1. 11Kai Tiaki Nursing New Zealand * vol 22 no 6 * July 2016
practice
Making HIV
testing routine
New Zealand has a good record of successfully
treating people diagnosed with HIV and has a low
rate of infection compared to other countries. But
reaching the undiagnosed remains a challenge.
By James Rice-Davies
U
ntil there is a cure or a vaccine for the
human immunodeficiency virus (HIV),
all health professionals have a role in
reducing the numbers of people infected with
it. The success of agencies such as the New
Zealand AIDS Foundation and the Prosti-
tutes Collective, and of the Needle Exchange
Programme means many health-care workers
(HCWs) nowadays may be unfamiliar with HIV
or are afraid to suggest testing.
HIV testing needs to be normalised to
reduce the spread of infection. The HIV test is
cheap and easy to carry out, and allows rapid
access to treatment.
I trained as a mental health nurse, then
as a general nurse, in the United Kingdom in
the mid to late ‘80s. I began working at the
then St Stephen’s Hospital in London in 1987,
which had set up a large unit for AIDS care.
Emotionally, it was one of the hardest areas I
have ever worked, but it also felt a privilege.
I am now the clinic nurse specialist for HIV
at Capital & Coast District Health Board. One
of my main aims is to reduce the barriers that
prevent HCWs from thinking about, and recom-
mending HIV testing.
Caring for patients with HIV
HIV care in New Zealand began 30 years ago.
There have been more than 4500 cases of HIV
infection diagnosed during this time and 1000
deaths recorded. Around 2500 patients are
still receiving care.1
Figure 1 on p12 shows the positive effect
of antiretroviral (ARV) treatment on one local
patient. When he presented to Wellington
Hospital in 1998, he had almost no detectable
CD4 cells (T Helper cells). Improvement has
continued for years on treatment. However,
better and quicker immune recovery usually
occurs with earlier diagnosis and treatment.
This reduces the level of HIV viral load (VL) to
undetectable levels in the
blood. CD4 cells are the
“conductor of the immune
system” and unfortunately
have the right receptor
for the HIV RNA virus to
“dock” onto. The virus then
uses the DNA inside the
CD4 cell to replicate and,
in doing so, slowly de-
stroys the immune system’s
normal function, leaving
the patient immunocom-
promised.
Patients with HIV usually
access care via an out-
patient setting, such as
infectious disease (ID) de-
partments or sexual health
clinics. This may be part
of the reason why HIV has
low Peter Saxon on gay men’s health, or men
who have sex with men (MSM), estimate that
approximately 6.5 per cent of the gay commu-
nity in Auckland has HIV and another 1.5 per
cent are undiagnosed.3
This indicates one MSM
out of every 20 has HIV infection. In Sydney,
the number of MSM estimated to have HIV is
one in five. I have not discussed HIV testing
for intravenous drug users in New Zealand,
as this group has more problems relating to
hepatitis C infection than HIV infection, but
HIV testing should not be forgotten for this
group of patients either.
Scenarios at Wellington Hospital
Recently – on the same day and within 10
minutes of each other – I witnessed two com-
pletely opposite scenarios at Wellington Hos-
pital. I was waiting in the medical assessment
and planning unit (MAPU) to give a positive
HIV result to a patient who had had an HIV
test added to his initial blood requests. This
was because an astute laboratory scientist had
suggested to the admitting medical team that
become a forgotten infection in some other
health-care settings. The advent of effective
HIV ARV treatment over the last 15 years gives
most patients an almost normal life expec-
tancy in developed countries. Many clinical
staff are aged under 30 and have never seen a
patient with an HIV-related illness.
The successful treatment of HIV may have
left other HCWs deskilled and lacking knowl-
edge and understanding about testing. I have
been alarmed when newly-diagnosed patients
have told me how the person giving the HIV
result informed them, wrongly, that they now
had less than five years’ life expectancy. I
have also had phone calls from HCWs asking
how to protect people sharing the same house
as a person with HIV. Those sharing the house
were not even sexual partners of that person.
This highlights the general lack of HIV under-
standing and how it is transmitted.
