By reflecting on current practice, the paper by Evans et al1 revisits a much-needed discussion about expanding HIV testing in UK general practice and the role of general practitioners (GPs) in the care of HIV-positive individuals (see page 520).

Discussions around shared care of HIV patients between specialists and GPs started with the introduction of highly active antiretroviral therapy (HAART) in the 1990s; people with HIV are becoming more stable and healthier, and like many long-term conditions, HIV can potentially be managed in primary care.2 One large HIV centre in central London audited their caseload and found at least a third of patients on HAART and 80% of those not on HAART and stable could have been managed by nurse practitioners or GPs; this has huge potential for freeing up capacity in busy urban clinics.3

However, this is a paradigm shift in HIV care, and anecdotally there is still concern among the very groups that would make this work: GPs, HIV specialists and users of HIV services. The Terrence Higgins Trust published a policy guidance based on literature review and interviews with selected GPs, HIV specialists and patients. Although many GPs and specialists felt there is a greater scope for GPs in HIV and general medical care, both groups had strong concerns about confidentiality and disclosure within general practice. Despite being comfortable with having GP involvement in their care, the same concerns about confidentiality and disclosure emerged from interviews with patients. Other concerns include GPs’ knowledge about HIV disease and some resistance among gay men to disclose their HIV status due to perceived discrimination.4 In addition, fears about insurance cover have been cited for resistance to test in general practice; but one can argue as to whether this is a real obstacle or a red herring.5 A recent study at an inner-London general practice suggests that rapid HIV testing as part of new patient check is feasible and acceptable; advantages include reduced waiting time, normalisation of testing and opportunity for those who are reluctant to use sexual health services.6

The Royal College of General Practitioner’s Sex, Drugs and HIV Task Group was formed in the late 1980s to challenge the notion that general practice has no place or understanding of HIV infection; it remains an active and key driving force in the formulation and implementation of sexual health policies that involve general practice in the UK. It has worked tirelessly to promote and maintain standards in sexual health in general practice.

With rising numbers of HIV infection and late diagnoses, there is an urgent need to increase access to HIV testing and timely treatment. The Chief Medical and Nursing Officers have responded to this, but it appears this has not been effective.7 8 Both the Chief Medical Officer/Chief Nursing Officer letter and UK National Guidelines for HIV Testing make references to useful materials for clinicians in non-HIV specialist settings to offer tests including advice on insurance, referring to the Association of British Insurers’ (ABI) code of practice.9 10 Even The Lancet conveys a former senior government health official’s frustration at the “appalling statistic” and that “no one is listening.”11

There is a lot to be done. We need better evidence for shared care and to understand better the barriers to testing and what we can do about them, especially issues about confidentiality, disclosure, stigma and discrimination. We need an effective strategy to help more people get tested—targeting the population registered with GPs and those admitted to hospitals.

Walt’s classic text in health policy analyses the roles of actors and their relative powers in effective policy making.12 The time is right for all actors involved to break down the barriers and stereotypes; no one actor has legitimate “ownership” of HIV than any other, and each is powerful in its own right to effect change. Only when the powers are harnessed and coordinated can we achieve what we all want: reduce late diagnoses, improve detection of HIV and improve the health of people already diagnosed. In response to The Lancet’s editorial, we are listening, and we are ready for action!