1 / 52

Women and HIV testing

2. Contents. Epidemiology of HIV in women. Underdiagnosis and late recognition of HIV . Increasing the uptake of testing. Target groups. Testing protocols, methods and settings. Pre- and post-test counselling. Case studies. Disclosure and confidentiality. Criminalisation of HIV transmission. . . . .

hollace
Download Presentation

Women and HIV testing

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Women and HIV testing This slide presentation has been produced as part of the Women for Positive Action initiative. Women for Positive Action aims to empower, educate and support women with HIV and the healthcare providers who treat them These slides overview: The HIV epidemic in women and The need to improved HIV testing, treatment access and prevention of onward transmission Initiatives to improve HIV testing The practical implementation of HIV testing guidelines The Women for Positive Action educational slide kits are intended for use by healthcare professionals, community representatives and patients who want to create or participate in learning opportunities relating to improving the care of women living with HIV. If you have any questions about WFPA and sponsorship please email the WFPA secretariat: wfpa@litmus-mme.com. This kit contains a PowerPoint presentation and a learning guide in Word format for use in any non-commercial setting. These files are provided by the Women for Positive Action initiative. By requesting these materials, you are agreeing to use them as provided. However, if you choose to significantly adapt or edit these slides, change the meaning or context of the information, or use them for a purpose other than that outlined above, you accept responsibility for the content of your presentation and agree to use a different slide template. Accuracy of Information and Disclaimer We do our best to ensure that all information and material on the slides is accurate as at 8 July 2009, and if you find anything that is inaccurate let us know and we will correct it as soon as practicable. We provide use of these resources free of charge and do so on the basis that we have no liability for their use. Women for Positive Action is supported by a grant from Abbott.This slide presentation has been produced as part of the Women for Positive Action initiative. Women for Positive Action aims to empower, educate and support women with HIV and the healthcare providers who treat them These slides overview: The HIV epidemic in women and The need to improved HIV testing, treatment access and prevention of onward transmission Initiatives to improve HIV testing The practical implementation of HIV testing guidelines The Women for Positive Action educational slide kits are intended for use by healthcare professionals, community representatives and patients who want to create or participate in learning opportunities relating to improving the care of women living with HIV. If you have any questions about WFPA and sponsorship please email the WFPA secretariat: wfpa@litmus-mme.com. This kit contains a PowerPoint presentation and a learning guide in Word format for use in any non-commercial setting. These files are provided by the Women for Positive Action initiative. By requesting these materials, you are agreeing to use them as provided. However, if you choose to significantly adapt or edit these slides, change the meaning or context of the information, or use them for a purpose other than that outlined above, you accept responsibility for the content of your presentation and agree to use a different slide template. Accuracy of Information and Disclaimer We do our best to ensure that all information and material on the slides is accurate as at 8 July 2009, and if you find anything that is inaccurate let us know and we will correct it as soon as practicable. We provide use of these resources free of charge and do so on the basis that we have no liability for their use. Women for Positive Action is supported by a grant from Abbott.

    2. 2 Contents

    3. Epidemiology of HIV in women

    4. 4 Epidemiology of HIV in women Globally, almost half the 33 million people living with HIV are women1 Women’s share of infection is rising1 Women represent a growing segment of the HIV epidemic Almost 50% of the 33 million people living with HIV in the world are women and girls1 The number of HIV-positive women is rising in all parts of the world, not just in developing countries1 In 2006, the proportion of new HIV cases that were women was approximately 35% in West Europe, 26% in Central Europe and 41% in East Europe2 In 2002, the rates were 34% WE, 32% CE and 32% EE In Canada, the incidence of HIV infection in women rose from 24%-27% between 2002 and 20053 References Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global HIV/AIDS epidemic 2008. July 2008. www.unaids.orgECDC EuroHIV. HIV/AIDS surveillance in Europe. End-year report 2006. 2007 no.75. Accessed November 2008. www.eurohiv.org Public Health Agency of Canada. HIV/AIDS Epi updates. November 2007 Women represent a growing segment of the HIV epidemic Almost 50% of the 33 million people living with HIV in the world are women and girls1 The number of HIV-positive women is rising in all parts of the world, not just in developing countries1 In 2006, the proportion of new HIV cases that were women was approximately 35% in West Europe, 26% in Central Europe and 41% in East Europe2 In 2002, the rates were 34% WE, 32% CE and 32% EE In Canada, the incidence of HIV infection in women rose from 24%-27% between 2002 and 20053 References Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global HIV/AIDS epidemic 2008. July 2008. www.unaids.orgECDC EuroHIV. HIV/AIDS surveillance in Europe. End-year report 2006. 2007 no.75. Accessed November 2008. www.eurohiv.org Public Health Agency of Canada. HIV/AIDS Epi updates. November 2007

    5. 5 Heterosexual transmission as a key driver of new infections in Europe and Canada Heterosexual contact is a leading cause of HIV transmission in many countries1–4 MSM = men who have sex with men; IDU = intravenous drug use References EuroHIV. HIV/AIDS surveillance in Europe. End-year report 2006. 2007 no.75. Accessed November 2008. www.eurohiv.org Public Health Agency of Canada. HIV/AIDS Epi updates. November 2007 Pan American Health Organization. Gender and HIV. Accessed November 2008. www.paho.org Larkin J et al. HIV in women: recognizing the signs. Medscape General Medicine 1999: 1(1). www.medscape.com Heterosexual contact is a leading cause of HIV transmission in many countries1–4 MSM = men who have sex with men; IDU = intravenous drug use References EuroHIV. HIV/AIDS surveillance in Europe. End-year report 2006. 2007 no.75. Accessed November 2008. www.eurohiv.org Public Health Agency of Canada. HIV/AIDS Epi updates. November 2007 Pan American Health Organization. Gender and HIV. Accessed November 2008. www.paho.org Larkin J et al. HIV in women: recognizing the signs. Medscape General Medicine 1999: 1(1). www.medscape.com