The greatest number of HIV cases in New
Zealand is in Auckland, where there are ap-
proximately 1000 patients. Studies carried out
by University of Auckland senior research fel-
Tonya Booker, devoted partner and mother, died from undiagnosed HIV
in 2014. She had carried the virus for 12 years and had never once been
tested. Earlier this year, the national support organisation for women
and families living with HIV and AIDS, Positive Women, launched a cam-
paign advocating that HIV testing be included in all routine diagnostic
procedures.

2. 12 Kai Tiaki Nursing New Zealand * vol 22 no 6 * July 2016
practice
HIV should be added to the other requested
tests.
The 68-year-old patient had already been
discharged after a brief admission, but he
agreed to have another test added and the
medical team had asked me to be present
when they called him back to discuss his
results. I was able to offer support to the pa-
tient and family, with clear information about
a nearly normal life expectancy, with minimal
side effects of treatment, and discuss testing
of sexual partner(s). Partner notification is an
important part of HIV care, in the interest of
public health, to reduce spread of infection
and enable early access to treatment.5
As I waited in the staff-only area, a nurse,
not knowing who I was, or any of the above,
suggested to one of the doctors that a young
man with a recent history of more than 10kg
weight loss, enlarged lymph glands and
fatigue, should be screened for HIV as part
of his blood work-up. This suggestion was
dismissed and the test not carried out, as the
registrar said he knew what was wrong with
the patient. He then went to “clerk in” the
patient, thereby missing an opportunity for
HIV screening.
I went back to MAPU the next day to discuss
the decision not to test the patient and dis-
covered the nurse had never cared for anyone
with HIV but had thought this might be a dif-
ferential diagnosis for the patient. She asked
me if her thinking process had been incorrect.
I explained why I had been in MAPU and how
I believed this type of thinking was so impor-
tant. I also asked the medical team that had
carried out the HIV test on the other patient,
to discuss the case as a team and include the
registrar in the discussion, in the hope of rais-
ing awareness about the importance of more
routine HIV screening.
Comparisons with other countries
Since the epidemic began, HIV infection rates
in New Zealand are half that of Australia and a
third less than the United States and Europe.
Tangata whenua are under-represented in HIV
infection rates, which is a change from their
usual health statistics. Saxton has produced
several studies around the rate of condom use
in gay men in New Zealand and how this has
reduced the rates of HIV, with less HIV per
capita compared to other developed coun-
tries.4
The work of non-government organisa-
tions such as Boby Positive, the Prostitutes
Collective, INA Indigenous HIV/AIDS Founda-
tion, Positive Women and the New Zealand
AIDS Foundation, and of the Needle Exchange
Programme has helped achieve this low rate.
This is something New Zealand can be proud of.
Undiagnosed HIV cases
There are a number of people in New Zealand
with undiagnosed HIV infection who are not
seeking testing and who are unknowingly
putting others at risk through their sexual
behaviour. The number of undiagnosed HIV
cases is estimated at 20 per cent.2
This means
there are approximately 600 undiagnosed
cases of HIV in New Zealand. These people will
become unwell from HIV-related conditions
and are possibly already attending their GP, or
regularly by GPs for almost two years before
their AIDS diagnosis.
Similarly, a recent Auckland audit looked at
the financial cost to the health system over a
two-year period of undiagnosed HIV patients
presenting several times at ED before eventu-
ally being tested for HIV.6
This audit suggests
that earlier HIV diagnosis would have saved
between $9-14 million by avoiding expensive
inpatient care and reducing transmission of
infection to others. The auditors advocate that
routine HIV screening for everyone present-
ing to ED be considered. This approach would
take the anxiety and fear out of HIV testing
for both staff and patients by normalising HIV
screening.6
HIV testing makes HCWs think of the
patient’s sexual orientation. However, this
subject, like the subject of death and dying,
still remains taboo, putting most people in an
uncomfortable space and more likely to avoid
suggesting HIV testing. Hopefully, the 2013
law reform regarding same-sex marriage will
help HCWs become more skilled when taking
a sexual history and make it easier for them
to ask questions about same-sex relationships
and identifying possible risk factors.
My recent teaching sessions have high-
lighted some of the thinking GPs and ED staff
have about HIV testing. There are still several
false beliefs about the need to carry out pre-
test counselling.7
Some HCWs still believe HIV
testing will cause problems with life insurance
and question what will happen if the patient is
discharged or transferred before the test result
is available.
