Comment
midwifery, to which I would recommend investigators add the satisfaction and workload of midwives. I await this analysis with anticipation. Petra ten Hoope-Bender Reproductive, Newborn and Child Health, ICS Integrare, Geneva 1202, Switzerland [email protected]
5
6
7
8
I declare that I have no conflicts of interest. 1
2
3 4
Tinajero AR, Loizillon A. The review of care, education and child development indicators in early childhood. Paris: United Nations Educational, Scientific and Cultural Organization, 2010. http://unesdoc. unesco.org/images/0021/002157/215729E.pdf (accessed Aug 8, 2013). Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2012; 5: CD003519. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013; 5: CD003766. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 2013; 8: CD004667.
9
10
Souza JP, Gülmezoglu AM, Vogel J, et al. Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. Lancet 2013; 381: 1747–55. Tracy SK, Hartz DL, Tracy MB, et al. Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. Lancet 2013; 382: 1723–32. International Confederation of Midwives. International definition of the midwife. http://www.internationalmidwives.org/assets/uploads/ documents/Definition%20of%20the%20Midwife%20-%202011.pdf (accessed Aug 7, 2013). Johanson R, Newburn M, Macfarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002; 324: 892–95. Villar J, Valladares E, Wojdyla D, et al. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006; 367: 1819–29. Requejo J, Bryce J, Victora C, et al. Countdown to 2015—maternal, newborn & child survival. Building a future for women and children: the 2012 report. Geneva: World Health Organization and UNICEF, 2012.
HIV in the UK: test, test, and test again HIV is a pervasive disease that disproportionately affects already vulnerable populations in the UK. Undiagnosed HIV and late presentation with advanced infection drive HIV-associated morbidity and mortality, as well as HIV acquisition and transmission. Nov 22–29, 2013, is UK National HIV Testing Week, during which HIV testing will be strongly promoted, adding impetus to the shift from the exceptionalism associated with HIV towards testing and diagnosis becoming routine. This shift is a crucial step towards harnessing the full potential of powerful interventions that are available for management and prevention of HIV infection. Reducing the numbers of people with undiagnosed HIV—estimated to be a quarter (23 000) of the 96 000 people with HIV in the UK1—through promotion of HIV testing is a key objective of current HIV prevention activities. Timely treatment, which in the UK is free to all regardless of residence status, radically improves prognosis, delivering a near-normal lifespan.2 Yet in 2012, nearly half (47%) of new HIV diagnoses were made late (ie, with a CD4 count two in 1000 adults aged 15–59 years). Yet rollout of expanded HIV testing in high prevalence areas has been disappointingly low,10 despite evidence showing feasibility, acceptability, effectiveness, and costeffectiveness in general medical services.11 To increase rates of HIV testing in general medical services requires training of and support for health-care providers, as well as the introduction of a routine HIV test offer in some services and for patients presenting with HIV-associated disorders.12 Commissioners could make a vital difference by including HIV testing as a requirement in service specifications. Expansion of HIV-testing methods to include home sampling and home testing can bypass traditional providers and offer new opportunities. Regulations prohibiting the sale of self-testing HIV kits will be repealed in April, 2014.13 Despite concerns that such a move might have adverse impacts (eg, that people with reactive results might not seek appropriate follow-up and care), these are outweighed by the reality that kits are easily available through the internet, irrespective of national legislation, and the benefit that access to quality-assured kits might increase HIV testing. One alternative is self-sampling at home, which facilitates access to an HIV test, is being promoted to at-risk populations during HIV testing week, and has been shown to be effective. In the first 6 months of operation, two national self-sampling services have distributed nearly 16 000 sample collection kits, of which more than 9000 were returned, leading to 170 people being newly diagnosed with HIV (McOwan A, Dean Street Clinic, Chelsea and Westminster Hospital Trust, London, UK; personal communication).14 Will expanded HIV testing control HIV infection in the UK? Modelling studies suggest that prompt diagnosis is a crucial element in HIV transmission control,5 making a major expansion in testing a key intervention in tackling HIV in the UK. Testing negative for HIV allows people access to health promotion interventions to prevent acquisition, and repeat testing for people at continuing risk is important to identify early HIV infection. National HIV Testing Week demands the support of all healthcare professionals. Testing makes a major contribution