    6. 6 Heterosexual transmission as the main route of infection for women Heterosexual transmission and is the predominant mode of transmission among women globally, in West and Central Europe and in Canada1–4 In 2006, there were 19,990 new HIV diagnoses in West Europe, 1805 in Central Europe and 59,866 in East Europe1 There were 2300–4500 newly diagnosed patients with HIV in Canada in 20052 MSM = men who have sex with men; IDU = intravenous drug use References EuroHIV. HIV/AIDS surveillance in Europe. End-year report 2006. 2007 no.75. Accessed November 2008. www.eurohiv.org Public Health Agency of Canada. HIV/AIDS Epi updates. November 2007 Pan American Health Organization. Gender and HIV. Accessed November 2008. www.paho.org Larkin J et al. HIV in women: recognizing the signs. Medscape General Medicine 1999: 1(1). www.medscape.com Heterosexual transmission and is the predominant mode of transmission among women globally, in West and Central Europe and in Canada1–4 In 2006, there were 19,990 new HIV diagnoses in West Europe, 1805 in Central Europe and 59,866 in East Europe1 There were 2300–4500 newly diagnosed patients with HIV in Canada in 20052 MSM = men who have sex with men; IDU = intravenous drug use References EuroHIV. HIV/AIDS surveillance in Europe. End-year report 2006. 2007 no.75. Accessed November 2008. www.eurohiv.org Public Health Agency of Canada. HIV/AIDS Epi updates. November 2007 Pan American Health Organization. Gender and HIV. Accessed November 2008. www.paho.org Larkin J et al. HIV in women: recognizing the signs. Medscape General Medicine 1999: 1(1). www.medscape.com

    7. 7 Diversity in women living with HIV Although heterosexual transmission is becoming increasingly common, the other routes of infection are still represented: Drug use Iatrogenic transmission Vertical infection Each woman will have an unique history and issues to consider

    8. 8 Women’s vulnerability to HIV Biological factors1–3 Greater surface area of tissues in female sexual organs, delicate tissues that can tear easily Ejaculate in direct contact with vaginal and cervical mucosal tissue Ejaculate released in larger quantities with higher viral load than female secretions Psychological factors2,4 Gender norms and inequalities (control over avoiding risk behaviour, frequency and nature of sexual interactions) Violence4 Forced sex may cause damage May prevent women from safe-sex negotiations, being tested, disclosing HIV status, receiving treatment Male to female heterosexual HIV transmission is 1.9 times more likely than female to male1 A number of biological factors contribute to the increased susceptibility of women For example, women have a larger area of mucosal tissue that can tear during sexual intercourse2 Semen contains a higher titre of HIV compared with vaginal secretions and comes into direct contact with the mucosal membranes of the female3 Gender inequalities and stigma may restrict the power women have over their own lives and relationships Women may have more limited power and control within relationships over the frequency and nature of sex, including use of condoms2,4 Physical, sexual or emotional violence brings an additional burden4. Violent sex can heighten the risk of transmission by causing tears and lacerations Fear of violence may also prevent women from negotiating sexual behaviour, disclosing their HIV status and/or accessing healthcare References European Study Group on Heterosexual Transmission of HIV. Comparison of female to male and male to female transmission of HIV in 563 stable couples. BMJ 1992; 304(6830): 809-813 Pan American Health Organization. Gender and HIV. Accessed November 2008. www.paho.org Larkin J et al. HIV in women: recognizing the signs. Medscape General Medicine 1999: 1(1). www.medscape.com WHO. Gender inequalities and HIV. Accessed November 2008. www.who-int Male to female heterosexual HIV transmission is 1.9 times more likely than female to male1 A number of biological factors contribute to the increased susceptibility of women For example, women have a larger area of mucosal tissue that can tear during sexual intercourse2 Semen contains a higher titre of HIV compared with vaginal secretions and comes into direct contact with the mucosal membranes of the female3 Gender inequalities and stigma may restrict the power women have over their own lives and relationships Women may have more limited power and control within relationships over the frequency and nature of sex, including use of condoms2,4 Physical, sexual or emotional violence brings an additional burden4. Violent sex can heighten the risk of transmission by causing tears and lacerations Fear of violence may also prevent women from negotiating sexual behaviour, disclosing their HIV status and/or accessing healthcare References European Study Group on Heterosexual Transmission of HIV. Comparison of female to male and male to female transmission of HIV in 563 stable couples. BMJ 1992; 304(6830): 809-813 Pan American Health Organization. Gender and HIV. Accessed November 2008. www.paho.org Larkin J et al. HIV in women: recognizing the signs. Medscape General Medicine 1999: 1(1). www.medscape.com WHO. Gender inequalities and HIV. Accessed November 2008. www.who-int

    9. Underdiagnosis and late recognition of HIV

    10. 10 Underdiagnosis and late recognition of HIV Of those living with HIV: In Europe and Canada, ~15–50% are undiagnosed1 In Canada, ~27% are unaware of their infection2 In the UK, ~33% are undiagnosed3 In the UK, ~25% had low CD4 counts on diagnosis indicating late diagnosis3 In France, ~33% were diagnosed late4 In spite of highly effective treatment being available, HIV is under-diagnosed In Europe, up to 50% of HIV-positive individuals remain undiagnosed1 In the UK, one-third of the HIV population is thought to be unrecognised and in 25% of newly diagnosed individuals the CD4 count has already fallen to <200 cells/mm3, indicating late identification2 Similarly, in a random sample of 2932 HIV-positive patients attending an HIV outpatient clinic in France, one-third had a CD4 cell count <200 cells/mm3 at diagnosis3 In Canada, an estimated 27% of those living with HIV remain unidentified4 References ECDC. HIV testing in Europe: from policies to effectiveness. 2008. www.ecdc.europa.eu Public Health Agency of Canada. HIV/AIDS Epi updates. November 2007 British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org Delpierre C et al. Correlates of late HIV diagnosis: implications for testing policy. Int J STD AIDS 2007; 18(5): 312-317 In spite of highly effective treatment being available, HIV is under-diagnosed In Europe, up to 50% of HIV-positive individuals remain undiagnosed1 In the UK, one-third of the HIV population is thought to be unrecognised and in 25% of newly diagnosed individuals the CD4 count has already fallen to <200 cells/mm3, indicating late identification2 Similarly, in a random sample of 2932 HIV-positive patients attending an HIV outpatient clinic in France, one-third had a CD4 cell count <200 cells/mm3 at diagnosis3 In Canada, an estimated 27% of those living with HIV remain unidentified4 References ECDC. HIV testing in Europe: from policies to effectiveness. 2008. www.ecdc.europa.eu Public Health Agency of Canada. HIV/AIDS Epi updates. November 2007 British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org Delpierre C et al. Correlates of late HIV diagnosis: implications for testing policy. Int J STD AIDS 2007; 18(5): 312-317

