Guidance

HIV: migrant health guide

Advice and guidance on the health needs of migrant patients for healthcare practitioners.

Main messages

Primary healthcare practitioners have an important role in:

  • the prevention and control of HIV infection in the population, through encouraging at risk groups to test for HIV infection, sexual health promotion, and management of other sexually transmitted diseases
  • supporting people living with HIV through long-term treatment

In the UK late diagnosis (CD4 cell count below 350 cells/mm3 within 3 months of first diagnosis) is the most important factor associated with HIV-related morbidity and mortality.

Offer and encourage HIV testing for patients who may be at increased risk of infection in a wide range of settings, including GP surgeries and A&E departments.

Offer and recommend a HIV test to all men and women:

Testing for HIV and associated pre- and post- test counselling are exempt under the National Health Service (Charges to Overseas Visitors) Regulations 2011.

HIV treatment is also free of charge.

Background

Globally, there were an estimated 38 million people living with human immunodeficiency virus (HIV) in 2020.

Sub-Saharan Africa remains the area most heavily affected by the HIV epidemic. Two-thirds of people living with HIV reside in this region.

In 2019, there were 4,139 people (3,000 men and 1,139 women) newly diagnosed with HIV in the UK, of whom an estimated 38% acquired their infection through heterosexual contact and 41% through sex between men.

The large majority of Black African people living in the UK do not have HIV. However, in 2018, approximately 56% of all heterosexual people living with HIV were Black African.

In 2018, there were an estimated 103,800 people living with HIV (both diagnosed and undiagnosed) in the UK, and the HIV prevalence among those aged 15 to 74 years was estimated to be 2.3 per 1,000 population. Approximately 7% of those living with HIV were estimated to be unaware of their infection.

A method to assign probable country of infection suggests that 34% of all heterosexual individuals diagnosed in 2018 acquired their infection in the UK, down from 59% in 2014.

New diagnoses are difficult to interpret in isolation but considered alongside data on recently acquired infections and incidence estimates, it is evident that transmission of HIV among gay and bisexual men (GBM) has declined significantly but remains ongoing.

For some GBM, migration may partly be a way to better accommodate their sexuality. This demonstrates the need for sexual health promotion among non-UK born people at risk of HIV in the UK.

HIV disrupts normal immune function by infecting and destroying cells which are vital in coordinating an immune response (specifically CD4+ T cells). This makes the body increasingly susceptible to opportunistic infections.

When a person living with HIV presents with particular indicator diseases they are said to have progressed to AIDS (Acquired Immune Deficiency Syndrome).

Without appropriate highly-active antiretroviral therapy (HAART), HIV infection usually progresses to AIDS in an average of 10 years, although this time period is highly variable.

With HAART, good health can be maintained for many years and the development of major opportunistic infections avoided.

See HIV: surveillance, data and management for more information.

Transmission

HIV can be passed on through:

  • infected blood
  • semen
  • vaginal fluids
  • breast milk

The most common routes of transmission are:

  • sexual transmission
  • sharing or use of contaminated equipment during injecting drug use, tattooing and body piercing
  • mother to child transmission during birth or breastfeeding
  • needlestick or other sharps injuries
  • receipt of infected blood or blood products (for example, clotting factors) in countries where screening does not take place or is inadequate (all blood and blood products are now screened in the UK)

Testing

In 2020, the British HIV Association updated the UK National Guidelines for HIV Testing.

The following guidance is based on the report and updated with the 2016 NICE guidelines for expanded testing among people who may have undiagnosed HIV.

Who should be offered a test?

Where the diagnosed HIV prevalence in the local population exceeds 2 in 1,000, offer and recommend an HIV test to:

  • all men and women newly registering in general practice regardless of country of origin
  • anyone having blood tests (regardless of reason) in primary or secondary care who has not had an HIV test in the previous year
  • individuals in areas of extremely high prevalence, based on clinical judgement

Offer and recommend HIV testing routinely to the following patients (irrespective of the prevalence of HIV in the local population):

  • all men and women known to be from a country of high HIV prevalence (>1%), including recently-arrived children

  • all men and women who report sexual contact abroad or in the UK with individuals from countries of high HIV prevalence – see the country pages of the guide

  • all patients presenting for healthcare where HIV, including primary HIV infection, enters the differential diagnosis (table of indicator diseases and primary HIV infection – typical symptoms of primary HIV infection include a combination of any of:
    • fever
    • rash (maculopapular)
    • myalgia
    • pharyngitis
    • headache / aseptic meningitis
  • all patients diagnosed with or who request testing for a sexually transmitted infection (STI)
  • all sexual partners of men and women known to be HIV positive
  • all men who have disclosed sexual contact with other men
  • all female sexual contacts of men who have sex with men
  • all patients reporting a history of injecting drug use
  • all those who may be at risk of exposure to the virus - this may be as a result of having a new sexual partner or because they have previously tested negative during the ‘window period’
  • all men who have not previously been diagnosed HIV positive, and who:
    • register in a practice in an area with a large community of men who have sex with men
    • are known to have sex with men and have not had an HIV test in the previous year
    • are known to have sex with men and disclose that they have changed sexual partner or disclose high risk sexual practices
    • request screening for an STI
  • infants and children with HIV-positive parents and/or siblings

Who can test?

Any doctor, midwife, nurse or trained healthcare worker should be able to obtain consent and conduct an HIV test.

Pre-test discussion

The primary purpose of pre-test discussion is to establish informed consent for HIV testing. Lengthy pre-test HIV counselling is not a requirement unless a patient requests or needs this. The essential elements that the pre-test discussion should cover are:

  • the benefits of testing to the individual
  • details of how the result will be given

It is important to be sensitive to cultural and religious beliefs when challenging stigmas and dispelling misconceptions surrounding HIV and HIV testing. Further guidance on what staff offering HIV tests should do are provided in NICE guidelines.

Some patients may need additional help to make a decision, for example, because English is not their first language. It is essential to ensure that these patients have understood what is proposed, and why.

It is also important to establish that the patient understands what a positive and a negative result mean in terms of infection with HIV as some patients could interpret ‘positive’ as good news.

Post-test discussion for individuals who test HIV positive

As is good clinical practice for any situation where you must convey bad news, the result should be given face to face in a confidential environment and in a clear and direct manner. If a patient’s first language is not English, consider using an appropriate confidential interpretation service.

If a positive result is being given by a non-genito-urinary medicine / HIV specialist, it is essential, prior to giving the result, to clarify local specialist services, and establish a clear pathway for onward referral.

Any individual testing HIV positive for the first time needs to see a specialist (HIV clinician, specialist nurse, sexual health advisor or voluntary sector counsellor) at the earliest possible opportunity, preferably within 48 hours and certainly within two weeks of receiving the result.

For full guidance see UK national guidelines for HIV testing and the 2011 NICE guidance on expansion of HIV testing:

Treatment

In the UK, HIV is generally managed by secondary care HIV physicians (usually genito-urinary medicine or infectious disease specialists depending on local arrangements).

Care pathways encourage the early start of combination antiretroviral therapy.

The role of the primary care practitioner is to encourage people at risk to be tested and to promptly refer those found to be positive. People living with HIV may also require primary care support through their long term treatment. The GP may need to work closely with the secondary care team in prescribing for non-HIV-related conditions.

Guidelines are available for the immunisation of HIV infected adults.

For other guidelines please refer to:

For guidelines on HIV-associated malignancies:

Prevention and control

Prevention of the spread of HIV infection relies on sexual health promotion, testing and treatment of at risk groups for HIV, and testing and treatment for other STIs.

Screening for HIV should be offered to all pregnant women to reduce the rate of mother to child transmission according to the NHS Infectious Diseases in Pregnancy Screening Programme. HIV-positive mothers should be counselled about breastfeeding. The primary care practitioner has an important role to play in all these aspects.

Guidance

NICE recommendations on one to one interventions to reduce the transmission of STIs including HIV.

NHS Infectious Diseases in Pregnancy Screening Programme Prevention of HIV transmission through breastfeeding: position statement supersedes the 2004 guidance from EAGA on HIV and infant feeding.

The latest guidance on post-exposure prophylaxis for HIV is published by the BHIVA.

HIV guidance for children is published by the CHIVA.

Resources

The NHS website has information on HIV and AIDs.

Patient.info leaflet on HIV and AIDS.

Country-specific HIV information is available from UNAIDS, WHO and the ECDC (for European countries). Country-specific guidance is also provided in the country pages of the Migrant Health Guide.

National Travel Health Network and Centre (NaTHNaC) information on HIV and AIDS and STIs.

The Terrence Higgins Trust (THT) has a wide range of publications and resources about HIV and to support HIV-positive individuals.

The NAM website provides resources in 24 languages. NAM patient information booklets are available online to download.

The NAZ Project London (NPL) provides free resources for service providers.

The National AIDS Trust is the UK’s leading HIV policy charity dedicated to transforming the UK’s response to HIV.

AVERT a range of resources aimed at patients and the public and professionals.

The British Association for Sexual Health and HIV (BASHH) is a professional representative body for those practising sexual health, including the management of STIs and HIV in the UK.

Sexual health, asylum seekers and refugees: a handbook for people working with refugees and asylum seekers in England published by the Family Planning Association.

The Zanzu website provides simple information on contraception, STIs, pregnancy, relationships and sexuality available in Albanian, Arabic, Bulgarian, Dutch, English, French, German, Polish, Romanian, Russian, Spanish, Turkish.

HIV: diagnosis and care in general practice webinar session from 2013.

Published 31 July 2014
Last updated 14 September 2021 + show all updates
  1. Updated prevalence statistics and testing guidance.

  2. Added link to new translated resources.

  3. First published.