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 Healthcare Workers (located in chapter: Testing in Specific Populations), 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 2008-2020: ⁴⁰

Sub-Saharan Africa

Angola

Benin

Botswana

Burkina Faso

Burundi

Cameroon

Central African Republic

Chad

Côte d'Ivoire

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

Belize

Dominican Republic

Guyana

Haiti

Jamaica

Panama

Suriname

Trinidad and Tobago

Eastern Europe

Russian Federation

Ukraine

North Africa

South Sudan

East Africa

Mauritius

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 (download here)

	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

Although HIV-related stigma and discrimination still exists in many settings, treatment for HIV is highly effective. With treatment, people living with HIV can expect a normal or near-normal life expectancy. Failure to diagnose HIV can result in serious illness and onward transmission to others. HIV testing should be offered in conjunction with STI and viral hepatitis screening to all patients who have had any risk exposure such as partner change or injecting drug use, and identification of a new clinical indicator condition (as defined in Table 1 above). The absence of an identified epidemiological or behavioural risk factor should not preclude HIV testing in appropriate clinical circumstances (see the previous section Indications for HIV Testing for a list of HIV indicator conditions). Obtaining a detailed history is not a prerequisite for testing, especially in the context of an individual request to be tested or another clear indication for testing such as the presence of an indicator condition. HIV testing should be routinely offered to pregnant women as part of the suite of screening tests performed in the first antenatal visit.

Inclusion of HIV in a differential diagnosis of a number of clinical conditions will help normalise HIV testing. All attempts should be made to access existing clinical data to facilitate the identification of HIV in those people with HIV infection who are undiagnosed.

The use of pathology results or hospital admission data should be considered to identify indicator diseases and raise greater awareness among clinicians treating diseases that might suggest HIV. See section Indications for HIV Testing for a list of HIV indicator conditions.

Where feasible during service planning or revisions, electronic clinician support tools should be automated to prompt testing when indicators for HIV arise.

Individuals may seek testing because they have been contacted as a person who may have been at risk of exposure to HIV. Most facilities conducting contact tracing establish a communication wall between the identity of the source patient and the contact (see also section Contact tracing and partner notification).

These patients are a priority for testing and should be afforded prompt access to testing. They may be unaware of their potential exposure and may have additional needs for counselling and information. They should be tested using a standard laboratory test in addition to any point-of-care test.

There may be circumstances where, on public health grounds (e.g. prevalence studies), anonymous delinked testing is legitimately performed in accordance with this policy. Such testing should occur only where there is compelling scientific justification, and ethical and administrative approval (see section Surveillance and Research). Those responsible for the project should consider making test results available on a confidential basis to participants who wish to receive their results. These studies must be independently judged by an ethics committee constituted in accordance with the National Health and Medical Research Council’s (NHMRC) National Statement on Ethical Conduct in Human Research.

HIV prevalence studies conducted before 2010 with gay and bisexual men in Australia found high levels of undiagnosed HIV (20-31%) but could not provide test results to participants because they took part anonymously.^19,20 More recent community-based prevalence studies have given participants the choice of receiving their test results, consistent with ethical obligations and international guidelines.^21,22

Recent prevalence studies with gay and bisexual men have found declining levels of undiagnosed HIV (< 10%) but have experienced difficulty in recruiting participants due to increasing levels of HIV testing and PrEP use in the population.^20,23,24 International guidelines suggest that bio-behavioural prevalence studies should only be conducted in populations with the highest HIV prevalence, with a minimum sample size of 500, and these studies should provide results quickly to participants.²¹

Mandatory screening refers to situations where people may not participate in certain activities or roles, or access certain services unless they agree to be screened. Circumstances in which mandatory screening is currently required under separate policy or legislation include:

as a condition of blood, tissue and organ donation
as a mandatory part of the health requirement assessment for specified visa subclasses
as a condition for entering training or service in the armed forces
as a condition for purchasing some types of insurance.

Compulsory testing refers to situations where a person has no choice in being tested, e.g. as directed under a public health order, or as authorised under legislation (e.g. in the context of a forensic or coronial inquiry, or under legislation in some jurisdictions that allows for forced testing of individuals accused of certain offences). While mandatory or compulsory testing may be performed in some situations, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) do not support mandatory or compulsory testing of individuals on public health grounds.²⁵

The processes involved in securing a sample and conveying an HIV test result, in the context of mandatory and compulsory testing, should be in accordance with the relevant enabling legislation and the principles in this policy and basic human rights pertaining to privacy of health information to the extent these rights do not contradict existing legislation. Situations deemed necessary to impose mandatory or compulsory screening should be closely scrutinised from an evidence-based perspective on a regular basis to ensure that decision-making guidelines are adequate, and that the breach of the principle that testing be voluntary is still warranted. There may be an extra need for psychosocial support for the person tested in such a circumstance. The decision to use a laboratory or non-laboratory-based test will be a decision for the agency requiring the test to be performed, based on any practical considerations (see section Testing in prisons). However, in situations where testing is being undertaken to exclude transmission of HIV, the most sensitive available laboratory test (i.e. tests that directly detect the HIV virus) rather than antibody tests such as antigen or nucleic acid tests, would be recommended.

The Communicable Diseases Network Australia (CDNA) has produced a Series of National Guidelines (SoNGs) on the public health management of HIV. The SoNGs outline management of individuals with HIV infection and generally outline indications for testing: National Guidelines for Managing HIV Transmission Risk Behaviours 2018. Individuals identified as contacts of a source patient may require special assistance as they may be unaware of their risk of exposure. SoNGs are endorsed by the Australian Health Protection Principal Committee (AHPPC) which provides advice and recommendations to the Australian Health Ministerial Advisory Council.