    11. 11 Problems of remaining undiagnosed Risks to the individual Late diagnosis increases mortality and morbidity as access to treatment is denied1,2 24% of deaths in HIV-positive people in the UK were directly attributed to late diagnosis1 43% of people in France diagnosed late had already progressed to AIDS3 HAART can be less effective if started late1 Risks to others More likely to pass on infection and engage in risk behaviour1 Late diagnosis has a major impact on morbidity in HIV infection, and may cause a 10-fold excess in mortality1,2 For example, a national audit in the UK in 2006 found that 24% of deaths in those with HIV were a direct result of late diagnosis1 In a random sample of 2932 patients attending HIV outpatient services in France, one-third had a CD4 count <200 cells/mm3 at diagnosis; and 43% of these had already progressed to AIDS3 Highly active antiretroviral therapy (HAART) should not be started too late to offer effective treatment3 The European Centre for Disease Prevention and Control (ECDC) recommends starting treatment while CD4 counts are >350 cells/mm3 to more effectively reconstitute and protect the immune system2 Diagnosis has an important impact on public health, as while a person is not diagnosed, they are more likely to continue high-risk behaviours and transmit the virus to others1 References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org ECDC. HIV testing in Europe: from policies to effectiveness. 2008. www.ecdc.europa.eu Delpierre C et al. Correlates of late HIV diagnosis: implications for testing policy. Int J STD AIDS 2007; 18(5): 312-317Late diagnosis has a major impact on morbidity in HIV infection, and may cause a 10-fold excess in mortality1,2 For example, a national audit in the UK in 2006 found that 24% of deaths in those with HIV were a direct result of late diagnosis1 In a random sample of 2932 patients attending HIV outpatient services in France, one-third had a CD4 count <200 cells/mm3 at diagnosis; and 43% of these had already progressed to AIDS3 Highly active antiretroviral therapy (HAART) should not be started too late to offer effective treatment3 The European Centre for Disease Prevention and Control (ECDC) recommends starting treatment while CD4 counts are >350 cells/mm3 to more effectively reconstitute and protect the immune system2 Diagnosis has an important impact on public health, as while a person is not diagnosed, they are more likely to continue high-risk behaviours and transmit the virus to others1 References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org ECDC. HIV testing in Europe: from policies to effectiveness. 2008. www.ecdc.europa.eu Delpierre C et al. Correlates of late HIV diagnosis: implications for testing policy. Int J STD AIDS 2007; 18(5): 312-317

    12. 12 “Testing is the essential entry point to timely treatment.” Kevin DeCock, HIV/AIDS Director, WHO1 Reference 1. Shetty P. Kevin DeCock: guiding HIV/AIDS policy at WHO. The Lancet Infectious Diseases 2008: 8(2): 98-100Reference 1. Shetty P. Kevin DeCock: guiding HIV/AIDS policy at WHO. The Lancet Infectious Diseases 2008: 8(2): 98-100

    13. Increasing the uptake of HIV testing

    14. 14 Increasing the uptake of HIV testing Information campaigns to increase HIV testing among women should be: Especially targeted at hard-to-reach populations Tailored to different: Age groups Cultures Social groups Maintained over the long term Revised guidelines for HIV testing are more likely to affect women than men Women are more likely than men to be affected by efforts to increase HIV testing rates since they have a greater contact with the healthcare system and have an increased vulnerability to HIV infection1 Common reasons for women to present to healthcare include contraception, pregnancy, menopause, fertility treatment and sexually transmitted infections. They are also likely to consult for issues such as drug misuse and may be affected by other issues such as depression, anxiety, conduct disorders, post-traumatic stress disorder, history of violence and/or abuse Healthcare inequality remains in many countries, however with homeless, migrant and women from ethnic minorities suffering a lower rate of access to healthcare Reference 1. Madge S, et al. Access to medical care one year prior to diagnosis in 100 HIV-positive women. Family Practice 1997; 14: 255-257 Women are more likely than men to be affected by efforts to increase HIV testing rates since they have a greater contact with the healthcare system and have an increased vulnerability to HIV infection1 Common reasons for women to present to healthcare include contraception, pregnancy, menopause, fertility treatment and sexually transmitted infections. They are also likely to consult for issues such as drug misuse and may be affected by other issues such as depression, anxiety, conduct disorders, post-traumatic stress disorder, history of violence and/or abuse Healthcare inequality remains in many countries, however with homeless, migrant and women from ethnic minorities suffering a lower rate of access to healthcare Reference 1. Madge S, et al. Access to medical care one year prior to diagnosis in 100 HIV-positive women. Family Practice 1997; 14: 255-257

    15. 15 Revised WHO/UNAIDS guideline on HIV testing Testing should be ‘normalised’ Opt-out testing should be adopted Testing should be voluntary Must include the three Cs Testing and counselling can be carried out by any specifically trained doctor, midwife, nurse or healthcare worker In May 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) issued a revised guideline on HIV testing that encourages an international opt-out approach to expand access to testing and thereby improve diagnosis and treatment rates1 It does not advise mandatory testing of all individuals but seeks to normalise screening for this disease. An HIV test should be performed with the patient’s consent and within a confidential and supportive environment The guideline on HIV testing from the British HIV Association supports the ethos of the WHO/UNAIDS recommendations2 Testing and counselling may be undertaken by any doctor, midwife, nurse or healthcare worker. However, it is imperative that these personnel are adequately trained to ensure that patients’ rights are not violated and protocols are followed correctly References 1. WHO/UNAIDS. Guidance on provider-initiated HIV testing and counselling in health facilities. May 2007. 2. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org In May 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) issued a revised guideline on HIV testing that encourages an international opt-out approach to expand access to testing and thereby improve diagnosis and treatment rates1 It does not advise mandatory testing of all individuals but seeks to normalise screening for this disease. An HIV test should be performed with the patient’s consent and within a confidential and supportive environment The guideline on HIV testing from the British HIV Association supports the ethos of the WHO/UNAIDS recommendations2 Testing and counselling may be undertaken by any doctor, midwife, nurse or healthcare worker. However, it is imperative that these personnel are adequately trained to ensure that patients’ rights are not violated and protocols are followed correctly References 1. WHO/UNAIDS. Guidance on provider-initiated HIV testing and counselling in health facilities. May 2007. 2. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org

