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The London Regional Office of the Communicable Disease Surveillance Centre (CDSC) has stated that all patients diagnosed with tuberculosis (TB) should be offered an HIV test.1 We sought to implement this by introducing a programme within two central London hospitals with high rates of TB, where TB specialist nurses saw all patients early in their treatment course and discussed HIV testing. A standard protocol was used which covered the reasons for offering a test, the “pros and cons” of testing, and the actual process involved (including how the results would be given). Staff training and support was supplied by local HIV psychologists. Pretest discussion took an average of 10–15 minutes per patient and was usually performed within the first month of treatment.
Between July 2002 and July 2003 there were 247 new cases of TB. The median age was 43 years and 60% were male. The main ethnic groups were black African (40%), white (22%), and Indian (11%). Eleven (4%) were already known to be HIV positive and were excluded from further analysis. Of the remaining 236, 131 (56%) were offered an HIV test. 109 (83% of those offered) took this up and 18 (17% of sample tested, 8% of all TB patients) were found to be HIV positive.
When subjects were divided on the basis of where the diagnosis of TB was made, striking differences in HIV rates were noted (table 1). Inpatients were much more likely to be offered, to accept, and to test positive on HIV testing. There was no difference in the demographic parameters between inpatients and outpatients, although inpatients tended to have more symptoms and to be smear positive (data not shown). Where no HIV test was offered, we found common themes in patient care. The most important of these was a lack of TB nurses to offer testing, and patients being diagnosed outside the focused TB service. A problem specific to the outpatient setting was the lack of appropriate clinic space in which to discuss HIV testing.
The most common reason given by patients who declined to undergo testing was a perceived inability to cope with the dual diagnosis (46% of cases), especially if the initial diagnosis of TB itself had been difficult to deal with. Such individuals would rarely agree to further discussion on HIV testing at a later date. Other reasons—such as patients regarding themselves to be at low risk of HIV infection—were much less frequently reported (10%).
The overall high rate of HIV co-infection is in line with other metropolitan studies.2 Our data, as well as that of others,3 may appear to suggest that we should predominately target inpatients (in whom the rates of HIV were 20 times greater than in outpatients). However, given the increasing HIV/TB rates in the UK, we feel that this is a short sighted approach as we would expect that more individuals will present with TB as their first HIV related illness in an outpatient setting.4
HIV testing was unacceptable to some patients. There is need for in-depth qualitative analysis to explore issues such as the timing of the discussion on HIV testing and the belief systems and coping mechanisms of individuals.5
Despite attempts to provide a focused HIV testing service within our TB clinics, we find low rates of uptake. Much of this stems from an apparent failure to offer testing to almost half our patients. This may be an overestimate as it is conceivable that other healthcare workers might have discussed testing but not documented it in the patient’s notes. Data systems need to be implemented which can accurately capture this information.
Achieving HIV testing targets will require dedicated resources as well as improvements in both staff and patient education. This would argue for a greater interaction between local TB and HIV services.