Compared to other countries, HIV testing rates in Australia are high. However, recent modelling and behavioural samples suggest that between 10 and 20% of people in Australia living with HIV have not yet been diagnosed. The National HIV Strategy 2010-2013 recognises that improving access to, and the uptake of, testing is important to reduce late diagnosis of HIV.
Australian HIV testing is governed by the 2011 National HIV Testing Policy (which is aligned with the National HIV Strategy 2010-2013). The policy is reviewed regularly.
The key principles guiding HIV testing are that:
- testing is demonstrably of the highest possible standard and timely
- testing should be voluntary and performed with informed consent
- test results will remain confidential (i.e. only the person being tested and the person providing the results will be entitled to information necessary to identify the individual result). Exceptions to this principle are identified in the Policy.
- testing must be accessible to all those at risk of HIV infection
- testing is critical to the interruption of transmission on a population level
- testing is of benefit to the person being tested and a critical trigger to initiating interventions including treatment
- testing is critical to understanding the epidemiology of HIV infection in the community
- anonymous testing should be available to individuals, subject to the need to obtain sufficient demographic information from those being tested to allow accurate aggregate information to contribute to surveillance
HIV testing is indicated in various contexts. A full list of indications for HIV testing are found at testingportal.ashm.org.au/hiv/indications-for-hiv-testing.
Voluntary confidential testing is the standard form of service delivery for HIV testing. Circumstances in which mandatory testing is currently permitted under separate policy or legislation include:
- as a condition of blood, tissue and organ donation
- under the migration Health Requirements applicable to specified visa subclasses
- as a condition for entering training or service in the armed forces
- as a condition for purchasing some types of insurance
- in the context of a legal instruction including in forensic or coronial settings
- in rare circumstances when a person’s behaviour is considered a risk to public health (see Management of People with HIV who Place Others at Risk
Informed consent for testing means that the person being tested understands HIV testing procedures, the reasons for testing and the personal implications of testing before agreeing to be tested. Informed consent is required for HIV testing, except for rare occasions when a legal order is made for compulsory testing or in emergency settings.
Point-of-Care (Rapid) and Home Based HIV Testing
Until recently, (rapid) point-of-care tests have been available as supplementary tests in laboratory settings but not as standard screening tests in clinical settings. Given renewed commitments to raise HIV testing rates and a growing awareness that point-of-care tests are available in most developed countries, community advocacy has recently triggered a revisiting of point-of-care testing policy.
During 2012, point-of-care HIV testing trials have been held in Sydney, Melbourne and Brisbane. Decisions on further rollout of rapid testing and TGA approval of rapid testing products for use in clinical and community setting are pending.
The 2011 National HIV Testing Policy outlines conditions under which point of care testing may be offered. These include the requirement that sites offering point of test care must be accredited. The 2011 National HIV Testing Policystresses that HIV testing in Australia should always be performed in a clinically supervised context, where there is an appropriate level of interaction between the individual being tested and a suitably qualified health professional.
Home based HIV testing is not supported. HIV home-testing kits from international suppliers are currently available over the internet. Their use is being monitored through social research, anecdotal reports and observation.
Changes in technology and knowledge base in this area are occurring rapidly. The National HIV Testing Policyis undergoing regular review to retain currency in this area. For further information on HIV Testing see 2011 National HIV Testing Policy.
For a useful overview of considerations and techniques when undertaking an HIV risk assessment see: Talking with the patient: risk assessment and history-taking In: HIV, viral hepatitis and STIs: a guide for primary care (ASHM, 2008).
Failure to follow up positive test results
Having plucked up the courage to have an HIV test, some people may feel fearful so may not contact their doctor to find out their results. It is vital that doctors check that their patients receive test results. Not doing so limits the person’s access to early appropriate treatment and may result in a finding of negligence (see case of Kite v. Malycha below). Not doing so may also lead to harm to third parties. For example, in a 2009 Canadian case, a man was convicted of four counts of having unprotected sex with four women between 2001 and 2005. During the trial he vigorously denied knowing he was HIV positive until late 2004. He testified that he had had six negative HIV tests in Zimbabwe, and also medical tests to facilitate his migration to Canada, believing they included an HIV test. They did not. A few months after arriving in Canada in 2001, the man was tested for HIV. He testified that when the clinic phoned him, they told him his results were ‘fine’ but he needed to come in for counselling. The man understood 'fine' to mean he did not have HIV. He did not go for counselling so did not receive his test result: he had tested positive for HIV. The man later had another test and learned he was HIV positive. He testified that from the time he learned he was HIV positive, the women knew he was HIV positive or they practised safe sex. This case exemplifies the simple scenario that if people are not informed of their HIV status they may place others at risk. It also reiterates the key point that doctors have a duty to follow up a positive test result. Clearly, it is important to have systems in place to facilitate the active follow-up of patients, for example, identifying instances when patients do not return to receive test results, which should trigger phone or other contact with the patient. It is not sufficient for health care providers to leave it to the patient to decide whether or not to come back. (The Australian case of BT v Oei while not referring to HIV, similarly raises the importance of following up test results – see Duty of Care to Third Parties and Civil Liability)
Negligence - Failing to relay test results
In the case of Kite v Malycha (1998) 71 SASR 321, Justice Perry found a surgeon negligent for not informing a patient that a fine-needle aspiration biopsy of a breast lump showed cancer cells. The surgeon did not have a system for detecting that the patient had not received the test result. Part of his defence was that the patient did not follow his advice to phone for the result in a few days and return for review in a few weeks. However, Justice Perry stated in his judgement that: ‘[Mrs Kite] was entitled to assume that if the outcome of the testing of the biopsy gave cause for concern, she would be informed’. Thus he rejected an argument that Mrs Kite contributed to or caused her own damage through her failure to carry out the surgeon’s advice regarding follow-up. Because testing for HIV antibody status is largely anonymous (that is, the blood sample is often sent without patient identification but with a code assigned by the referring doctor), the judgement in Kite v Malycha establishes that doctors have a duty to follow up abnormal test results and therefore must have systems in place to enable them to do so.
In a more recent case (2009), two medical practitioners admitted liability before the NSW Supreme Court after failing to inform a woman of her ‘indeterminate’ HIV test results. The medical centre sent a letter asking her to return for further testing but the letter was sent to an old address. The woman was contacted by phone some three weeks later but had infected her partner in the interim. A settlement of more than $700,000 was paid to her partner (see further details in Duty of Care to Third Parties).
Note: in some instances a patient may request anonymous testing or may refuse to give contact details (or provide false contact details). This should not preclude access to HIV testing. Instead, the practitioner should stress the importance of the patient’s attending to receive the results.
For more information on clinical manifestations of HIV, see Giles M, Workman C. Clinical manifestations of HIV disease. In: Hoy J, Lewin S. Post JJ, Street A. HIV Management in Australasia: a guide for clinical care. Darlinghurst: Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine2; 2009.
1In law, the term ‘consent’ includes the requirement that a person had full knowledge of key issues before making a decision, so consent cannot be given unless it is ‘informed’. The term ‘informed consent’ is used in the National HIV Testing Policy to stress practitioners’ role in providing the information that may or may not facilitate a patient giving consent.
2Giles M, Workman C. Clinical manifestations of HIV disease. In: Hoy J, Lewin S. Post JJ, Street A. HIV Management in Australasia: a guide for clinical care. Darlinghurst: Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine; 2009. Available at http://www.ashm.org.au/images/Publications/Monographs/HIV_Management_Australasia/hiv-management-mono_WHOLE.pdf