If this was the case, health professionals
would not order a chest X-ray or a full blood
count, as this might be the start of identifying
a life-threatening illness, eg cancer. Converse-
Figure 1
A simple, cheap and easy HIV
blood test would mean earlier
access to treatment and avoid-
ance of further ill health.
after hours services, and will eventually attend
emergency departments (EDs) with opportu-
nistic infections (OI), such as oral candidiasis,
Pneumocystis pneumonia (PCP – now called
Pneumocystis jiroveci), B-cell lymphoma,
tuberculosis or toxoplasmosis, if they are not
offered HIV testing earlier.
Twelve people have attended Wellington
Hospital’s ED in the last three years with AIDS,
due to undiagnosed HIV infection, 10 of whom
were men. These patients have been lucky to
live through treatment of their OIs and have
gone on to start ARV treatment, slowly regain-
ing functioning immune systems.4
Conversely,
in the last two years in New Zealand, two
women and one man did not survive their
OI and AIDS diagnosis, leaving their family
and friends devastated. This could have been
avoided, had they been tested earlier. None of
these people were perceived to be at risk from
HIV infection, although all had been seen

3. 13Kai Tiaki Nursing New Zealand * vol 22 no 6 * July 2016
practice
James Rice-Davies, RN, MNSc, is the HIV/ID clini-
cal nurse specialist at Wellington Hospital, Capital
& Coast District Health Board.
ly, a simple, cheap and easy HIV blood test
would mean earlier access to treatment and
avoidance of further ill health. The only thing
needed for an HIV test is informed consent,
just as it is for hepatitis B or C testing.
How to make testing easier
Approximately a third of our newly-diagnosed
cases are referred from GPs, usually after pa-
tients have attended several times with unex-
plained bouts of illness. They are then offered
HIV testing as part of a screening-out process,
rather than HIV being seen as a possible dif-
ferential diagnosis for unexplained weight loss,
dry itchy skin, change in bowel motions, or
altered blood films, such as neutropenia or low
platelet count. When these patients are finally
diagnosed with HIV, they often have low im-
mune systems, CD4 cells ranging from 50-350
(normal range being 600-1400), indicating
that HIV infection has been an issue for these
patients, possibly for a number of years.
In contrast, referrals from the New Zealand
AIDS Foundation have CD4 counts between
400-1000 and patients who are physically well.
This allows for earlier access to ARV treatment,
which leads to undetectable HIV VL, reducing
the spread of infection to others.
In the Wellington region, the vast majority
of positive HIV test results occur at the New
Zealand AIDS Foundation, where a service
using HIV Rapid Card takes 20 minutes to get
a result. The method used looks similar to a
home pregnancy testing device and uses a few
droplets of blood on a card. One bar on the
card indicates a negative result; two bars, an
HIV-positive result.8
This service is obviously
attracting an at-risk group who want an in-
stant result. The patient is then referred to the
ID department for a confirmation HIV antigen/
antibody combination test. An HIV VL is also
done via the hospital laboratory.
The goal is to test patients at risk of con-
tracting HIV, eg MSM or people from countries
with high prevalence of HIV who are sexually
active, as these groups will be more likely
to have HIV infection. They should also be
offered re-testing, if they are at ongoing risk
of HIV.
If HCWs remain uncomfortable about what
questions to ask regarding HIV testing when
assessing patients, they could either upskill
on how to take a sexual history or ask another
team member to take a history.
What we need to avoid is people presenting
in ED acutely unwell with OIs and an AIDS di-
agnosis. Of the Wellington regional HIV cohort
of 353 cases, more than 70 per cent identify
as gay/bisexual or MSM. This group includes
57 women, half of whom were not aware of be-
ing at risk of contracting HIV infection before
testing.
If HIV was regarded as a differential diag-
nosis to rule out unexplained symptoms of
ill health in service re-attenders, HIV testing
would give us more opportunities for ruling
out HIV infection in those who may not know
they have been at risk of HIV. It would also
provide the opportunity to rule out the infec-
tion in those who may not disclose risk factors
to their GP or ED and currently miss out on
being offered HIV testing earlier.
HIV, once diagnosed, can be well controlled
by medication, by gaining an undetectable VL.
This allows CD4 cells to be reconstituted to a
nearly normal immune system. For 80 per cent
of our cohort in the Wellington region, current
HIV management is six-monthly blood checks
to ensure HIV VL is undetectable. This tells us
the patient is taking their medication and also
monitor for liver and kidney function.
