Evidence

2021 exceptional surveillance of HIV indicator conditions (NICE guidelines NG52, CG153, NG122 and NG203)

Surveillance decision

Surveillance decision

We propose to make an amendment to the NICE guidelines on non-Hodgkin's lymphoma: diagnosis and management and psoriasis: assessment and management to highlight that they are HIV indicator conditions.

We propose not to amend the NICE guidelines on lung cancer: diagnosis and management or chronic kidney disease: assessment and management as we did not have clinical consensus on the need to highlight that these are HIV indicator conditions. Instead, this will be noted for consideration in future surveillance.

Exceptional surveillance review summary

Reason for considering this area

A stakeholder highlighted that NICE's guideline on HIV testing: increasing uptake among people who may have undiagnosed HIV recommends HIV testing for people with indicator conditions. Despite this, NICE's guidelines that feature indicator conditions themselves do not always reference HIV testing, or link back to NICE's guideline on HIV testing. The enquirer thought this was an important omission that might explain some of the low testing for HIV in indicator conditions. As part of the UK mission to end new HIV transmissions by 2030, the enquirer explained that this is 1 area where improvement is needed.

Methods

To review the impact of this query on NICE guidance we took the following approach:

  • Assessed the enquiry against the relevant NICE guidelines.

  • Mapped the indicator conditions to NICE guidance.

  • Considered the HIV indicator conditions which have relevant NICE guidelines for possible update.

  • Contacted experts on the NICE adoption and impact panel to understand any implementation issues.

  • Sought the views of topic experts.

It was concluded that full updated literature searches were not needed because the information we obtained was enough to establish whether an amendment to the guidelines was needed.

For further information, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.

Surveillance proposal

New intelligence

The enquirer explained that they are especially looking at ways to improve HIV testing for people with indicator conditions in 3 clinical speciality areas: dermatology, gynaecology and haematology. They noted several clinical knowledge summaries (CKS), however, these are not NICE guidance and the enquirer's comments on these CKS were handled separately. The enquirer did however highlight NICE's guideline on psoriasis as a potentially useful guideline to highlight HIV testing.

Current NICE guidance

The NICE guideline on HIV testing has the following recommendations.

Secondary and emergency care

Recommendation 1.1.5 In all areas, offer and recommend HIV testing on admission to hospital, including emergency departments, to everyone who has not previously been diagnosed with HIV and who:

GP surgeries

Recommendation 1.1.8 In all areas, offer and recommend HIV testing to everyone who has not previously been diagnosed with HIV and who:

  • has symptoms that may indicate HIV or HIV is part of the differential diagnosis (for example, infectious mononucleosis-like syndrome), in line with HIV in Europe's HIV indicator conditions.

These recommendations were developed on the basis of evidence on targeted testing based on HIV indicator conditions. This evidence highlighted the importance of testing for people with indicator conditions and identified mononucleosis-like illness as the likely indicator condition most associated with undiagnosed HIV infection. The committee discussed the effectiveness of offering testing to people who present to health services with conditions that might indicate HIV. The effectiveness of this depends to some extent on the accuracy of the list of indicator conditions used. The committee agreed that defining a list of indicator conditions was outside the scope of this guideline; and agreed that the HIV in Europe's HIV indicator conditions guide was sufficiently evidence-based to inform recommendations 1.1.5 and 1.1.8.

Please note that NICE does not have a guideline on mononucleosis-like illness. There is a CKS on glandular fever (infectious mononucleosis), which already highlights that HIV may be a differential diagnosis. However, CKS are not NICE guidance and are not part of this surveillance review as they are produced, updated and maintained externally to NICE. Nevertheless, all comments received on the CKS were passed across to the producer of the CKS and these have subsequently been updated.

HIV indicator conditions relevant to NICE guidelines

The HIV indicator conditions guide lists over 30 conditions and symptoms that are associated with, or likely to be associated with, an undiagnosed HIV prevalence of >0.1%. All of these indicator conditions were assessed for relevance to NICE guidelines. NICE's guidelines on sexually transmitted infections and under-18 conceptions: prevention, hepatitis B (chronic): diagnosis and management, hepatitis B and C testing: people at risk of infection and antenatal care, already mention the need for HIV testing in indicator conditions or as part of routine care.

Some of the indicator conditions and symptoms do not currently have a NICE guideline. However, the following list shows the indicator conditions which are mapped to NICE guidelines and that do not currently mention HIV.

