“ITS DIFFERENT NOW”: THE CHANGING LANDSCAPE OF HIV

TESTING

Cristin Muecke, RMOHNick Scott, ED AIDS NB

Objectives Why HIV testing remains important Treatment as prevention Discuss advantages/disadvantages of

various testing encounters Explore real and perceived barriers to HIV

testing in clinical practice Promote normalization of HIV testing as

part of comprehensive STI testing approaches

The Issue An estimated 25% of HIV infected

persons in Canada are unaware of their status More likely to spread HIV in the population After being notified of their HIV status, newly

diagnosed people substantially reduce frequency of unprotected behaviors

The Issue• A substantial number of HIV infected

persons are diagnosed late in their illness

60% are diagnosed after they should already be on treatment

In US (2005), over a third of newly diagnosed cases developed AIDS within a year

The Canadian annual incidence rate has remained largely unchanged for the past decade (estimated 2300-4300 per year)

HAART Highly Active AntiRetroviral Therapy

makes it harder for the HIV virus to replicate, thus lower level of virus in the body

Implications for HIV positive patients: HIV infection is transformed from a death sentence to a

chronic, manageable condition

If people are otherwise healthy, practicing safe sex, and reducing other risks of transmission it is extremely unlikely they will transmit HIV to another person while on HAART (“treatment as prevention”)

Treatment as prevention

Concept pioneered by Dr. Julio Montaner and team at BC Centre for Excellence in HIV/AIDS

• HPTN 052 (phase 3 clinical trial) Randomized trial involving 1763 HIV discordant

couples in 9 countries Due to run until 2015, but interim results led

monitoring board to publicly release results in 2011

Demonstrated a 96% reduction in risk of HIV transmission for immediate versus delayed HAART

Types of testing encounters

Client initiated – client asks for testing based on perceived risk assessment

Risk assessment based – provider gathers info on HIV risk factors, determines need for test

Routine provider initiated – use of a defined threshold from which to offer HIV testing

Standard of care (“opt out”) – patient informed that test will be performed as part of routine screening unless it is specifically declined

Why test patients with no risk factors?

Everyone who has ever been sexually active is at some risk of HIV

Patients don’t always know if they are at risk and they rarely tell their health care providers even if they do know

HIV testing is simple, inexpensive, and acceptable to most patients

Types of testing Nominal – normal lab testing with

patient identifiers Non-nominal – lab testing using an

identity code that is only identifiable to patient and provider

Anonymous – only legal use is for HIV testing; only patient knows their true identity; patient does not have access to early therapy or other clinical supports without further identification

Barriers to HIV testing in practice - real and perceived

Insufficient time Competing priorities Lack of knowledge and training Burden of consent, counselling

requirements Lack of patient acceptance Inadequate reimbursement Paperwork

What about pre-test counselling?

Detailed pre-test counselling is increasingly being recognized as a barrier to testing

For most patients, offer the test as part of routine care and provide written info for those who have questions

Sample statement: “I recommend an HIV test for all my patients, whether or not they think they are at risk.”

Moving forward

Prevention Education Support

On the Horizon - HIV prevention technologies -

HIV prevention options that are still in clinical trials Preventive vaccines Vaginal and rectal microbicides Pre-exposure prophylaxis(Treatment as prevention)(Medical male circumcision)

Questions/Discussion