The main problem now is patients grow-
ing old with HIV and the co-morbidities that
often come with advanced age. This is not the
specialist area of ID or sexual health clini-
cians. In Sydney, HIV care is normalised by
a GP-led service, as most patients will never
become unwell from HIV, if they take their ARV
treatment. This could be the way forward for
New Zealand. This makes perfect sense when
we now have an aging cohort of people with
HIV who need a more generalist approach to
their overall health-care needs.
Eradicating HIV
In the future, it is possible the virus capability
to replicate could be switched off altogether,
even in sanctuary sites such as memory lymph
cells and places such as the cerebrospinal
fluid and genital tract.9
This may prove easier
than finding a cure or a vaccine. HIV is a poor
replicator and therefore similar to the common
cold, proving too difficult to find a cure or a
drug to eradicate it.
Lack of understanding may make HCWs
reluctant to offer HIV testing as a routine pro-
References
1) University of Otago, Dunedin School of Medicine. (2015). AIDS – New Zealand, 74-June. ISSN 1178-2692.
2) Saxton, P. J., Dickson, N. P., Griffiths, R., Hughes, A. J., & Rowden J. (2012). Actual and undiagnosed HIV prevalence in a community
sample of Men that have Sex with Men in Auckland New Zealand. BMC Public Health 12:92. doi: 10.1186/1471-2458-12-92
3) Dickson, N. P., McAllister, S., Sharples, K., & Paul, C. (2010). Late presentation of HIV infection among adults in New Zealand: 2005-2010.
HIV Medicine 13(3), 182-189.
4) Saxton. P., & Ludlam, A. (2015). Submission to the Select Committee on Health Public Health (Protection) Amendment Bill. New Zealand.
Retrieved from www.fmhs.auckland.ac.nz
5) Deblonde, J., De Koker, P. & Hamers, F. F. et al. (2010). Barriers to HIV testing in Europe: a systematic review. European Journal of Public
Health, 20(4), 422-432.
6) Auckland District Health Board. (2015). Potential impact of routinely offering HIV screening at Auckland DHB. HIV Update Day, May. Power-
Point presentation.
7) New Zealand AIDS Foundation. (2015). Getting a Rapid HIV Test in 20 minutes. Retrieved from https://www.youtube.com/
watch?v=ToNwta5LBW8
8) Eisele, E. & Siliciano, F. R. (2012) Redefining the viral reservoirs that prevent HIV-1 eradication. Immunity, 37(3), 377-388.
9) Salim, S. & Karim, A. (2015). Overcoming impediments to global implementation of early antiretroviral therapy. The New England Journal of
Medecine, 373(875-876). doi: 10.1056/NEJMe1508527
10) Cairns, G. (2015). START trial finds that early treatment improves outcomes for people with HIV. Aidsmap. Retrieved from http://www.
aidsmap.com/START-trial-finds-that-early-treatment-improves-outcomes/page/2972328/
cedure. The HIV test is both highly sensitive
and specific, with a window of up to 28 days
before a positive test result shows (depend-
ing on local laboratory testing methods). If a
health professional is testing to screen people
anxious about a recent sexual situation, a
window period and testing at the right time is
necessary.
What possible harm could happen to the
patient who has an HIV test and receives a
HIV testing would give us more
opportunities for ruling out HIV
infection in those who may not
know they have been at risk of
HIV . . .
negative result? I imagine none, except a story
to tell friends about how the hospital thought
they might have HIV. Meanwhile, those pa-
tients ending up diagnosed with HIV infection
will have an improved outcome.10
People infected with HIV are part of our
working lives and include our work colleagues,
people on the bus, neighbours and friends
who often hide their diagnosis, due to stigma
still associated with this infection. If all HCWs
thought about HIV as a differential diagnosis,
sooner rather than later, for those with unex-
plained symptoms, this would help reduce the
spread of infection and late presentation.
Until there is a cure or a vaccine for HIV, we
all have a role in reducing the numbers of peo-
ple becoming infected with HIV. A way to do
this is by being more proactive in offering and
routinely carrying out HIV testing. This starts
with health professionals not being frightened
to ask about HIV testing and making it easier
for everyone to get a test. •