1688
to improving outcomes for people with HIV, is a key determinant in HIV prevention, and helps to counteract HIV-related stigma. The message is clear: test, test, and test again. *Anthony Nardone, Valerie Delpech, O Noel Gill, Kevin A Fenton, Jane Anderson HIV and STI Department, Centre for Disease Surveillance and Control, Health Protection Directorate (AN, VD, ONG), and Health and Wellbeing Directorate (KAF, JA), Public Health England, London NW9 5EQ, UK [email protected] JA has received honoraria and travel expenses for speaking engagements, advisory boards, and educational programmes from Gilead Sciences, ViiV, Merck Sharp & Dohme, AbbVie, Bristol-Myers Squibb, and Janssen, and project or research grant funding from Gilead Sciences. All other authors declare that they have no conflicts of interest. 1
2 3
4
5
6
7
8
9
10
11
12
13
14
Health Protection Agency. HIV in the United Kingdom: 2012 report. London: Health Protection Services, Colindale, 2012. http://www.hpa.org. uk/webc/HPAwebFile/HPAweb_C/1317137200016 (accessed Nov 4, 2013). Nakagawa F, Lodwick RK, Smith CJ, et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS 2012; 26: 335–43. Cohen MS, Smith MK, Muessig KE, Hallett TB, Powers KA, Kashuba AD. Antiretroviral treatment of HIV-1 prevents transmission of HIV-1: where do we go from here? Lancet 2013; 382: 1515–24. Brown AE, Gill ON, Delpech VC. HIV treatment as prevention among men who have sex with men in the UK: is transmission controlled by universal access to HIV treatment and care? HIV Med 2013; 14: 563–70. Phillips AN, Cambiano V, Nakagawa F, et al. Increased HIV incidence in men who have sex with men despite high levels of ART-induced viral suppression: analysis of an extensively documented epidemic. PLoS One 2013; 8: e55312. Birrell PJ, Gill ON, Delpech VC, et al. HIV incidence in men who have sex with men in England and Wales 2001–10: a nationwide population study. Lancet Infect Dis 2013; 13: 313–18. Ellis S, Curtis H, Ong EL, for the British HIV Association (BHIVA), BHIVA Clinical Audit and Standards sub-committee. HIV diagnoses and missed opportunities. Results of the British HIV Association (BHIVA) national audit 2010. Clin Med 2012; 12: 430–34. British HIV Association, British Association for Sexual Health and HIV, British Infection Society. UK national guidelines for HIV testing 2008. http://www.bhiva.org/HIVTesting2008.aspx (accessed Nov 4, 2013). National Institute for Health and Care Excellence. Increasing the uptake of HIV testing among men who have sex with men. March, 2011. http:// publications.nice.org.uk/increasing-the-uptake-of-hiv-testing-amongmen-who-have-sex-with-men-ph34 (accessed Nov 4, 2013). Hartney T, Kennedy I, Crook P, Nardone A. Expanded HIV testing in highprevalence areas in England: results of a 2012 audit of sexual health commissioners. HIV Med 2013; published online Oct 3. DOI:10.1111/ hiv.12099. Public Health England. Time to test for HIV: expanded healthcare and community HIV testing in England. Sept, 2011. http://www.hpa.org.uk/ timetotesthiv2011 (accessed Nov 4, 2013). Sullivan AK, Raben D, Reekie J, et al. Feasibility and effectiveness of indicator condition-guided testing for HIV: results from HIDES I (HIV indicator diseases across Europe study). PLoS One 2013; 8: e52845. Department of Health. Modernisation of HIV rules to better protect public. August, 2013. https://www.gov.uk/government/news/modernisation-ofhiv-rules-to-better-protect-public (accessed Nov 4, 2013). Brady M, Ward P, Ogunyemi A, et al. Home HIV sampling linked to national HIV testing campaigns: a novel approach to improve HIV diagnosis. Public Health England Conference; Warwick, UK; Sept 10–11, 2013. https://www. phe-events.org.uk/hpa/frontend/reg/absViewDocumentFE.csp?popup=1& documentID=6177&eventID=173 (accessed Nov 15, 2013).
