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Women and HIV testing

Women and HIV testing. Women for Positive Action is supported by a grant from Abbott. 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.

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Women and HIV testing

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  1. Women and HIV testing Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  3. Epidemiology of HIV in women Women for Positive Action is supported by a grant from Abbott

  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 Proportion of HIV infections in women, by region Women for Positive Action is supported by a grant from Abbott

  5. Heterosexual transmission as a key driver of new infections in Europe and Canada Cause of transmission in all new HIV cases, in Europe1 and Canada2 % cases Women for Positive Action is supported by a grant from Abbott

  6. Heterosexual transmission as the main route of infection for women Cause of transmission in new HIV cases in women, in Europe1 and Canada2 % cases Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  9. Underdiagnosis and late recognition of HIV Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  12. “Testing is the essential entry point to timely treatment.” Kevin DeCock, HIV/AIDS Director, WHO1 Women for Positive Action is supported by a grant from Abbott

  13. Increasing the uptake of HIV testing Women for Positive Action is supported by a grant from Abbott

  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 for Positive Action is supported by a grant from Abbott

  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 Consent Confidentiality Counselling Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  18. Opt-out HIV testing in pregnancy in Europe and Canada Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  20. Access to antiretroviral therapy Women for Positive Action is supported by a grant from Abbott

  21. Target groups Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  24. Testing guidelines: Clinical indicator diseases Women for Positive Action is supported by a grant from Abbott

  25. Testing guidelines: Clinical indicator diseases (cont’d) Women for Positive Action is supported by a grant from Abbott

  26. Testing guidelines: Clinical indicator diseases (cont’d) Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  28. Testing protocols, methods and settings Women for Positive Action is supported by a grant from Abbott

  29. Testing guidelines: Frequency of testing Repeat test for:1 HIV-negative women but possible recent exposure In 7 days Annually or more frequent if symptoms of primary HIV infection Injecting drug users Women in antenatal care refusing test at booking visit (or HIV negative but risk factors for infection) Re-offer at 36 weeks. Consider POCT for infant once born if mother still refuses Women in labour presenting for first time Offer POCT Women for Positive Action is supported by a grant from Abbott

  30. 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 Testing guidelines: Which test to use? Women for Positive Action is supported by a grant from Abbott

  31. Access to testing across Europe and Canada Number of people tested for HIV, per 1000 population Women for Positive Action is supported by a grant from Abbott

  32. Settings providing HIV testing HIV centres STI clinics Common Antenatal clinics GP practices* TB services Less common NGOs Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  34. Pre- and post-test counselling Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  36. Testing guidelines: Pre-test counselling Discussiontopics How results will be given Availability of treatment Benefits of knowing HIV status Difference between HIV and AIDS Nature of HIV antibody test • process of seroconversion • window period for testing Possible need to tell others of positive result Women for Positive Action is supported by a grant from Abbott

  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 Women for Positive Action is supported by a grant from Abbott

  38. Individualizing counselling Socio-economic class Age Family issues Sexual issues Medical history HIV counselling should vary depending on the unique needs and personal circumstances of each woman . . . Pregnancy Support Stage of HIV journey Immigration Child-bearing potential Violence or sexual abuse Co-morbid problems (e.g. alcoholism, drug use, depression) Acceptance of diagnosis Culture or religion Language and understanding Women for Positive Action is supported by a grant from Abbott

  39. Individualizing counselling . . . and consider women in their social contexte.g. as a mother, a partner, a daughter, a caregiver Women for Positive Action is supported by a grant from Abbott

  40. Communication barriers • Additional help may be required in the presence of: • Language barriers • Cultural issues • Learning difficulties • Mental health problems Women for Positive Action is supported by a grant from Abbott

  41. Result is reassuring, BUT . . . The individual must be: Testing guidelines: A ‘negative’ result – the ‘window period’ HIV-ve • Retested if it is less than 3 months since the last risk-taking event the window periods means • Advised against further risk-taking activity Women for Positive Action is supported by a grant from Abbott

  42. 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: Testing guidelines: A positive result • Linked immediately to treatment and care • Educated on how to avoid infecting others, especially an HIV-negative partner • Assessed for immune status • Offered psychological and peer support HIV+ve Women for Positive Action is supported by a grant from Abbott

  43. 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 Disclosure and doctor–patient confidentiality Pre- andpost-test counselling should address the issue of disclosure Women for Positive Action is supported by a grant from Abbott

  44. Case studies Women for Positive Action is supported by a grant from Abbott

  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 How should this woman be managed? Which issues should be discussed with her during pre-test counselling? Can and should she be persuaded to take the test? Should the infant be tested once it is born? 45 Women for Positive Action is supported by a grant from Abbott

  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 As well as managing her diagnosis and potential pregnancy, what other issues should be considered? 46 Women for Positive Action is supported by a grant from Abbott

  47. Disclosure and confidentiality Women for Positive Action is supported by a grant from Abbott

  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 48 Women for Positive Action is supported by a grant from Abbott

  49. Criminalisation of HIV transmission Women for Positive Action is supported by a grant from Abbott

  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: • ScotlandStephen 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 Women for Positive Action is supported by a grant from Abbott

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