    16. 16 Opt-out and opt-in testing regimes: definitions Opt-out strategies Where everyone attending specific settings (e.g. antenatal clinics) is offered/recommended an HIV test as part of routine care The offer is made regardless of risk, symptoms etc The patient has the option to refuse the test Opt-out strategies increase the rate of HIV testing and may improve treatment outcomes and reduce the risk of transmission1–4 Opt-in strategies Individuals need to proactively request an HIV test May dissuade people from coming forward for testing There has been much debate that opt-out policies may be detrimental for women since they play on the relationship of trust between women and healthcare professionals, and the women may be coerced into taking the test If a woman takes a test because she feels that she cannot refuse, she may be less likely to return for the results and the delicate trust between women and their physicians may be lost If the availability of antenatal testing, and the wording used to offer it to women, is standardized it would lower refusal rates and prevent pre-judging a woman to be at risk or not. This would also prevent HIV from remaining undiagnosed in a women thought to be an ‘unlikely’ to be infected References 1. Simpson WM et al. Uptake and acceptability of antenatal HIV testing: randomised controlled trial of different methods of offering the test. BMJ 1998; 316: 262-267 2. Hakoos JS et al. Opt-out rapid HIV screening in the emergency department. Preliminary results from a prospective clinical trial. CROI 2008; Abstract 544b. 3. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org 4. National Collaborating Centre for Infectious Diseases. Routine (opt-out) HIV screening. June 2008. www.nccid.ca 5. Maman S, King E. Changes in HIV testing policies and the implications for women. J Midwifery Womens Health 2008; 53(3): 195-201 There has been much debate that opt-out policies may be detrimental for women since they play on the relationship of trust between women and healthcare professionals, and the women may be coerced into taking the test If a woman takes a test because she feels that she cannot refuse, she may be less likely to return for the results and the delicate trust between women and their physicians may be lost If the availability of antenatal testing, and the wording used to offer it to women, is standardized it would lower refusal rates and prevent pre-judging a woman to be at risk or not. This would also prevent HIV from remaining undiagnosed in a women thought to be an ‘unlikely’ to be infected References 1. Simpson WM et al. Uptake and acceptability of antenatal HIV testing: randomised controlled trial of different methods of offering the test. BMJ 1998; 316: 262-267 2. Hakoos JS et al. Opt-out rapid HIV screening in the emergency department. Preliminary results from a prospective clinical trial. CROI 2008; Abstract 544b. 3. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org 4. National Collaborating Centre for Infectious Diseases. Routine (opt-out) HIV screening. June 2008. www.nccid.ca 5. Maman S, King E. Changes in HIV testing policies and the implications for women. J Midwifery Womens Health 2008; 53(3): 195-201

    17. 17 Testing in pregnancy Universal antenatal HIV testing has been successful in:1 Improving the diagnosis rate in pregnancy Identifying HIV earlier Women can become HIV positive after initial testing during pregnancy If testing is not re-offered, and where partners are not tested In the UK, the rate of undiagnosed HIV infections in pregnant women has dropped from 18% in 2000 to fewer than 10% in 2006, since the introduction of routine opt-out HIV testing in antenatal settings1. Furthermore, the CD4 count at diagnosis is typically higher in this setting than in other female populations, indicating diagnosis at an earlier stage of the disease1 However, HIV positive women’s networks such as ICW and PozFem UK have highlighted that being diagnosed during pregnancy is very traumatic. Those networks recommend testing women (when possible) before they get pregnant, when accessing contraception or other health services.   Reference 1. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org In the UK, the rate of undiagnosed HIV infections in pregnant women has dropped from 18% in 2000 to fewer than 10% in 2006, since the introduction of routine opt-out HIV testing in antenatal settings1. Furthermore, the CD4 count at diagnosis is typically higher in this setting than in other female populations, indicating diagnosis at an earlier stage of the disease1 However, HIV positive women’s networks such as ICW and PozFem UK have highlighted that being diagnosed during pregnancy is very traumatic. Those networks recommend testing women (when possible) before they get pregnant, when accessing contraception or other health services.   Reference 1. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org

    18. 18 Opt-out HIV testing in pregnancy in Europe and Canada Routine opt-out HIV testing has become a normal part of antenatal care in Canada and many European countries1,2 References National Collaborating Centre for Infectious Diseases. Routine (opt-out) HIV screening. June 2008. www.nccid.ca Mounier-Jack S et al. HIV testing strategies across European countries. HIV Medicine 2008; 9(suppl 2): 13-19 Routine opt-out HIV testing has become a normal part of antenatal care in Canada and many European countries1,2 References National Collaborating Centre for Infectious Diseases. Routine (opt-out) HIV screening. June 2008. www.nccid.ca Mounier-Jack S et al. HIV testing strategies across European countries. HIV Medicine 2008; 9(suppl 2): 13-19

    19. 19 Refusing a test Refusing a test may: Be part of a denial mindset or have deeper roots, such as fear of the threat of violence, reluctance to question the HCP, language barriers Imply that the woman believes that she is HIV positive and does not want to be confronted with the truth Women who refuse antenatal HIV testing are more likely to be HIV positive1 Implications for onward transmission The new guidelines make it more difficult for a woman to say no to an HIV test; yet the test should still be voluntary The opt-out policy may increase the number of women coerced into taking the test; reports of tests being taken without a patient’s permission are unacceptable Refusing a test may not just be based on denial For some women, having an HIV test would expose them to violence from their partner. In some cultures a male relative may be required to give consent. Other women may not feel confident to question the advice given by medical professionals due to gender norms that limit a woman’s freedom to be proactive in their healthcare decisions. Furthermore, there may be a lack of sufficient understanding of what the woman is agreeing to Reference British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org Maman S, King E. Changes in HIV testing policies and the implications for women. J Midwifery Womens Health 2008; 53(3): 195-201. The new guidelines make it more difficult for a woman to say no to an HIV test; yet the test should still be voluntary The opt-out policy may increase the number of women coerced into taking the test; reports of tests being taken without a patient’s permission are unacceptable Refusing a test may not just be based on denial For some women, having an HIV test would expose them to violence from their partner. In some cultures a male relative may be required to give consent. Other women may not feel confident to question the advice given by medical professionals due to gender norms that limit a woman’s freedom to be proactive in their healthcare decisions. Furthermore, there may be a lack of sufficient understanding of what the woman is agreeing to Reference British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org Maman S, King E. Changes in HIV testing policies and the implications for women. J Midwifery Womens Health 2008; 53(3): 195-201.