www.thelancet.com Vol 382 November 23, 2013
midwifery, to which I would recommend investigators add the satisfaction and workload of midwives. I await this analysis with anticipation. Petra ten Hoope-Bender Reproductive, Newborn and Child Health, ICS Integrare, Geneva 1202, Switzerland [email protected]
5
6
7
8
I declare that I have no conflicts of interest. 1
2
3 4
Tinajero AR, Loizillon A. The review of care, education and child development indicators in early childhood. Paris: United Nations Educational, Scientific and Cultural Organization, 2010. http://unesdoc. unesco.org/images/0021/002157/215729E.pdf (accessed Aug 8, 2013). Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2012; 5: CD003519. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013; 5: CD003766. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 2013; 8: CD004667.
9
10
Souza JP, Gülmezoglu AM, Vogel J, et al. Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. Lancet 2013; 381: 1747–55. Tracy SK, Hartz DL, Tracy MB, et al. Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. Lancet 2013; 382: 1723–32. International Confederation of Midwives. International definition of the midwife. http://www.internationalmidwives.org/assets/uploads/ documents/Definition%20of%20the%20Midwife%20-%202011.pdf (accessed Aug 7, 2013). Johanson R, Newburn M, Macfarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002; 324: 892–95. Villar J, Valladares E, Wojdyla D, et al. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006; 367: 1819–29. Requejo J, Bryce J, Victora C, et al. Countdown to 2015—maternal, newborn & child survival. Building a future for women and children: the 2012 report. Geneva: World Health Organization and UNICEF, 2012.
HIV in the UK: test, test, and test again HIV is a pervasive disease that disproportionately affects already vulnerable populations in the UK. Undiagnosed HIV and late presentation with advanced infection drive HIV-associated morbidity and mortality, as well as HIV acquisition and transmission. Nov 22–29, 2013, is UK National HIV Testing Week, during which HIV testing will be strongly promoted, adding impetus to the shift from the exceptionalism associated with HIV towards testing and diagnosis becoming routine. This shift is a crucial step towards harnessing the full potential of powerful interventions that are available for management and prevention of HIV infection. Reducing the numbers of people with undiagnosed HIV—estimated to be a quarter (23 000) of the 96 000 people with HIV in the UK1—through promotion of HIV testing is a key objective of current HIV prevention activities. Timely treatment, which in the UK is free to all regardless of residence status, radically improves prognosis, delivering a near-normal lifespan.2 Yet in 2012, nearly half (47%) of new HIV diagnoses were made late (ie, with a CD4 count two in 1000 adults aged 15–59 years). Yet rollout of expanded HIV testing in high prevalence areas has been disappointingly low,10 despite evidence showing feasibility, acceptability, effectiveness, and costeffectiveness in general medical services.11 To increase rates of HIV testing in general medical services requires training of and support for health-care providers, as well as the introduction of a routine HIV test offer in some services and for patients presenting with HIV-associated disorders.12 Commissioners could make a vital difference by including HIV testing as a requirement in service specifications. Expansion of HIV-testing methods to include home sampling and home testing can bypass traditional providers and offer new opportunities. Regulations prohibiting the sale of self-testing HIV kits will be repealed in April, 2014.13 Despite concerns that such a move might have adverse impacts (eg, that people with reactive results might not seek appropriate follow-up and care), these are outweighed by the reality that kits are easily available through the internet, irrespective of national legislation, and the benefit that access to quality-assured kits might increase HIV testing. One alternative is self-sampling at home, which facilitates access to an HIV test, is being promoted to at-risk populations during HIV testing week, and has been shown to be effective. In the first 6 months of operation, two national self-sampling services have distributed nearly 16 000 sample collection kits, of which more than 9000 were returned, leading to 170 people being newly diagnosed with HIV (McOwan A, Dean Street Clinic, Chelsea and Westminster Hospital Trust, London, UK; personal communication).14 Will expanded HIV testing control HIV infection in the UK? Modelling studies suggest that prompt diagnosis is a crucial element in HIV transmission control,5 making a major expansion in testing a key intervention in tackling HIV in the UK. Testing negative for HIV allows people access to health promotion interventions to prevent acquisition, and repeat testing for people at continuing risk is important to identify early HIV infection. National HIV Testing Week demands the support of all healthcare professionals. Testing makes a major contribution
