 33! !! 33! 9! 27.3%! 9! 0! 0.0%! 0!!
London! Mental!
Health!
33! !! Croydon!University!Hospital! AAU/MAU/EA 3709! 3709! 100%! 3709! 1390! 37.5%! 1390! 8! 0.6%! 5.8!
U!
) ) ADJUSTED*)HOSPITAL)SUBTOTAL) ) 31,574) 8,183) 25.9%) 9,752) 4,580) 47.0%) 5,739) 44) 0.8%) 7.7)
• Adjusted!calculations!include!only!projects!where!both!necessary!figures!are!available!for!the!rate/percentage!calculation!!
%)Screened)Positive)
Subproject)Number)
Number)of)Positive)
Eligible)Population)
Number)of)Tests)
Number)of)Tests)
Number)Offered)
Number)Offered)
Project)Number)
Screening)Tests)
Rate)per)1000)
Conducted)
Conducted)
%)Offered)
%)Uptake)
Host)
Organisation) Setting)
15! !! Newham! Others! NR! NR! !! NR! 118! !! 118! 1! 0.8%! 8.5!
University!
Teaching!
Hospital/!
NewhamPCT/!!!
Positive!East!
16! I! NHS!SE!London! New! 6275! 4925! 78.5%! 4925! 905! 18.4%! 905! 11! 1.2%! 12.2!
Registrants!
16! ii! NHS!SE!London! New! 16241! 6405! 39.4%! 6405! 3229! 50.4%! 3229! 12! 0.4%! 3.7!
Registrants!
Number)of)Positive)Screening)
Number)of)Tests)Conducted)
Number)of)Tests)Conducted)
%)Screened)Positive)
Subproject)Number)
Eligible)Population)
Number)Offered)
Number)Offered)
Project)Number)
Rate)per)1000)
%)Offered)
%)Uptake)
Tests)
Host)Organisation) Setting)
4! ii! Royal!Liverpool!Hospital,! Clinic! NR! NR! !! NR! 328! !! 328! 2! 0.6%! 6.1!
Liverpool!
5! !! Birmingham!Heartlands! Venue! 129! 129! 100%! 129! 129! 100%! 129! 6! 4.7%! 46.5!
Hospital!
13! !! Sheffield!Teaching!Hospitals! Out(reach! NR! NR! !! NR! 11! !! 11! 1! 9.1%! 90.9!
NHS!!!!Foundation!Trust!
14! ! Belfast!Health!&!Social!Care! Venue! NR! NR! ! NR! 354! ! 354! 5! 1.4%! 14.1!
Trust!&!!!!!!!!!Royal!Victoria!
Hospital,!Belfast!
17! !! Guys!and!St!Thomas!NHS! Clinic! NR! NR! !! NR! 35! !! 35! 0! 0%! !0.0!
Trust,!!!!!!!!!!!!!!!!!Kings!College!
London!
19! !! Whittall!Street!Clinic,! Event! NR! 406! !! 406! 398! 98.0%! 398! 6! 1.5%! 15.1!
Birmingham!
22! !! The!Michael!Wood!Centre!(! Event! NR! NR! !! NR! 430! !! 430! 4! 0.9%! 9.3!
Leicester!!!!!!!!!Aids!Support!
Service!
27! !! Chelsea!and!Westminster! Out(reach! NR! 411! !! 411! 163! 39.7%! 163! 0! 0%! 0.0!!
NHS!!!!!!!!!Foundation!Trust!
31! !! Sheffield!Teaching!Hospitals! Home! NR! 46! !! 46! 36! 78.3%! 36! 3! 8.3%! 83.3!
NHS!!!!Foundation!Trust!
32! i! Homerton!University! CMHT! 79! 79! 100%! 79! 53! 67.1%! 53! 0! 0%! 0.0!!
Hospital,!London!
35! !! NHS!Greater!Manchester/!!!!!!!!!!!!! Home! NR! 2750! !! 2750! 1375! 50.0%! 1375! 2! 0.1%! 1.5!
Sexual!Health!Network!
37! !! Barking!,!Havering!&! Clinic! NR! NR! !! NR! 12! !! 12! 0! 0%! 0.0!!
Redbridge!!!!!!!!!University!
Hospitals!Trust,!Essex!
39! !! Chelsea!and!Westminster! Out(reach! 152! 152! 100%! 152! 152! 100%! 152! 2! 1.3%! 13.2!
NHS!!!!!!!!!Foundation!Trust!
ADJUSTED*)COMMUNITY)SUBTOTAL)(N) ) 360) 360) 100%) 3,973) 2,306) 58%) 3,477) 31) 0.9%) 8.9)
%)Screened)Positive)
Number)of)Positive)
Eligible)Population)
Number)of)Tests)
Number)of)Tests)
Number)Offered)
Number)Offered)
Screening)Tests)
Rate)per)1000)
Conducted)
Conducted)
%)Offered)
%)Uptake)
)
* * )Adjusted)calculations)include)only)projects)where)both)necessary)figures)are)available)for)the)rate/ percentage)calculation)
5.3.2 Impact
The table below provides an overview of the total volumes of tests offered and delivered
by the programme by main setting type. This gives insight into the overall capacity
impact of the UKIFP programme.
N) %)of)all) N) %)of)all)
Overall, the UKIFP programme enabled the offer of at least 25,987 tests, and delivered
13,771 tests. The majority of test offers were made in a primary care setting (47.2%),
and the majority of tests delivered in hospital settings (41.7%).
Also, insight into the on-going impact of the UKIFP projects has been provided by a
recent Gilead commissioned audit22 of project sustainability, operational status, and
related publications. The audit reported a 66% response rate from HIV projects and
drew the following conclusions:
• 71% (17/24) of projects funded in 2009 and 2010 remained operational, and of
these 64% reported continuation through NHS funding.
• 57% of project leads considered their project achieved the expected results and
93% regarded the project a success.
!
5.3.3 Feasibility
While the scale of testing delivery detailed earlier in section 5.3.2 provides insight into
the scale of the programme’s testing impact, it is important to consider this in terms of
its potential achievement in light of the total population eligible to receive an offer of a
test, and to whom a test is delivered.
This is an indicator of the feasibility of testing in the health system, particular settings,
approaches to testing strategy and testing delivery models.
As set-out earlier, a high proportion (59%) of projects did not report their eligible
population, and as a result the figures below are based on 13 projects in total.
As shown in full earlier in Tables D-G, and in summary in Table H above, the overall
testing offer rate was 37%, with a wide range across included projects: 10.4% to 100%.
The testing offer rates in the three main settings varies, appearing to be as high as
100% in community settings, 51.3% (range: 39.4% to 78.5) in primary care, and 25.6%
(range: 10.4% to 100%) in hospitals.
Attempts to analyse test delivery rates in addition to test offer rates were abandoned
due to poor levels of data completeness in the required data variables.
In addition to outcome data, a minority of projects (20.5% [8/39]) also reported findings
from some form of feedback from staff: six (31.6%) in hospital settings, two in
community settings (13.3%), and none in primary care. Fuller details are available in
Appendix 4.
Again, given the small sample, and the unvalidated methods or lack of consistency in
their use, these summary findings are likely to be biased and so must be regarded with
caution.
However, the following can be stated:
• Stigma and misperceptions regarding HIV testing persist among clinicians
(e.g. informed consent).
• Workload influences the feasibility of reliably offering and providing tests in
hospital settings.
!
5.3.5 Effectiveness
Given the ultimate aims of testing, effectiveness is ideally measured in terms of the
number of new confirmed HIV cases detected. Unfortunately, as discussed earlier, the
substantial amounts of missing data allowing classification of positive tests as confirmed
and new, means that only screen-positive tests results were consider reliable and
considered fully below.
As shown in full earlier in Tables D-G, and in summary in Table H earlier, based on the
available data (n=32), 103 screen positive cases were identified, yielding an overall
screen positive rate of 0.7% [7.4/1000], with a relatively large range across projects:
0% to 9.1%.
6. Discussion
6.1 Introduction
Chapter 2 of the report set-out the UK context including the following:
• A summary of current trends in HIV and its treatment
• The rationale for HIV testing (i.e. population screening) in extended settings
• A summary and chronology of UK HIV testing (i.e. population screening) policy
• A cursory examination of the evidence base on wider population HIV testing in
extended settings.
Chapters 3 to 5 have described the background, aims, characteristics and outcome
findings of the UKIFP HIV testing projects 2009-2011.
This chapter seeks to consider the findings of our review of the UKIFP outcomes, and
discuss them in light of the wider context, in order to examine their additional
contribution to the current evidence base influencing HIV testing policy.
6.3 Limitations
The priority in delivering the UKIFP was to provide support to grass-roots innovation,
rather than as an R&D initiative. As a result individual project grant-holders held
responsibility for contributing evaluation and monitoring resources and expertise, and
chose their own approaches accordingly. This undoubtedly impacted on the scope,
methods and quality of individual project evaluation, monitoring and reporting.
As outlined in more detail in earlier Chapters, the limitations are associated with study
design (i.e. retrospective observational), and quality and completeness of reporting of
intervention (design, delivery model, and test type), population characteristics, and
outcomes.
Unfortunately, the impact of low quality and incomplete reporting is more severe in
these small sub-samples, and it was considered methodologically inappropriate to
undertake aggregate analysis at these levels in addition to the main setting categories
(i.e. hospital, primary care, and community settings).
Despite these limitations, the UKIFP sample provides a rich pool for potential additional
learning on extended HIV testing.
Interpreting and attributing the outcome findings requires an appropriate balance to be
struck between the strengths and limitations of evaluation design and reporting that are
set-out earlier in the report, and some caution to be exercised in the confidence with
which conclusions that can be drawn the UKIFP alone.
Consequently while recognising important differences in their respective aims, discussion
of the UKIFP’s key outcome findings is put in context with those of the DH pilot projects
as reported in the HPA evaluation publication Time to Test2.
6.4 Feasibility
Based on a 33% (13/39) sample of total testing projects, UKIFP projects achieved an
overall test offer rate of 37% (range 10.4% to 100.0%). This clearly raises doubts
regards the feasibility of testing, which merit further examination.
Offer rates varied between settings, with the highest rates (100%) appearing to be
achieved in community settings. However, it is likely that this is due to the difficulty of
accurately reporting or estimating the true eligible population in such settings.
Rates in primary care (51.3% [range: 39.4% to 78.5%]) were higher than in hospital
settings (25.6% [range: 10.4% to 100%]), though again both exhibited broad ranges
across projects.
The more straightforward test offer to all new patients in a non-acute less urgent
environment, as opposed to more complex clinical protocols, may be easier to administer
and deliver than in some hospital environments. This would seem more likely where
POCT methods are used, though this analysis has not been able to explore the
differences between test methods themselves.
The calculation of the test eligible populations is easier in primary care projects; where
available, results from primary care may be more reliable. Also, it is possible that eligible
populations in acute settings may have been over estimated, resulting in spuriously low
offer rates.
6.5 Acceptability
Based on a 56% [22/39] sample of testing projects, UKIFP projects achieved an overall
uptake rate of 44% (range: 39.7% to 100.0%).
Uptake rates in different settings were: 47% (range: 13.2% to 100.0%) in hospital
settings, 44% (range: 39.7% to 100%) in community settings, and 37% (range: 18.4%
to 66.3%) in primary care.
This overall uptake rate is disappointing, and are also lower than the 69.9% (range:
59% to 91%) reported in Time to Test.
Within the methodological and data completeness limitations of the UKIFP it is difficult to
examine the wide variation. However, it is likely to result from actual differences in
populations tested, in acceptability across settings and in approaches to operational
delivery. It is also difficult accurately to enumerate the population offered tests,
especially at community events and some busy hospital settings.
The limited UKIFP patient and participant survey findings available suggest that eligible
populations do not generally find the offer of HIV testing unacceptable in extended
settings. However, a substantial proportion may not consider it appropriate for
themselves as individuals, due to their perception of their level of risk. Some MSM
projects highlighted positive feedback of providing POCT tests in non-health care
settings. Some projects found lower levels of acceptability in black African populations.
