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BASICS OF HIV TESTING: HIV testing in a time-limited setting - Aleasha Hacault STI/HIV outreach RN - Ida-Lynn Gregan MD, CCFP.

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Presentation on theme: "BASICS OF HIV TESTING: HIV testing in a time-limited setting - Aleasha Hacault STI/HIV outreach RN - Ida-Lynn Gregan MD, CCFP."— Presentation transcript:

1 BASICS OF HIV TESTING: HIV testing in a time-limited setting - Aleasha Hacault STI/HIV outreach RN - Ida-Lynn Gregan MD, CCFP

2 N=125

3 Objectives Review current HIV testing recommendations, including HIV indicator conditions that should trigger testing Perform a basic HIV risk assessment Confidently offer HIV testing ( obtaining consent and offer the variety of testing available) Deliver an HIV +ve test result Perform an initial assessment on a newly diagnosed HIV+ve individual

4 A. HIV RISK ASSESSMENT Case Study 47 year old female (Susan) Aboriginal Recently divorced Dating for last 6 months Sexually active c/o notable change in vaginal discharge & experiencing dysuria

5 Demographic analysis new patients to care Manitoba HIV program, 2008-2010 2008 % 2009 % 2010 % Male57.5%55%75% Female40%45%25% Trans2.5% heterosexual71%52%63% endemic18%21%20% MSM23% 22% IDU15%13%16% Aboriginal26%43%38% Caucasian33%31%36% CD4 <20035%36%35% Total (N)8199102 *Risk Factors - Multiple responses; totals add up >100% 35%

6 26% HIV+ in Canada are unaware –Undiagnosed estimated to contribute to >50 % of new HIV infections. –Being aware of HIV status reduces risk behavior in majority of HIV+ –Missed benefit of treatment on decreased transmission Undiagnosed HIV need to test to diagnose!

7 Benefits of early HIV diagnosis Benefits to the infected individual – Antiretroviral therapy (ART) Reduced mortality & morbidity (near normal life expectancy) Benefits to the public health – Reduced onward transmission - Reduction in unsafe sexual behaviour (68%) - ART-reduced infectiousness ( x 96% in HPTN 0523) – Reduced health care costs

8 Cost-effectiveness of HIV testing (2010) Routine HIV Screening in France: Clinical Impact and Cost-Effectiveness. PLoS ONE 5(10): e13132.

9 Objectives –Increase screening –Foster early detection –Identify and counsel persons with unrecognized HIV infection and link them to clinical and preventative services –Reduce perinatal transmission US guidelines OPT-OUT September 22, 2006 Routine voluntary testing for patients ages 13-64 in all health care settings Persons at high risk should be screened annually No separate consent for HIV Prevention counseling should not be required

10 Test for HIV Unprotected sex (anal or vaginal w/o barrier) Sex under the influence of ETOH or drugs Tested +ve for an STI (GC, CT, Hep, syphilis) Shared needles/drug equipment Tatooing, piercing, or accupuncture (unsterile) Blood or blood products prior to Nov 1986 PHAC April 2012

11 Testing Only 5-10% of Manitobans (07-08) (Between Ages 15-65 yrs) