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 35 million people living with human immunodeficiency virus (HIV) in 2013.

Sub-Saharan Africa remains the area most heavily affected by the HIV epidemic. Almost 1 in every 20 adults is living with HIV in this region.

In 2013, there were 6,151 people (4,611 men and 1,540 women) newly diagnosed with HIV in the UK, of whom an estimated 41% acquired their infection through heterosexual contact and 55% through sex between men.

The large majority of black-African people living in the UK do not have HIV. However, in 2013 approximately two-thirds of all heterosexual people living with HIV were black-African.

By the end of 2014, there were an estimated 103,700 people living with HIV (both diagnosed and undiagnosed) in the UK, and the HIV prevalence among those aged 15 to 44 years was estimated to be 2.3 per 1,000 population (2.8 per 1,000 men and 1.7 per 1,000 women). Approximately 17% of those living with HIV were estimated to be unaware of their infection.

A method to assign probable country of infection suggests that 59% of all heterosexuals diagnosed in 2014 acquired their infection in the UK, up from 52% in 2010. This highlights the need for further prevention efforts within the UK, particularly among black African communities.

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 men who have sex with men is ongoing in the UK, and remains substantial.

For some men who have sex with men, 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’.

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 2008, the British HIV Association published ‘UK National Guidelines for HIV Testing’.

The following text is based on the report and updated with the 2011 NICE guidelines for expanded testing among the black African community and among men who have sex with men.

Who should be offered a test?

Where the diagnosed HIV prevalence in the local population exceeds 2 in 1000, offer and recommended an HIV test to:

  • all men and women newly registering in general practice regardless of country of origin
  • all general medical admissions
  • anyone having blood tests (regardless of reason) in primary or secondary care

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%)

  • 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 pregnant women

  • all patients presenting for healthcare where HIV, including primary HIV infection, enters the differential diagnosis (table of indicator diseases [UK National Guidelines for HIV Testing 2008, page 7] and primary HIV infection [UK National Guidelines for HIV Testing 2008, page 13]). Typical symptoms of primary HIV infection include a combination of any of:
    • fever
    • rash (maculopapular)
    • myalgia
    • pharyngitis
    • headache / aseptic meningitis
  • all patients diagnosed with a sexually transmitted infection
  • 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 a sexually transmitted infection

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

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 sexually transmitted infections (STIs).

Screening for HIV should be offered to all pregnant women to reduce the rate of mother to child transmission. 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 sexually transmitted infections (STIs) including HIV, and to reduce the rate of under 18 conceptions, especially among vulnerable and at risk groups.

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.

Resources

NHS Choices: HIV

Patient UK leaflet HIV and AIDS information

National Travel Health Network and Centre (NaTHNaC) STI leaflet

Terrence Higgins Trust (THT) publications

Mambo: the healthier lifestyle magazine for Africans has a specific section about HIV.

Positively UK magazine provides peer-led support, advocacy and information for women, men and young people living with HIV.

NAM patient information booklets are available online to download.

The NAM website provides resources in Arabic, Czech, Dutch, French, German, Hebrew, Italian, Norwegian, Polish, Portuguese, Romanian, Russian, Somali, Spanish, Swedish, Thai and Turkish.

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

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

HIV: diagnosis and care in general practice

HIV: diagnosis and care in general practice

HIV: diagnosis and care in general practice training video from HPA migrant health event 12 November 2012

AVERT has contact details for local HIV/AIDS services available in the UK.

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

The Medical Foundation for AIDS & Sexual Health (MedFASH) is a UK based charity which works with policy-makers and health professionals, supported by the British Medical Association.

MedFASH publishes HIV for non-HIV specialists, Diagnosing the undiagnosed: for healthcare professionals working in secondary care who aren’t HIV specialists to help improve their skills and confidence in diagnosing HIV.

HIVinsight provides e-tutorials for nurses, an online educational initiative which has been developed by the National HIV Nursing Association (NHIVNA)

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

Published 31 July 2014