In summary, overall the UKIFP projects reported substantially lower uptake rates
compared to Time to Test (44% vs 69.9%). Rates were substantially lower in both
settings where comparison was feasible: hospital (47% vs 72.5%) and primary care
(37% vs 65.3%). However, both evaluations reported higher uptake in hospital
compared to primary care. This could be due to different perceptions of risk between the
populations served in these settings (i.e. healthy new registrations in primary care).
6.7.1 Hospital
Five testing projects were based in AAU/MAU settings and achieved widely contrasting
outcome results, suggesting that more detailed evaluation of the reasons for this could
be valuable. Four projects were set in A&E, though unfortunately the minority provided
complete reporting at this time. Project No. 18i focussing on CIC criteria found very high
screen positive levels. However, from description of the cases, it seems likely that these
would have been diagnosed later as in-patients. Consequently, the added value of
testing for CICs in A&E appears unclear. Also, it remains unclear as to whether A&E or
AAU/MAU settings represent the optimal large through-put hospital setting.
In projects in hospital outpatient settings, one of two projects (No.s 24 and 25) set in
colposcopy clinics reported a much lower level of acceptability (i.e. uptake) (13.2% vs
75.4%). This seems to have been due to a lack of dedicated phlebotomy capacity.
Project No.10, set in a termination of pregnancy clinic, reported high levels of uptake
(84.2%) and a screen positive rate of 1.2% (11.8/1000). However, this was based on a
relatively small sample.
6.8 Overview
The UKIFP and Time to Test outcome findings suggest that barriers remain to be
overcome in improving the feasibility of offering HIV testing in extended settings. Where
tests were offered, uptake rates were variable and often disappointing and substantially
lower than in Time to Test. These findings suggest that further insight is required about
the operational characteristics of optimally successful models of test delivery.
Despite these apparent limitations associated with feasibility (offer rates) and
acceptability (uptake rates), the UKIFP found that population test positive rates (albeit
screen positive as opposed to confirm and new positive findings) that are reasonably
high when judged by conventional thresholds adopted in HIV testing research.
7. Conclusion
There is increasing international evidence of the effectiveness and cost effectiveness of
early HIV diagnosis and prevention. This is reflected by the adoption of a Public Health
Outcome measure intended to reduce late diagnosis in England. We should therefore
make use of any opportunity to increase the knowledge base about the contribution of
widespread testing to this goal.
Within the limitations in relation to research conduct and design, which are well
documented in this report, the UKIFP HIV testing projects represent a rich and
substantial sample. As a result, the findings make a further helpful contribution to the
UK knowledge base on the topic. In addition, findings from a project sustainability audit
carried out suggest that a significant number of projects funded in 2009 and 2010 report
continued operation in 2012 through NHS funding.
Balancing these considerations affects the weight and confidence that can be associated
with the findings, and hence their influence in isolation for policy.
However, considered alongside other evidence the following contributions can be drawn:
• Contribution: The UKIFP HIV testing projects have made a substantial additional
contribution, both in terms of testing capacity, tests, and learning.
• Feasibility: Measured in terms of test offer rates, in absolute terms, the UKIFP
suggests offer rates remain relatively low. Also, in relative terms, UKIFP’s rates
are lower than reported in the Time to Test report. It appears that consistently
higher rates are possible in primary care, and potentially in community settings.
Rates in hospital settings appear lower, probably due to organisational
complexities, clinician beliefs regarding consent, workload and urgency of patient
needs in some settings.
• Acceptability: Measured in terms of test uptake rates, in absolute terms, the
UKIFP results were only moderately high, and compared to the findings in Time to
Test, UKIFP uptake results were relatively low. Acceptability appears greater in
hospital settings and in some higher risk populations. Some qualitative findings
suggest that while people may find the offer of a HIV test in extended settings
acceptable in general terms, they may not believe the test necessary for
themselves, due to their perception or knowledge of their personal risk. Also,
some evidence suggests that convenience appears to be an influence on uptake,
and that acceptability may be lower among some black African people. As HIV
testing in extended settings becomes more normalised, it seems plausible that
acceptability will increase.