    20. 20 Access to antiretroviral therapy Increasing the uptake of HIV testing is only part of the picture. It is important also to improve access treatment and care for those with HIV Many countries provide antiretroviral therapy that is free at the point of care, but there improvement to be made in terms of coverage and access to treatment Reference 1. UNAIDS. Report on the global AIDS epidemic, 2008. August 2008 Increasing the uptake of HIV testing is only part of the picture. It is important also to improve access treatment and care for those with HIV Many countries provide antiretroviral therapy that is free at the point of care, but there improvement to be made in terms of coverage and access to treatment Reference 1. UNAIDS. Report on the global AIDS epidemic, 2008. August 2008

    21. Target groups

    22. 22 Testing guidelines: Who should be tested? HIV screening is recommended for women in the following settings:1,2 Sexual health clinics Antenatal clinics Drug dependency programmes Healthcare services for those diagnosed with tuberculosis, lymphoma and hepatitis B or C Consider testing in all healthcare setting in areas of high prevalence of HIV infection1,2 The following slides summarize the testing guidelines from UNAIDS and the British HIV Association However, targeting groups considered to have risky behaviours or which come from places of high prevalence can be resented and the campaign to improve diagnosis can backfire References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org UNAIDS. HIV testing and counselling. Policy and practice. Accessed November 2008. www.unaids.orgThe following slides summarize the testing guidelines from UNAIDS and the British HIV Association However, targeting groups considered to have risky behaviours or which come from places of high prevalence can be resented and the campaign to improve diagnosis can backfire References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org UNAIDS. HIV testing and counselling. Policy and practice. Accessed November 2008. www.unaids.org

    23. 23 Testing guidelines: Who should be tested? HIV testing should be routinely recommended to women:1,2 Diagnosed with a sexually transmitted infection With an HIV-positive sexual partner Who have had sexual contact with a male who has sex with men With a history of drug use or a current or previous partner with a history of drug use From a country with high HIV prevalence Who have had sexual contact with an individual from a country with high HIV prevalence Presenting for healthcare where HIV is among the differential diagnoses UNAIDS publishes an updated list of countries with a high prevalence of HIV infection (i.e. >1%). Routine HIV testing must also be carried out on blood donors, dialysis patients and organ transplant donors and recipients1 References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org UNAIDS. HIV testing and counselling. Policy and practice. Accessed November 2008. www.unaids.org UNAIDS publishes an updated list of countries with a high prevalence of HIV infection (i.e. >1%). Routine HIV testing must also be carried out on blood donors, dialysis patients and organ transplant donors and recipients1 References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org UNAIDS. HIV testing and counselling. Policy and practice. Accessed November 2008. www.unaids.org

    24. 24 Testing guidelines: Clinical indicator diseases The next slides list the clinical indicator diseases for adult HIV infection, as described in the guidelines1. As HIV may be responsible for any of these diseases, an HIV test should be offered and recommended for all women presenting with these diseases Reference British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org 2. Liddicoat RV et al. Assessing missed opportunities for HIV testing in medical settings. J Gen Intern Med 2004; 19: 349-356. *indicates strong or reasonable strong likelihood for HIV cause2 The next slides list the clinical indicator diseases for adult HIV infection, as described in the guidelines1. As HIV may be responsible for any of these diseases, an HIV test should be offered and recommended for all women presenting with these diseases Reference British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org 2. Liddicoat RV et al. Assessing missed opportunities for HIV testing in medical settings. J Gen Intern Med 2004; 19: 349-356. *indicates strong or reasonable strong likelihood for HIV cause2

    25. 25 Testing guidelines: Clinical indicator diseases (cont’d) As HIV may be responsible for any of these diseases, an HIV test should be offered and recommended for all women presenting with these diseases1 *indicates strong or reasonable strong likelihood for HIV cause2 References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org 2. Liddicoat RV et al. Assessing missed opportunities for HIV testing in medical settings. J Gen Intern Med 2004; 19: 349-356. As HIV may be responsible for any of these diseases, an HIV test should be offered and recommended for all women presenting with these diseases1 *indicates strong or reasonable strong likelihood for HIV cause2 References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org 2. Liddicoat RV et al. Assessing missed opportunities for HIV testing in medical settings. J Gen Intern Med 2004; 19: 349-356.

    26. 26 Testing guidelines: Clinical indicator diseases (cont’d) As HIV may be responsible for any of these diseases, an HIV test should be offered and recommended for all women presenting with these diseases1 *indicates strong or reasonable strong likelihood for HIV cause2 References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org 2. Liddicoat RV et al. Assessing missed opportunities for HIV testing in medical settings. J Gen Intern Med 2004; 19: 349-356.As HIV may be responsible for any of these diseases, an HIV test should be offered and recommended for all women presenting with these diseases1 *indicates strong or reasonable strong likelihood for HIV cause2 References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org 2. Liddicoat RV et al. Assessing missed opportunities for HIV testing in medical settings. J Gen Intern Med 2004; 19: 349-356.

    27. 27 Testing guidelines: Who should be tested? Infants, children and young women1 Test if thought to be at significant risk of HIV, including those: With HIV-positive parents or siblings Whose mother had refused a test during pregnancy At high risk who present for fostering or adoption Arriving from countries of high HIV prevalence With signs or symptoms of HIV Being screened for congenital immunodeficiency Receiving post-exposure HIV prophylaxis With a history of sexual abuse The laws governing consent for testing minors varies between countries Reference British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org The laws governing consent for testing minors varies between countries Reference British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org

    28. Testing protocols, methods and settings

    29. 29 Testing guidelines: Frequency of testing POCT = point-of-care testing There is currently discussion on testing twice in pregnancy to pick up women who sero-convert during pregnancy. Reference 1. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org POCT = point-of-care testing There is currently discussion on testing twice in pregnancy to pick up women who sero-convert during pregnancy. Reference 1. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org

    30. 30 Testing guidelines: Which test to use? 4th generation assay Requires blood sample Identifies HIV antibody and p24 antigen Highly accurate Sample sent to laboratory for testing Results delayed POCT (point-of-care testing) Requires finger prick or mouth swab sample Reduced sensitivity and specificity versus assays (chance of false positive result) Test carried out on-site Results within minutes Viral load tests are not advised Viral load tests are not advised

    31. 31 Access to testing across Europe and Canada Access to free, anonymous HIV testing varies across European countries and Canada The slide shows the number of people tested for HIV per thousand population in key European countries in 20061 and Canada in 20032. Data are not available for other European countries. In Canada in 2003, 27% of individuals aged over 15 years had been tested for HIV2 References ECDC. ECDC factsheet on HIV in Europe 2006. Accessed November 2008. www.ecdc.europa.eu Public Health Agency of Canada. HIV/AIDS Epi updates. November 2007Access to free, anonymous HIV testing varies across European countries and Canada The slide shows the number of people tested for HIV per thousand population in key European countries in 20061 and Canada in 20032. Data are not available for other European countries. In Canada in 2003, 27% of individuals aged over 15 years had been tested for HIV2 References ECDC. ECDC factsheet on HIV in Europe 2006. Accessed November 2008. www.ecdc.europa.eu Public Health Agency of Canada. HIV/AIDS Epi updates. November 2007

    32. 32 Settings providing HIV testing HIV testing can be accessed via a range of settings in Europe1 *Access through primary care is highly variable and relatively few countries have a testing strategy that is led by the GP. In many countries, GPs have no role in HIV testing STI = sexually transmitted infections; TB = tuberculosis; NGO = non-government organizations Reference Mounier-Jack S et al. HIV testing strategies across European countries. HIV Medicine 2008; 9(suppl 2): 13-19. HIV testing can be accessed via a range of settings in Europe1 *Access through primary care is highly variable and relatively few countries have a testing strategy that is led by the GP. In many countries, GPs have no role in HIV testing STI = sexually transmitted infections; TB = tuberculosis; NGO = non-government organizations Reference Mounier-Jack S et al. HIV testing strategies across European countries. HIV Medicine 2008; 9(suppl 2): 13-19.

