“Its Different Now”: The Changing Landscape of HIV testing

1. “Its Different Now”: The Changing Landscape of HIV testing Cristin Muecke, RMOH Nick Scott, ED AIDS NB

2. 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

3. 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

4. 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)

5. 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”)

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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.”

12. Moving forward • Prevention • Education • Support

13. 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)

14. Questions/Discussion