• Effectiveness: Measured in terms of screen positive case rates, in absolute
terms, the UKIFP results are encouraging. However, the lack of a consistent case
definition across projects means that it is unclear how the number of screen
positive cases would relate to the true confirmed new case rate. Similarly, in
relative terms, as might be expected given that Time to Test reported confirmed
new cases, the UKIFP rates were higher. Despite caveats in relation to case
definition, UKIFP’s findings appear to lend further support to the effectiveness of
HIV testing in extended settings, against conventional thresholds implied or
stated in HIV research. Also, by US standards the findings are substantially above
accepted cost effectiveness threshold (i.e. 1 new diagnosed case per 1000
tests)12 13.
• Evaluation: Future UKIFP projects and other extended HIV testing projects
should be subject to higher quality evaluation arrangements. A clearer distinction
should be drawn in terms of aims and likely levels of screen positive rates, and
between HIV testing as population screening, as opposed to case-finding or
diagnosis.
Appendix)1)–)Database)dataentry)pages)
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A p p e n d i x 2 – D a t a b a se d a t a f i e l d d e f i n i t i o n s a n d so u r ce s
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Field&Name& Field&Type& Field&Description& Data&Source&(if¬&from&project&review)&
!
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Implementation! Text! ! !
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A p p e n d i x 3 – Pr o j e ct l o ca t i o n ch a r a ct e r i st i cs
!
Region' 2009' 2010' 2011' Total'(n)' Total'(%)'
London! 3! 16! 6! 25! 56!
North!West! 3! 1! 2! 6! 13!
West!Midlands! 1! 2! 1! 4! 9!
Yorkshire!and!the!Humber! 0! 1! 1! 2! 4!
North!East! 1! 0! 1! 2! 4!
East!Midlands! 1! 1! 0! 2! 4!
South!West! 1! 0! 0! 1! 2!
South!East! 0! 1! 0! 1! 2!
East!of!England! 0! 0! 1! 1! 2!
Northern!Ireland! !0! 1! !0! 1! 2!
All' 10' 23' 12' 45' 100'
!
' TOTAL' TOTAL'
London'Borough' 2009' 2010' 2011' (n)' (%)'
Lambeth!and!Southwark! 2!
Boroughs)! 0!! 1! 0! 1! 4!
Barking!and!Dagenham! !0! 0! 1! 1! 4!
Camden! 1! 1! 0! 2! 8!
Croydon! !0! 0! 1! 1! 4!
Enfield! !0! 1! 0! 1! 4!
Hackney! !0! 2! 2! 4! 16!
Hammersmith!and!Fulham! !0! 1! 0! 1! 4!
Kensington!and!Chelsea! !0! 1! 0! 1! 4!
Lambeth! !0! 2! 0! 2! 8!
Newham! !0! 2! 0! 2! 8!
Tower!Hamlets! 1! 1! 0! 2! 8!
Wandsworth! !0! 2! 0! 2! 8!
Westminster! 1! 2! 2! 5! 20!
London' 3' 16' 6' 25' 100!
!
ONS'Area'Classification' 2009' 2010' 2011' TOTAL'(n)' TOTAL'(%)'
London!Centre! 3! 11! 4! 18! 40!
Cities!and!Services! 5! 5! 7! 17! 38!
London!Cosmopolitan! !0! 4! 0! 4! 9!
London!Suburbs! !0! 2! 1! 3! 7!
Coastal!and!Countryside! 2! 0! 0! 2! 4!
Mining!and!Manufacturing! !0! 1! 0! 1! 2!
All' 10' 23' 12' 45' 100'
'
A p p e n d i x 4 – Qu a l i t a t i v e f e e d b a ck f i n d i n g s
!
Table!H!(!Projects!in!hospital!settings! n=19)!
Project!Number!
Subproject!
Number!
(!7%!has!recent!HIV!test! (!Misperceptions!on!requirements!of!HIV!testing!
(!!5%!worried!about!impact!of!+ve!test!
(!5%!didnʼt!believe!MAU!appropriate!setting!
(!89.9%!liked!testing!information!via!video!