    33. 33 Community-based testing HIV testing previously available only in medical settings Current move to offer screening in the community since the introduction of new testing technologies Advantages1 May be preferred by patients Does not require patient to be registered with physician Can be focussed towards testing women Less stigmatisation Women may find it easier to disclose risk-taking behaviour to non-medical personnel The introduction of new HIV testing technologies such as point-of-care testing (POCT) has enabled community-based HIV screening to come into force. Many individuals prefer to be screened in a non-medical setting1. However, the limitations of POCT technologies versus conventional laboratory testing must be borne in mind; namely higher rates of false positive results, and a tendency for recent infection to remain undetected Reference 1. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org The introduction of new HIV testing technologies such as point-of-care testing (POCT) has enabled community-based HIV screening to come into force. Many individuals prefer to be screened in a non-medical setting1. However, the limitations of POCT technologies versus conventional laboratory testing must be borne in mind; namely higher rates of false positive results, and a tendency for recent infection to remain undetected Reference 1. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org

    34. Pre- and post-test counselling

    35. 35 Testing guidelines: Pre-test counselling The primary purpose is to obtain informed consent for the test Consent is mandatory Lengthy pre-test counselling is not usually necessary The patient must be given adequate time for her decision Explore reasons for refusals All women must be counselled before an HIV test1,2. Although pre-test counselling has been simplified recently, it is still an important prerequisite to testing and women should not be coerced into taking a test Written consent is not necessary and may indeed discourage patients from undergoing the test. Verbal consent is adequate. Consent is mandatory, however and women should not be tested against their will or without their knowledge Although a lengthy discussion is usually not required, some women may need more extensive explanations. It may be useful to explain why an HIV test has been recommended, for example when infection is among the differential diagnoses for the patient’s symptoms Women typically need more pre-test counselling than men in order to arrive at an informed decision. Preparation for the disclosure process begins at this point. The implications of disclosure for women can be immense and can be a major barrier to testing (see later slide) Women should be free to ask questions and not rushed into a decision If a patient opts out of screening, it is important to explore the reasons to rule out misunderstanding of the virus or the implications of HIV testing. The individual should be reassured that declining the test will not affect their access to medical treatment that does not depend on a confirmation of HIV status References WHO/UNAIDS. Guidance on provider-initiated HIV testing and counselling in health facilities. May 2007 British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org All women must be counselled before an HIV test1,2. Although pre-test counselling has been simplified recently, it is still an important prerequisite to testing and women should not be coerced into taking a test Written consent is not necessary and may indeed discourage patients from undergoing the test. Verbal consent is adequate. Consent is mandatory, however and women should not be tested against their will or without their knowledge Although a lengthy discussion is usually not required, some women may need more extensive explanations. It may be useful to explain why an HIV test has been recommended, for example when infection is among the differential diagnoses for the patient’s symptoms Women typically need more pre-test counselling than men in order to arrive at an informed decision. Preparation for the disclosure process begins at this point. The implications of disclosure for women can be immense and can be a major barrier to testing (see later slide) Women should be free to ask questions and not rushed into a decision If a patient opts out of screening, it is important to explore the reasons to rule out misunderstanding of the virus or the implications of HIV testing. The individual should be reassured that declining the test will not affect their access to medical treatment that does not depend on a confirmation of HIV status References WHO/UNAIDS. Guidance on provider-initiated HIV testing and counselling in health facilities. May 2007 British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org

    36. 36 Testing guidelines: Pre-test counselling Pre-test counselling should reinforce the benefits of revealing one’s HIV status, for example, limiting the risk of transmission to partners and offspring and being able to commence treatment that can reduce the likelihood of death or weakening of the immune system1,2. Treatment is more effective if begun earlier in the course of the disease and may help women to live otherwise healthy lives Pregnant women must be advised about transmission of HIV to infants, the measures that can be taken to reduce the risks, and the benefits for the infant of early diagnosis1 The concept of seroconversion will need to be discussed briefly so that women are aware that a negative result may be misleading and that a repeat test may be required Furthermore, both pre- and post-testing counselling should address the issues surrounding disclosure Although not specifically addressed in the clinical guidelines, should explore the woman’s individual circumstances and how these can impact on the test: for example, the possible route of infection, the woman’s social and family issues, her culture and migrant status References WHO/UNAIDS. Guidance on provider-initiated HIV testing and counselling in health facilities. May 2007 British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org Pre-test counselling should reinforce the benefits of revealing one’s HIV status, for example, limiting the risk of transmission to partners and offspring and being able to commence treatment that can reduce the likelihood of death or weakening of the immune system1,2. Treatment is more effective if begun earlier in the course of the disease and may help women to live otherwise healthy lives Pregnant women must be advised about transmission of HIV to infants, the measures that can be taken to reduce the risks, and the benefits for the infant of early diagnosis1 The concept of seroconversion will need to be discussed briefly so that women are aware that a negative result may be misleading and that a repeat test may be required Furthermore, both pre- and post-testing counselling should address the issues surrounding disclosure Although not specifically addressed in the clinical guidelines, should explore the woman’s individual circumstances and how these can impact on the test: for example, the possible route of infection, the woman’s social and family issues, her culture and migrant status References WHO/UNAIDS. Guidance on provider-initiated HIV testing and counselling in health facilities. May 2007 British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org