Views of topic experts

The approach of adding a new recommendation advocating HIV testing to each of the guidelines above was explored with clinicians with expertise in the 4 topic areas as well as an expert in HIV medicine.

A total of 9 experts responded with expertise in nephrology, lymphoma, chronic kidney disease, HIV medicine, radiology, psoriasis and general practice. There was variable agreement with the proposals, each is discussed in turn below. One expert generally commented that more NICE guidelines should offer HIV testing for people with HIV indicator conditions; however as noted above NICE does not have guidance on all indicator conditions. In contrast to this, other experts generally felt that the evidence for HIV testing in the indicator conditions was uncertain and that adding a recommendation was unjustified and highlighted particular concerns around the patient populations being targeted.

NICE's guideline on psoriasis

A total of 6 experts responded; 5 agreed and 1 disagreed with the need for a recommendation to offer HIV testing in severe or atypical psoriasis. The expert who disagreed did so on the basis that psoriasis is not mentioned in NICE's guideline on HIV testing as an indicator condition. However, that guideline does not explicitly list all indicator conditions and instead links to the HIV indicator conditions guide, which provides a comprehensive overview of indicator conditions and does list severe or recalcitrant psoriasis as an indicator condition.

NICE's guideline on non-Hodgkin's lymphoma

A total of 6 experts responded and all agreed that a recommendation is needed to offer HIV testing for malignant lymphoma. However, 1 expert queried whether this would go beyond the scope of non-Hodgkin's lymphoma, although this would not be considered a scope expansion as HIV testing is already recommended for lymphoma in NICE's guideline on HIV testing.

NICE's guideline on lung cancer

A total of 6 experts responded; 3 agreed with the need for a recommendation to offer HIV testing for lung cancer and 3 disagreed. The comments received which disagreed with the proposal did so on the basis that they did not feel this was a strong HIV indicator condition. One expert also commented that lung cancer is not explicitly mentioned in NICE's guideline on HIV testing as an indicator condition. However, that guideline does not explicitly list all indicator conditions and instead links to the HIV indicator conditions guide, which provides a comprehensive overview of indicator conditions and does list primary lung cancer as an indicator condition.

NICE's guideline on chronic kidney disease

A total of 7 experts responded; 5 disagreed with the need to add a recommendation to offer HIV testing for CKD and 2 agreed. The comments received which disagreed with the proposal did so on the basis that they did not feel this was a strong HIV indicator condition. One expert also commented that CKD is not explicitly mentioned in NICE's guideline on HIV testing as an indicator condition. However, that guideline does not explicitly list all indicator conditions and instead links to the HIV indicator conditions guide, which provides a comprehensive overview of indicator conditions and does list chronic kidney disease as an indicator condition. A further comment was received that CKD affects around 10% of the population, generally occurring in older age groups and the cause is often not apparent; therefore, the utility and cost-effectiveness of HIV testing in all people with unexplained chronic renal impairment needs to be established before it is recommended.

How we plan to address this

There was consensus across experts that it would be helpful to clinical practice to highlight that NICE's guidelines on non-Hodgkin's lymphoma and psoriasis are recognised indicator conditions. As such, each of these will be amended to highlight they are HIV indicator conditions.

There was no consensus for chronic kidney disease and lung cancer, as experts highlighted uncertainty on the exact population that may benefit from HIV testing. As such, neither of these guidelines will be amended to highlight HIV testing. Instead, this will be noted for consideration in future surveillance. NICE's 5 year strategy is currently prioritising which parts of the guidelines portfolio will be actively maintained, including updating the process for reacting to events (such as enquiries) and performing updates.

Equalities

An expert highlighted that HIV associated nephropathy, which occurs mostly in untreated people (including those who are undiagnosed as having HIV), has a higher prevalence in people of black African and African-Caribbean ethnicity. Another expert explained that erythrodermic/severe psoriasis may be under recognised in people of colour, particularly those people with black and brown skin colours.

Overall decision

We propose to make an amendment to NICE's guidelines on non-Hodgkin's lymphoma and psoriasis to highlight that they are HIV indicator conditions. We propose not to editorially amend NICE's guidelines on lung cancer or chronic kidney disease as we did not have clinical consensus on the need to highlight that these are HIV indicator conditions. Instead, this will be noted for consideration in future surveillance.

ISBN: 978-1-4731-4311-1


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