2013 HIV Screening and Testing GuideA guide for care providers developed in response to the need

to reduce the number of undiagnosed HIV infections in Canada

Dr. Robert Gervais, CCDICPHPC Continuing Professional Development Day, Ottawa, June 9th 2013

Foreword

• The HIV Screening and Testing Guide is designed to complement existing efforts to support care providers involved in HIV testing, including primary care providers, public health nurses, counsellors, social workers, community health workers, midwives, community-based service providers and others in an effort to reduce the number of undiagnosed HIV infections in Canada.

• The guide does not supersede any provincial/territorial legislative, regulatory, policy and practice requirements or professional guidelines that govern and inform the practice of care providers in their respective jurisdictions.

• Care providers should comply with local Public Health regulations when conducting HIV testing.

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Background

An Ad Hoc Expert Working Group made up of representatives with clinical and community expertise in current HIV testing practices was established to inform the development of the Guide.

Further input was obtained through a literature review, an online public consultation and input from laboratory experts, STI experts, and provincial and territorial governments.

The guidelines provide expert opinion and evidence-informed recommendations reflecting advances in our ability to detect and treat HIV infection.

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HUMAN IMMUNODEFICIENCY VIRUS

HIV SCREENING AND TESTING GUIDE

Context

• An estimated 71,300 people in Canada (58,600-84,000) are currently living with HIV infection of which an estimated 25% (14,500-21,500) are undiagnosed and unaware that they are infected

• Evidence demonstrates that many people at “moderate risk” who are outside of traditional high-risk populations are not being offered HIV testing

• Two recent Canadian surveys of the general population found that only 29% and 37% of respondents reported having ever been tested for HIV

• Conversely, evidence demonstrates that vulnerable populations have a high rate of ever having been tested, but could benefit from more regular testing

• In spite of many interactions with the healthcare system, some “low-risk” clients are testing HIV-positive at late stages of their HIV disease and cannot benefit from available treatment.

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Opportunities

• Fourth generation tests can now detect HIV infection in the acute, and most infectious, stage of infection - within 15 to 20 days of exposure for most people

• Undiagnosed cases are a missed opportunity and represent a significant public health challenge – single greatest contributor to the ongoing transmission of HIV infection

• The longer people are unaware of their HIV infection the more likely they are to unknowingly transmit the virus to others

• Every discussion around HIV testing is an opportunity to reinforce risk reduction messaging for clients

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Barriers to HIV Testing

• The literature identifies several barriers to offering HIV testing. The new guide provides approaches to overcome these barriers.

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REPORTED BARRIER RECOMMENDATIONS IN THE GUIDE

Inability to accurately assess levels of risk for exposure to HIV by some clients and providers

Normalise HIV testing; simplify risk assessments; make the consideration of an HIV test part of periodic routine medical care.

Lack of comfort discussing HIV testing and knowledge about HIV among some clients and providers

Normalise HIV testing; simplify risk assessments; make the consideration of an HIV test a part of periodic routine medical care.

Provider time constraints for risk assessments and pre- and post-test counselling

Simplify risk assessments; streamline the provision of pre-test information using print, video, mobile and web-based resources; alternate approaches offered to provide negative results.

Cumbersome consent procedures

Verbal consent for HIV testing, as with other tests, is sufficient; testing remains voluntary.

Fear of stigma and discrimination associated with risk behaviours and/or testing HIV-positive

Normalise HIV testing and simplify risk assessment to reduce discomfort and stigma and increase uptake of testing; emphasize HIV as a chronic manageable condition and the benefits of treatment to reduce fear of HIV diagnosis.

Key Recommendations

• Provider-initiated HIV testing discussion be made a part of periodic routine medical care, moving away from an exclusive risk-based approach

• Greater integration of HIV testing as part of testing for other sexually transmitted and blood borne infections, and as part of other related clinical services such as tuberculosis, antenatal, hepatitis C, and drug/alcohol treatment

• Flexible streamlined approaches based on the testing situation to make risk assessment and counselling more time efficient

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Risk Assessment

• HIV testing does not necessarily involve in-depth assessments of sexual risks or drug use behaviors

• Brief explanation of transmission risks such as: » “HIV is transmitted primarily through unprotected sex, shared drug equipment

use and from a pregnant mother to her child. Would you like me to order an HIV test as part of your blood work today?”