    37. 37 Testing guidelines: Post-test counselling Testing sites should have: Agreed method for communicating the results at the time of testing Recall systems for patients testing positive who fail to attend for their results Established relationship with treatment referral centres Counselling should be given once the test results are available, even if the result is negative1,2 The testing centre, or community testing service, must be linked to the local HIV treatment clinic and clear referral pathways in place to ensure women testing positive for the first time are able to access appropriate management and support promptly References WHO/UNAIDS. Guidance on provider-initiated HIV testing and counselling in health facilities. May 2007 British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org Counselling should be given once the test results are available, even if the result is negative1,2 The testing centre, or community testing service, must be linked to the local HIV treatment clinic and clear referral pathways in place to ensure women testing positive for the first time are able to access appropriate management and support promptly References WHO/UNAIDS. Guidance on provider-initiated HIV testing and counselling in health facilities. May 2007 British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org

    38. 38 Individualizing counselling The method and approach to HIV counselling and care will vary from woman to woman according to their unique needs and personal circumstances1 Religious and spiritual beliefs can influence a woman’s experience of HIV dramatically and may present specific challenges for treatment. For example, fasting periods may impact a woman’s ability to take her medication correctly. In addition, language and cultural barriers among migrant women can make communication and management difficult, leaving this group vulnerable2 References Myers T et al. HIV testing and counselling: test providers’ experiences of best practices. AIDS Educ Prevention 2003; 15(4): 309–319 Kreps GL, Sparks L. Meeting the health literacy needs of immigrant populations. Patient Educ Couns 2008; 71(3): 328–332The method and approach to HIV counselling and care will vary from woman to woman according to their unique needs and personal circumstances1 Religious and spiritual beliefs can influence a woman’s experience of HIV dramatically and may present specific challenges for treatment. For example, fasting periods may impact a woman’s ability to take her medication correctly. In addition, language and cultural barriers among migrant women can make communication and management difficult, leaving this group vulnerable2 References Myers T et al. HIV testing and counselling: test providers’ experiences of best practices. AIDS Educ Prevention 2003; 15(4): 309–319 Kreps GL, Sparks L. Meeting the health literacy needs of immigrant populations. Patient Educ Couns 2008; 71(3): 328–332

    39. 39 Individualizing counselling Prescribing for women must take into consideration the social roles of women. For example, acknowledging: Their future plans for, or likelihood of, becoming pregnant The impact of treatment side effects on their ability to look after family members, including HIV-positive children The convenience of regimens in relation to their daily activitiesPrescribing for women must take into consideration the social roles of women. For example, acknowledging: Their future plans for, or likelihood of, becoming pregnant The impact of treatment side effects on their ability to look after family members, including HIV-positive children The convenience of regimens in relation to their daily activities

    40. 40 Communication barriers Additional help may be required in the presence of: Language barriers Cultural issues Learning difficulties Mental health problems

    41. 41 Testing guidelines: A ‘negative’ result – the ‘window period’ Result is reassuring, BUT . . . The individual must be: During the ‘window period’, people infected with HIV have no antibodies. Since a small proportion of people take over 3 months to seroconvert after initial infection, the HIV test should be repeated if any high-risk activity has occurred within the past 3 months1,2 References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org Busch MP et al. Time course of viremia and antibody seroconversion following HIV exposure. Am J Med 1997; 102: 117-124 During the ‘window period’, people infected with HIV have no antibodies. Since a small proportion of people take over 3 months to seroconvert after initial infection, the HIV test should be repeated if any high-risk activity has occurred within the past 3 months1,2 References British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org Busch MP et al. Time course of viremia and antibody seroconversion following HIV exposure. Am J Med 1997; 102: 117-124

    42. 42 Testing guidelines: A positive result Results should be delivered: Clearly, with care and in person By the testing clinician – not via a third party In a private, confidential environment The individual must be: If a woman tests positive, it is imperative to explain that she is infectious and must take precautions against transmitting the virus to others1. Advice should be given as to which activities constitute a risk Furthermore, counselling should address the need for disclosure and suggest when and how this could occur and who they must tell. The threat of violence against a woman upon disclosure may need to be considered and steps taken to ensure her physical safety Additionally, for pregnant women, issues surrounding the birth plan, interventions to reduce the risk of transmission such as infant feeding options, treatment, and partner testing need to be discussed Women will need to be supported through this difficult time. In addition to medical care, a woman’s emotional wellbeing should be considered and psychosocial intervention may be required (see separate presentation on Emotional wellbeing of women living with HIV) as may referral to peer support Acceptance is a critical early step on a woman’s HIV journey. A positive therapeutic relationship between women and their healthcare professionals is fundamental to support women on this journey (see separate presentation on Supporting the patient-HCP relationship) Reference British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org If a woman tests positive, it is imperative to explain that she is infectious and must take precautions against transmitting the virus to others1. Advice should be given as to which activities constitute a risk Furthermore, counselling should address the need for disclosure and suggest when and how this could occur and who they must tell. The threat of violence against a woman upon disclosure may need to be considered and steps taken to ensure her physical safety Additionally, for pregnant women, issues surrounding the birth plan, interventions to reduce the risk of transmission such as infant feeding options, treatment, and partner testing need to be discussed Women will need to be supported through this difficult time. In addition to medical care, a woman’s emotional wellbeing should be considered and psychosocial intervention may be required (see separate presentation on Emotional wellbeing of women living with HIV) as may referral to peer support Acceptance is a critical early step on a woman’s HIV journey. A positive therapeutic relationship between women and their healthcare professionals is fundamental to support women on this journey (see separate presentation on Supporting the patient-HCP relationship) Reference British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. September 2008. www.bhiva.org

    43. 43 Disclosure and doctor–patient confidentiality Patient issues Behaviour to reduce risk of infecting partners Need for post-exposure prophylaxis for partners Barriers: fear of violence, abandonment, social isolation/ discrimination, fear of losing support from partner Criminalisation of HIV transmission Physician issues Preserve patient confidentiality unless special circumstances call for disclosure Doctors may be held liable for non-disclosure Although it may be mandatory, disclosure without the woman’s consent may ruin the doctor–patient relationship A positive diagnosis of HIV is still heavily stigmatised. Receiving the news is a shock and the thought of disclosing it to partners and family may seem unbearable Since the uptake of HIV testing is increasing, the problem of disclosure is likely to become a common issue for which women will need support and advice Some women may be at risk of violence, abandonment, financial loss, social discrimination and isolation Many national guidelines preserve patient confidentiality unless special circumstances call for disclosure, i.e. where non-disclosure represents a risk to the public or to another individual’s health. Indeed, there have been legal cases where doctors have been held accountable for non-disclosure Counselling before HIV testing should introduce the topic of disclosure and, in the event of a positive result, post-test counselling can explore the specifics of who and how to tell Peer support is essential in addressing Disclosure:  Sharing experiences Strategies Encouragement Role models A positive diagnosis of HIV is still heavily stigmatised. Receiving the news is a shock and the thought of disclosing it to partners and family may seem unbearable Since the uptake of HIV testing is increasing, the problem of disclosure is likely to become a common issue for which women will need support and advice Some women may be at risk of violence, abandonment, financial loss, social discrimination and isolation Many national guidelines preserve patient confidentiality unless special circumstances call for disclosure, i.e. where non-disclosure represents a risk to the public or to another individual’s health. Indeed, there have been legal cases where doctors have been held accountable for non-disclosure Counselling before HIV testing should introduce the topic of disclosure and, in the event of a positive result, post-test counselling can explore the specifics of who and how to tell Peer support is essential in addressing Disclosure:  Sharing experiences Strategies Encouragement Role models