(!81.5%!found!that!the!video!answered!their!questions!about!
testing!
(!74%!accepted!offer!of!test! 80.6%!in!UK!Born!and!68.3%!overseas!
born)!
(!98%!considered!testing!appropriate!in!TOP!setting!
(!!Black!African!women!born!overseas!had!highest!rate!of!test!
refusal!
!
!
!
partners!attending!
ante(natal!clinics)! (!59%!accepting!had!never!been!previously!tested!
(!40%!of!those!consenting!to!test!but!not!receiving!one!cited!
phlebotomy!waiting!times!as!reason!
!
Table!I!–!Projects!in!primary!care!settings!(n=5)!
Project!Number!
Subproject!
Staff!survey/ feedback:!
Number!
(!77%!stated!they!were!ʻnot!at!riskʼ!
(!2%!stated!it!was!ʻnot!a!good!ideaʼ!
(!13%!ʻotherʼ!reasons!
(!8%!undisclosed!reason!
(!Recent!test!
(!Had!had!ante(natal!test!
(!Scarred!of!needles!
(!Deferred!
(!Not!at!risk!
(!Language!barriers!
(!91.2%!rated!the!peer!testers!as!good!or!very!good!
(!98.2%!said!they!would!use!the!service!again!
(!59.6%!had!not!preference!between!a!choice!of!nurse!or!peer!tester!
!
!
!
Table!J!–!Projects!in!community!settings!(n=15)!
Subproject!Number!
Project!Number!
“Itʼs!nice!to!be!able!to!go!somewhere!not!in!a!hospital!setting!“!
“Flexibility!good!with!appointment!times!,!able!to!come!straight!
from!work”!
“Speed!of!result!excellent!couldn't!believe!I!had!them!within!15!
mins”!
“Staff!were!really!friendly”!
“Not!having!to!book!an!appointment!gives!me!the!opportunity!to!
drop!in!whenever!i!feel!the!need!to”!
(!Salivary!testing!was!unacceptable!to!some!who!suspected!it!may!
be!used!for!DNA!testing!and!stored!for!policing!immigration!issues!
(!Concerns!expressed!over!impact!of!a!positive!HIV!result!
included:!stigma;!status!in!the!family;!future!sexual!activity!
(!Some!cultural!event!co(ordinators!and!church/ mosque!leaders!
discouraged!HIV!testing!
(!71.1%!felt!this!should!be!done!using!a!mouth!swab!
Concerns!regarding!testing:!
• !35%!had!no!concerns!regarding!HIV/ HCV!testing!but,!in!those!
who!did,!dislike!of!needles,!receiving!a!positive!result!and!
confidentiality!were!the!commonest!barriers!to!testing!
!
!
!
!
!
A p p e n d i x 5 – Pr o j e ct o u t co m e s: N o n - t e st i n g p r o j e ct s su m m a r y ( n = 6 )
Subproject!Number!
Project!Number!
Location!Type! Grant!
Group! Project!Title! Grant!Holder(s)! Year! Host!Organisation! Project!Type! Output/ Impact!Summary!
!
PH A ST Co n t a ct D e t a i l s
D r Ca t h e r i n e B r o g a n
Pu b l i c H e a l t h A ct i o n Su p p o r t Te a m CI C
West lingt on Far m
Dint on
Buck s
HP17 8UL
Appendix!6!–!References!
!
!
!
1
!HPA.!HIV$in$the$UK:$2011$report.$London:!Health!Protection!Services,!Colindale.!November!2011.!
2
!Health!Protection!Agency.!Time$to$test$for$HIV:$Expanding$HIV$testing$in$healthcare$&$community$services$in$
England..$Final$Report.!September!2011!
3
!Health!Protection!Agency.!Summary!of!antenatal!screening!for!infectious!diseases!in!England:!2010!update.!
Health$Protection$Report$2011;!34 5).!
4
!Health!Protection!Agency,!Centre!for!Infections.!The!UK!Collaborative!Group!on!HIV!&!STI!surveillance.!
Testing$Times.$HIV$&$other$STIs$in$the$UK.!2007.!
