Indications for HIV Testing


Jurisdictional and community-based approaches, guidelines and protocols developed in line with the Eighth National HIV Strategy 2018-2022 should reflect local epidemiology and demographic data to facilitate the appropriate testing frequency among populations at risk of HIV. These approaches support firstly the public health goal of diagnosing at least 95% of those living with HIV, in accordance with the specific targets of the Eighth National HIV Strategy 2018-2022 to work towards the elimination of HIV; and secondly the individual benefit of people unknowingly living with HIV in Australia, especially the still significant proportion of people living with HIV who present late (with a CD4+ cell count at diagnosis below 350 µL) who would have a significant health benefit from an earlier diagnosis. In Australia, between 2013 and 2017, almost 50% of new HIV diagnoses among people reporting heterosexual exposure, or origin from a high prevalence country, and 26% of new diagnoses among gay and bisexual men, were late HIV diagnoses.15 Testing for HIV infection is currently considered to be cost effective even when the prior likelihood of positivity is as low as 1 in 1000,16 so the perceived risk does not have to be high in order to test.

HIV testing is indicated in a number of contexts:

Behavioural and epidemiological indicators

  • Gay men and other men who have sex with men, in accordance with the Australian Sexually Transmitted Infection & HIV Testing Guidelines 2019: For asymptomatic men who have sex with men
  • Transgender women and people who identify as gender diverse who have sex with men
  • Aboriginal and Torres Strait Islander peoples
  • People who inject drugs
  • People who have recently changed partners, who have multiple concurrent sex partners, or who have had multiple partners since their last HIV test
  • Sexual and injecting partners of all the above groups of people, including those coming forward following contact tracing and the sexual and injecting partners of people known to be living with HIV
  • A reported high-risk exposure, including: unprotected sexual intercourse with a partner whose HIV status is unknown or a person diagnosed with HIV with a detectable viral load, the reported reuse of equipment used for skin penetration including for recreational drugs or cosmetic procedures such as tattooing or piercing
  • Individuals who report a history of incarceration
  • Individuals who have received care in certain health-care settings, such as services overseas where there may be poor infection control practices or where infection control breaches have been identified
  • People from high-prevalence countries (see table below), recently-arrived refugees, asylum-seekers and people who have arrived as humanitarian entrants or other refugee-like circumstances
  • People who have travelled to countries of high prevalence and engaged in risk behaviour/exposure, especially unprotected sex with a person not known to be HIV-negative
  • A health-care worker conducting exposure-prone procedures. See section 7.1 of this policy, The Australian Guidelines for the Prevention and Control of Infection in Healthcare 2019  and the Communicable Diseases Network of Australia (CDNA) policy on infected health care workers for more information. To meet CDNA guideline requirements, testing of health-care workers should be performed in accredited laboratories. Health-care workers should not perform or request tests for themselves, including laboratory tests; self-testing in any form does not meet CDNA testing requirements.
  • The following countries were recognised by UNAIDS to be high HIV prevalence countries (national HIV prevalence above 1%) between 2008-2017: 15
Sub-Saharan Africa