    44. Case studies

    45. 45 Case study: Untested pregnant, migrant women 24 year old woman presents for prenatal care 29 weeks pregnant Recently migrated from Africa History of violence from husband who is a current drug user Has not been tested for HIV previously Woman refuses to agree to HIV screening What are the most significant aspects of her medical and family history? What barriers might this woman fact to HIV testing? How might she be feeling about being tested or the possibility of being HIV positive? What might persuade her to take a test? If she refuses, should a testing be re-offered?What are the most significant aspects of her medical and family history? What barriers might this woman fact to HIV testing? How might she be feeling about being tested or the possibility of being HIV positive? What might persuade her to take a test? If she refuses, should a testing be re-offered?

    46. 46 Case study: Discordant HIV test result 33 year old woman and male partner undertake HIV screening before stopping condoms and planning a family Woman screens HIV+ while partner screens HIV- Woman refuses to inform partner of her HIV+ result for fear of abandonment

    47. Disclosure and confidentiality

    48. 48 Issues to consider Disclosure and doctor-patient confidentiality Many national guidelines preserve confidentiality to patients except in special circumstances Pre- and post-test counselling should openly discuss HIV+ outcome and propose how to prepare for ‘bad news’ Cases of criminalisation of HIV+ patients who infected others, as well as doctors being criminally liable for non-disclosure Disclosure without the woman’s consent may be mandatory but consequences for trust within the doctor-patient relationship Many national guidelines preserve confidentiality to patients unless there are special circumstances – such as an overriding public interest or risk to another individual’s health Pre- and post-test counselling should openly discuss and anticipate such an outcome and propose how patients should prepare for ‘bad news’ There have been cases of criminalisation of HIV positive patients who infected others, as well as doctors being criminally liable for non-disclosure Disclosing to the HIV negative partner without the woman’s consent may be mandatory but will also have consequences for trust within the patient-HCP relationship that need to be anticipated Many national guidelines preserve confidentiality to patients unless there are special circumstances – such as an overriding public interest or risk to another individual’s health Pre- and post-test counselling should openly discuss and anticipate such an outcome and propose how patients should prepare for ‘bad news’ There have been cases of criminalisation of HIV positive patients who infected others, as well as doctors being criminally liable for non-disclosure Disclosing to the HIV negative partner without the woman’s consent may be mandatory but will also have consequences for trust within the patient-HCP relationship that need to be anticipated

    49. Criminalisation of HIV transmission

    50. 50 Criminalisation of HIV transmission In many jurisdictions the law is unclear in this area It is unlikely that a person could be successfully and ethically prosecuted for unintentional HIV transmission Some convictions in Europe have occurred in rare cases where individuals were aware of their status, for example: Scotland Stephen Kelly case (Glenochil judgement) – March 2001 (Scottish Common Law) Convicted of ‘recklessly injuring’ his former partner England Mohammed Dica, November 2003 Grievous bodily harm for knowingly infecting two women with HIV Conviction upheld at retrial in March 2005 In certain countries, transmitting or exposing another person to HIV has now been criminalised1. For example, in Scotland intravenous drug user Stephen Kelly was convicted after passing HIV to his female partner2. Similarly, in England, the first successful prosecution for HIV transmission was brought against Mohammed Dica2. Both convictions were based on the men acting recklessly or intentionally – as they were aware of their HIV status and the risk to their partners A case came to court in England sometime ago of an HIV+ve mother breast feeding, the outcome wasn’t clear as the mother disappeared. However, advice should be taken from in-country bodies However, it is unlikely that a person could be prosecuted for unintentional HIV transmission if they are ignorant of their own HIV status. The conviction in England of an undiagnosed HIV-positive man was a case where the patient had been treated for other sexually transmitted infections and warned of the high probability that he was HIV positive, but he failed to attend for a test.2 This is a complex area and as this may differ from country to country it is important to take country specific advice on the current legal thinking. References UNAIDS. Policy brief: Criminalization of HIV transmission. August 2008. www.unaids.org HIV transmission and the criminal law. Accessed November 2008. www.aidsmap.comIn certain countries, transmitting or exposing another person to HIV has now been criminalised1. For example, in Scotland intravenous drug user Stephen Kelly was convicted after passing HIV to his female partner2. Similarly, in England, the first successful prosecution for HIV transmission was brought against Mohammed Dica2. Both convictions were based on the men acting recklessly or intentionally – as they were aware of their HIV status and the risk to their partners A case came to court in England sometime ago of an HIV+ve mother breast feeding, the outcome wasn’t clear as the mother disappeared. However, advice should be taken from in-country bodies However, it is unlikely that a person could be prosecuted for unintentional HIV transmission if they are ignorant of their own HIV status. The conviction in England of an undiagnosed HIV-positive man was a case where the patient had been treated for other sexually transmitted infections and warned of the high probability that he was HIV positive, but he failed to attend for a test.2 This is a complex area and as this may differ from country to country it is important to take country specific advice on the current legal thinking. References UNAIDS. Policy brief: Criminalization of HIV transmission. August 2008. www.unaids.org HIV transmission and the criminal law. Accessed November 2008. www.aidsmap.com

    51. 51 Conclusions Expanded access to HIV testing will enable more women to access treatment for themselves and their families However, stigma surrounds HIV diagnosis and adequate support (medical, psychosocial and peer) should be made available for women Care must be taken with the consent process and in delivering the results Testing must be undertaken in an informed, voluntary and supportive environment Reference 1. Maman S, King E. Changes in HIV testing policies and the implications for women. J Midwifery Womens Health 2008; 53(3): 195-201 Reference 1. Maman S, King E. Changes in HIV testing policies and the implications for women. J Midwifery Womens Health 2008; 53(3): 195-201

    52. Thank you for your attention Any questions?

More Related