5
!British!HIV!Association! BHIVA).!2005 6$mortality$audit.!
6
!Sullivan!A!K!et!al.!Newly!diagnosed!HIV!infections:!review!in!UK!&!Ireland.!BMJ,!2005,!330,!1301(2.!
7
!Mayer!K!et!al.!Sustained$treatment$as$prevention:$continued$decreases$in$unprotected$sex$&$virological$
supresssion$after$HAART$initiation$among$patients$in$HPTN$052.!Oral!Poster!Presentation!MOPDC0106.!XIX!
International!AIDS!Conference.!July!2012,!Washington!DC.!
8
!Chen!Y!Q!et!al.!Time to ART Initiation:$A$risk$factor$analysis$of$the$HPTN$052$HIV infected$partners$on$delayed$
therapy.$Poster!TUPE083.!XIX!International!AIDS!Conference.!July!2012,!Washington!DC.!
!
9
!Grinsztejn!M!et!al.!Effect$of$early$versus$delayed$initiation$of$antiretroviral$therapy$(ART)$on$clinical$outcomes$
in$the$HPTN$052$randomized$trial.!Late(breaker!Presentation!FRLBC01.!XIX!International!AIDS!Conference.!July!
2012,!Washington!DC.!
!
10
!Walensky!R!P!et!al.!The$cost effectiveness$of$treatment$as$prevention:$analysis$of$the$HPTN$052$trial.!Late(
breaker!presentation!FRLBC01.!XIX!International!AIDS!Conference.!July!2012,!Washington!DC.!
!
11
!Health!Protection!Agency.!Evidence$&$resources$to$commission$expanded$HIV$testing$in$priority$medical$
services$in$high$prevalence$areas.!April!2012!
12
!Walensky!R!P!et!al.!Routine!human!immunodeficiency!virus!testing:!an!economic!evaluation!of!current!
guidelines.!The$American$Journal$of$Medicine,!118 3),!292(300,!2005.!
13
!Paltiel!A!D!et!al.!Expanded!testing!for!HIV!in!the!United!States!–!an!analysis!of!cost!effectiveness.!New$
England$Journal$of$Medicine,!352 6),!586(595,!2005.!!
14
!UK!CMOs!&!CNOs.!Improving$the$detection$&$diagnosis$of$HIV$in$non HIV$specialties$including$primary$care.!
Sept(Oct!2007.!
15
!British!HIV!Association! BHIVA),!British!Association!of!sexual!Health!&!HIV! BASHH),!and!the!British!Infection!
Society! BIS).!UK$National$Guidelines$for$HIV$Testing$2008.!September!2008.!
16
!National!Institute!for!Health!and!Clinical!Excellence,!2011.$$$Increasing$the$uptake$of$HIV$testing$among$black$
Africans$in$England.$NICE$public$health$guidance$33.!www.nice.org.uk/ guidance/ PH33
!
17
!!National!Institute!for!Health!and!Clinical!Excellence,!2011.!Increasing$the$uptake$of$HIV$testing$among$men$
who$have$sex$with$men.$NICE$public$health$guidance$34.!www.nice.org.uk/ guidance/ PH34
!
!
!
!
18
!Select!Committee!on!HIV!and!AIDS!in!the!United!Kingdom.!No$vaccine,$no$cure:$HIV$and$AIDS$in$the$United$
Kingdom.!Sept!2011!
!
19
!Department!of!Health.!Government$response$to$the$House$of$Lords$Report$of$Session$2010 12:$No$vaccine,$
no$cure:$HIV$and$AIDS$in$the$United$Kingdom.$Oct!2011!
!
20
!Department!of!Health.!Healthy!lives,!healthy!people:!Improving!outcomes!&!supporting!transparency.!Jan!
2012!
21
!Tweed!E,!et!al.!Monitoring!HIV!testing!in!diverse!healthcare!settings:!results!from!a!sentinel!surveillance!pilot!
study.!Sex$Transm$Infect!2010:!86 5):!360(364!
22
!Gilead.!Key$findings$of$the$2009 2011$UKIFP$HIV/ HBV$projects$sustainability$audit:$phase$I.!May!2012.!