Angola

Benin

Botswana

Burkina Faso

Burundi

Cameroon

Central African Republic

Chad

Republic of the Congo

Djibouti

Ethiopia

Equatorial Guinea

Gabon

Gambia

Ghana

Guinea

Guinea-Bissau

Kenya

Lesotho

Liberia

Malawi

Mali

Mozambique

Namibia

Nigeria

Rwanda

Sierra Leone

South Africa

Swaziland

Tanzania

Togo

Uganda

Zambia

Zimbabwe

Americas

Bahamas

Barbados

Dominican Republic

Guyana

Haiti

Jamaica

Panama

Suriname

Trinidad and Tobago

Eastern Europe

Russian Federation

Ukraine

North Africa

South Sudan
Southeast Asia

Thailand

Clinical indicators

  • In the setting of contact tracing
  •  A patient**-initiated request to a health-care service for an HIV test
  • Patients admitted with recreational drug-related mental health conditions or mental health conditions leading to risk taking behaviour
  • Any patient admitted to a hospital with methamphetamine-related illness because of the high association of methamphetamine and related stimulant use reported among people who acquire HIV
  • Pregnant women (retesting should occur if there is ongoing acquisition risk during pregnancy)
  • People with particular medical conditions (please refer to the table below for a list of these indicators)
  • People who received a blood transfusion or blood from overseas in a context where safety of the blood supply and other human-derived tissues may not be assured
  • An individual who reports having a reactive or invalid result on an HIV point-of-care test, HIV self-test or an HIV test performed overseas
  • In the context of Post-Exposure Prophylaxis (PEP), subject to national and jurisdictional guidelines and policy17
  • As part of an initial and ongoing assessment for Pre-Exposure Prophylaxis (PrEP) or in the management of a patient taking PrEP18
  • HIV testing should be recommended in clinic-based settings servicing groups of known high HIV prevalence e.g. men who have sex with men, intravenous drug users, and migrants from high prevalence countries. The UK National Guidelines for HIV Testing (2008) recommend universal HIV testing in areas where the prevalence of HIV is above a threshold of 2:1000.14
  • Some jurisdictions have implemented programs to screen individuals presenting to emergency departments with symptoms that may indicate HIV infection, such as fever of unknown origin
  • The presence of any symptom or diagnosis which could be indicative of HIV infection (a so-called indicator condition*) when HIV would be in the differential diagnosis as underlying such a condition, especially opportunistic infections, or impact the way a disease is managed (such as tuberculosis [TB], or in a condition which shares a transmission route with HIV, such as any sexually transmissible infections [STI], hepatitis B [HBV] or hepatitis C [HCV]). See list below.

* Clinical indicator diseases for adult HIV infection (adapted from UK National Guidelines for HIV Testing 2008)

** For ease of reading, the term ‘patient’ is used throughout this document to refer to the person being tested and should be read interchangeably with the term ‘client’.


Table 1. Indicator conditions for HIV testing

 

AIDS-defining conditions

Other conditions where HIV testing should be offered

Sexually transmissible infections

 

Gonorrhoea, chlamydia, hepatitis B, hepatitis C, syphilis, or any other sexually transmissible infection

 

Respiratory infections

Tuberculosis

Pneumocystis

Recurrent bacterial pneumonia

Aspergillosis

Neurological diseases

Cerebral toxoplasmosis

Primary cerebral lymphoma Cryptococcal meningitis, Progressive multi-focal leukoencephalopathy

Aseptic meningitis/encephalitis

Cerebral abscess

Space occupying lesion of unknown cause

Guillain–Barré syndrome

Transverse myelitis

Peripheral neuropathy

Dementia

Leukoencephalopathy

Dermatological diseases

Kaposi sarcoma

Severe or recalcitrant seborrhoeic dermatitis

Severe or recalcitrant psoriasis

Multi-dermatomal or recurrent herpes zoster (shingles)

Gastroenterological diseases

Persistent cryptosporidiosis

Oesophageal candidiasis

Chronic oral candidiasis

Oral hairy leukoplakia

Chronic diarrhoea of unknown cause

Weight loss of unknown cause Nontyphoidal salmonella (bacteraemia, osteomyelitis and septic arthritis), recurrent enteric salmonellosis, shigellosis or campylobacter

Hepatitis B infection

Hepatitis C infection

Oncology

 

Non-Hodgkin lymphoma

Anal cancer or high grade anal squamous intraepithelial lesion

Penile cancer

Seminoma

Human papillomavirus-related head and neck cancer

Hodgkin lymphoma

Castleman disease

Gynaecology

Cervical cancer

Vaginal, vulval or cervical or high-grade intraepithelial lesion

Haematology

Any unexplained blood dyscrasia including:

·         thrombocytopenia

·         neutropenia

·         lymphopenia

Ophthalmology

Cytomegalovirus retinitis

Infective retinal diseases including herpesviruses and toxoplasma

Ear, Nose and Throat

Lymphadenopathy of unknown cause

Chronic parotitis

Lymphoepithelial parotid cysts

Other

Mononucleosis-like syndrome (primary HIV infection)

Pyrexia of unknown origin

Any lymphadenopathy of unknown cause

Any sexually transmissible infection