1688
to improving outcomes for people with HIV, is a key determinant in HIV prevention, and helps to counteract HIV-related stigma. The message is clear: test, test, and test again. *Anthony Nardone, Valerie Delpech, O Noel Gill, Kevin A Fenton, Jane Anderson HIV and STI Department, Centre for Disease Surveillance and Control, Health Protection Directorate (AN, VD, ONG), and Health and Wellbeing Directorate (KAF, JA), Public Health England, London NW9 5EQ, UK [email protected] JA has received honoraria and travel expenses for speaking engagements, advisory boards, and educational programmes from Gilead Sciences, ViiV, Merck Sharp & Dohme, AbbVie, Bristol-Myers Squibb, and Janssen, and project or research grant funding from Gilead Sciences. All other authors declare that they have no conflicts of interest. 1
2 3
4
5
6
7
8
9
10
11
12
13
14
Health Protection Agency. HIV in the United Kingdom: 2012 report. London: Health Protection Services, Colindale, 2012. http://www.hpa.org. uk/webc/HPAwebFile/HPAweb_C/1317137200016 (accessed Nov 4, 2013). Nakagawa F, Lodwick RK, Smith CJ, et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS 2012; 26: 335–43. Cohen MS, Smith MK, Muessig KE, Hallett TB, Powers KA, Kashuba AD. Antiretroviral treatment of HIV-1 prevents transmission of HIV-1: where do we go from here? Lancet 2013; 382: 1515–24. Brown AE, Gill ON, Delpech VC. HIV treatment as prevention among men who have sex with men in the UK: is transmission controlled by universal access to HIV treatment and care? HIV Med 2013; 14: 563–70. Phillips AN, Cambiano V, Nakagawa F, et al. Increased HIV incidence in men who have sex with men despite high levels of ART-induced viral suppression: analysis of an extensively documented epidemic. PLoS One 2013; 8: e55312. Birrell PJ, Gill ON, Delpech VC, et al. HIV incidence in men who have sex with men in England and Wales 2001–10: a nationwide population study. Lancet Infect Dis 2013; 13: 313–18. Ellis S, Curtis H, Ong EL, for the British HIV Association (BHIVA), BHIVA Clinical Audit and Standards sub-committee. HIV diagnoses and missed opportunities. Results of the British HIV Association (BHIVA) national audit 2010. Clin Med 2012; 12: 430–34. British HIV Association, British Association for Sexual Health and HIV, British Infection Society. UK national guidelines for HIV testing 2008. http://www.bhiva.org/HIVTesting2008.aspx (accessed Nov 4, 2013). National Institute for Health and Care Excellence. Increasing the uptake of HIV testing among men who have sex with men. March, 2011. http:// publications.nice.org.uk/increasing-the-uptake-of-hiv-testing-amongmen-who-have-sex-with-men-ph34 (accessed Nov 4, 2013). Hartney T, Kennedy I, Crook P, Nardone A. Expanded HIV testing in highprevalence areas in England: results of a 2012 audit of sexual health commissioners. HIV Med 2013; published online Oct 3. DOI:10.1111/ hiv.12099. Public Health England. Time to test for HIV: expanded healthcare and community HIV testing in England. Sept, 2011. http://www.hpa.org.uk/ timetotesthiv2011 (accessed Nov 4, 2013). Sullivan AK, Raben D, Reekie J, et al. Feasibility and effectiveness of indicator condition-guided testing for HIV: results from HIDES I (HIV indicator diseases across Europe study). PLoS One 2013; 8: e52845. Department of Health. Modernisation of HIV rules to better protect public. August, 2013. https://www.gov.uk/government/news/modernisation-ofhiv-rules-to-better-protect-public (accessed Nov 4, 2013). Brady M, Ward P, Ogunyemi A, et al. Home HIV sampling linked to national HIV testing campaigns: a novel approach to improve HIV diagnosis. Public Health England Conference; Warwick, UK; Sept 10–11, 2013. https://www. phe-events.org.uk/hpa/frontend/reg/absViewDocumentFE.csp?popup=1& documentID=6177&eventID=173 (accessed Nov 15, 2013).
www.thelancet.com Vol 382 November 23, 2013
