Conveying Positive HIV Test Results: Features of a Good Diagnosis (a guide for health practitioners)
Summary
A brief guide for health practitioners when conveying an HIV positive result, including when encountering challenging cases.
The process of conveying an HIV test result to the person being tested, irrespective of the specific result, is affected by the type of test performed, the setting of the consultation and testing and extent, if any, of additional testing required to determine the true HIV status of the person. The person who requests the test is responsible for ensuring that appropriate mechanisms are in place for delivering the test results.
Some laboratories provide information for the diagnosing practitioner to contact a more experienced clinician to discuss the procedure of giving a positive test result at the time the results of confirmatory testing are forwarded. Following notification by a laboratory of an HIV-positive test result, practitioners in New South Wales (NSW) will receive support from officers of the NSW Ministry of Health to assist in this process, and referral of the patient to specialist care if required. Any practitioner can use the resources listed below if they require support in this situation.
The first step to take before delivering an HIV-positive result is to check that the result has been confirmed as a true positive on confirmatory testing by a reference laboratory. Check with the laboratory if you are unsure if this has occurred.
A positive result should ideally be provided in person by asking the patient to return for the result as soon as possible. Some sexual health clinics have recently commenced delivering positive results over the phone where a patient has declined to re-attend the clinic quickly. Practitioners should use clinical discretion balancing the risk of not conveying test results when considering alternate communication methods.
Conveying a confirmed positive result – in the context of conventional testing
A positive test result has significant implications for an individual and their clinician. A positive result may result in considerable distress for an individual. The discussion when conveying a positive result should include:
• Giving the test result in person and in a manner that is sensitive and appropriate to the gender, culture, behaviour and language of the person who has been tested
• Providing information about HIV infection and the benefits of early treatment to prevent illness and reduce the risk of transmission to others.
• Providing an opportunity to immediately commence the patient on treatment if at an HIV service or rapid referral to such a service
The discussion when conveying a positive result should include:
• Giving the test result in person and in a manner that is sensitive and appropriate to the gender, culture, behaviour and language of the person who has been tested
• Providing information about HIV infection and the benefits of early treatment to prevent illness and reduce the risk of transmission to others.
• Providing an opportunity to immediately commence the patient on treatment if at an HIV service or rapid referral to such a service
• Providing contact tracing and partner notification strategies, and whether there are any recent contacts of the person (within 72 hours of sexual contact) who would benefit from HIV post-exposure prophylaxis (PEP)
• Assessing support mechanisms of the person and offering immediate referral to a support agency, or information to facilitate access at the person’s discretion
• Arranging appropriate referral for HIV-specific medical care
• Discussing legal obligations relevant to the local jurisdiction about disclosure of HIV status (see ASHM’s Guide to Australian HIV Laws and Policies for Healthcare Professionals)
• Discussing transmission of HIV and how onward transmission may be prevented, including pre-exposure prophylaxis (PrEP) for HIV-negative partners
• Offering a timely follow up appointment.
People who are given a new diagnosis often have difficulty absorbing information in the initial consultation. It is usually necessary to cover the issues above over a period of time and subsequent consultation, or referral to specialist care should be offered in a timely manner at the time of diagnosis.
Challenging cases
Indeterminate results
A small number of patients will have indeterminate results with conventional testing, where the presence or absence of infection is not established. Such a result may represent infection that cannot be definitively diagnosed at the point in time the test was performed or may represent non-specific test reactivity.
Patients unconvinced by a negative or positive result
Patients who fall into this category can be time consuming and may have psychological issues that need to be addressed. Assistance in dealing with these patients can be obtained from specialist services and the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine who can offer help to refer a patient in this predicament to an alternative service for a second opinion.
Patients who do not return for positive test results
These patients can place others at risk if they do not know their status. It is important to try to actively contact these patients. Clinicians should use discretion when relaying results by phone to the individual or in written correspondence. The request should be for the individual to re-contact the testing service.
The decision to stop trying to follow up a patient can be a difficult one. Attempts to contact patients should be documented in the patient’s file. General practice, in particular, may have limited capacity to perform patient follow-up and general practitioners should pass this responsibility to the local public health unit if they have exhausted their resources.
The RACGP Standards for General Practices provides guidelines for follow-up of pathology results that should be referred to.
Post-mortem testing
HIV tests are not standardised in the post-mortem setting. A pathologist undertaking HIV testing as part of the process of a coronial examination or other post-mortem examination is responsible for ensuring that the other provisions of this policy are adhered to, including notification and contact tracing. Mortuary staff may need assistance in approaching contact tracing and this can be provided by public health units and sexual health clinics.