• Allows clients to assess their own risk without feeling obliged to disclose information they might find sensitive

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Who to Test?

• Those who request a test

• Pregnant women and those planning to become pregnant, and their partners as appropriate

• Individuals presenting with symptoms and signs of HIV infection or with illnesses associated with a weakened immune system

• Sexually active clients who have never been tested

• Individuals who have shared drug use equipment with a partner whose HIV status is positive or unknown

• Victims of sexual assault

• Individuals who have had unprotected vaginal or anal intercourse with a partner whose HIV status is positive or unknown

• Additional factors that can increase an individual’s risk for exposure to HIV (e.g. multiple partnering, men with a history of sex with men, etc.)

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Frequency of retesting

• Individuals involved in high risk practices should be screening for HIV at least annually

• Insufficient evidence to provide recommendations for exact frequency of HIV testing for each scenario due to the number of variables involved with each individual’s potential for exposure

• Care providers are encouraged to consider the following factors: » Populations at increased risk (e.g. MSM)» Characteristic of sexual partnering» Local epidemiology

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Pre-test Counselling

• A streamlined approach recommends to quickly outline the benefits and potential disadvantages of being tested for HIV infection including:

» Knowing ones HIV status and risk reduction practices » Confidentiality vs. reporting positive results to public health» Partner notification in the event of positive result (e.g. how it would work, public

health benefit)

• Consent does not have to be provided in writing; verbal consent is sufficient» Clients do need to have a basic understanding of the advantages and

disadvantages of the test and be able to understand the test results

• Including HIV testing as part of a range of tests means that patients can be told they will be asked to return for results only “if any of the test results are of concern”

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Post-test Counselling

• Negative test results do not have to be provided in person, but any time results are provided it’s an opportunity to reinforce prevention messages for people who may be at ongoing risk

• Post-test guidance for positive HIV test results include:» Reiterating that HIV is a chronic manageable condition» Discussing the benefits of entering into and being retained in care » Providing the client with risk reduction information to prevent reinfection and

onward transmission» Establishing a partner notification strategy» Connecting clients with support and informational resources as needed

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Role of Public Healthas determined by applicable Public Health Acts

• Public Health will be notified or informed of any positive HIV test results as per provincial or territorial legislation

• Public Health is recommended as a key resource to care providers needing to provide local referrals to those newly diagnosed with HIV

• Care providers are encouraged to consult or engage local Public Health to support with partner notification as appropriate

• The Guide directs care providers to report to Public Health any instance where the actions or behaviours of an HIV-positive client presents a risk of infection to others

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Opportunities for knowledge transfer and exchange

• At the Family Medicine Forum 2012 of The College of Family Physicians of Canada, PHAC developed a seminar on HIV/STI Guidelines and conducted a needs assessment among 207 participants

• 2/3 indicated they offered HIV testing to 25% or less of their patients in the past year

• Following presentation of the Guide recommendations, 83% indicated a willingness to expand the offer of HIV testing in their practice

• Increasingly preferred electronic formats to inform decision-making and update clinical knowledge, but traditional methods are still valued

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Suggestions on how to promote uptake of the Guide

• Chief Medical Officers of Health

• MOH in local Public Health Units» HIV/STI case management group» Publications, Newsletters, etc.

• Conference and KT events

• Others?

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Key Resources

• HIV Screening and Testing Guide & Appendixes» http://www.catie.ca/en/resources/human-immunodeficiency-virus-screening-and-t

esting-guide» http://www.catie.ca/fr/ressources/virus-limmunodeficience-humaine-guide-depista

ge-diagnostic-linfection-vih

• HIV transmission risk: A summary of the evidence» http://www.catie.ca/sites/default/files/HIV-TRANSMISSION-RISK-EN.pdf» http://www.catie.ca/sites/default/files/RISQUE-DE-TRANSMISSION-DU-VIH-FR.

pdf

HIV Screening and Testing Guide

• Condensed version of the Guide under development

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