by Dr Chris Eades, Consultant in Infectious Diseases and Medical Mycology
HIV testing in clinical settings is vital not only for medical reasons but also from a medico-legal perspective. Research demonstrates that people living with HIV (PLHIV) have significantly better health outcomes when diagnosed and treated early, before symptoms develop. Healthcare professionals play a key role in offering and performing HIV tests, helping undiagnosed individuals access care and start antiretroviral therapy (ART). Modern ART regimens rapidly reduce the viral load in the blood to undetectable levels, preventing further health complications. Early diagnosis allows PLHIV to live as long and as healthily as individuals without HIV. An undetectable viral load also eliminates the risk of transmitting HIV to sexual partners—a concept known as ‘U=U’ (‘undetectable = untransmissible’). This groundbreaking understanding enables PLHIV to lead full lives, free from the stigma of transmission. Knowing one’s HIV status empowers individuals to make informed decisions about their health and lifestyle. For those at risk of transmission, testing provides an opportunity to protect their own and their partner’s sexual health. In contrast, individuals unaware of their HIV status are the most likely to transmit the virus, further underscoring the public health importance of testing.
Current guidelines and testing practices
Guidelines recommend routine HIV testing in areas with high (over 0.2%) or very high (over 0.5%) prevalence. Many urban hospitals test patients in emergency departments (EDs) or upon hospital admission, while GP surgeries often test new registrants. No special consent is required for HIV testing beyond that for other routine tests, and all healthcare professionals are expected to offer testing when clinically indicated.
Testing is especially critical for patients presenting with ‘indicator conditions,’ illnesses or symptoms more commonly seen in individuals with undiagnosed or uncontrolled HIV. Examples include unexplained blood count abnormalities, bacterial pneumonia, and unexplained weight loss. These differ from ‘AIDS-defining’ conditions, a term from the pre-ART era describing advanced HIV-related illnesses such as Pneumocystis pneumonia and Kaposi sarcoma. Testing is essential in cases involving either indicator or AIDS-defining conditions.
The medico-legal implications of HIV testing
HIV testing is a critical medico-legal consideration for healthcare providers. Failure to offer testing in appropriate situations can lead to preventable harm or death, potentially breaching the duty of care owed to patients. Missed or delayed diagnoses of HIV may result in complaints, legal claims, or regulatory actions. This obligation is particularly pronounced in cases involving symptoms of indicator or AIDS-defining conditions. Failure to test in such cases is likely to fall below the expected standard of care, as judged by a responsible body of opinion, as outlined in the landmark case, Bolam v Friern Hospital Management Committee.[1] Retrospective reviews often reveal missed opportunities to test in such cases, despite clear indicators. Despite increased efforts by the NHS and advocacy groups to normalise HIV testing, many PLHIV remain unaware of their diagnosis. While this is a multifaceted issue, universal testing—regardless of perceived risk—is likely to improve diagnostic rates. Healthcare professionals have a legal duty to protect patients from foreseeable harm, underscoring the importance of routine, proactive testing. By adhering to best practices, clinicians fulfil their duty to act in patients’ best interests, prevent harm, and contribute to reducing HIV transmission and improving public health. Early and widespread testing is not only good medical practice but also an essential component of ethical and legal care.
[1] [1957] 1 WLR 582
Further reading
Palfreeman, A et al., 2020. BHIVA/BASHH/BIA Adult HIV Testing Guidelines 2020. British HIV Association. Available at: https://www.bhiva.org/file/5f68c0dd7aefb/HIV-testing-guidelines-2020.pdf [Accessed 15 November 2024]
Local Authorities with High or Very High HIV Prevalence (2019) (updated 2021). Department of Health and Social Care. Available at: https://www.gov.uk/government/publications/towards-zero-the-hiv-action-plan-for-england-2022-to-2025/annex-b-local-authorities-with-high-or-very-high-hiv-prevalence-2019 [Accessed 15 November 2024]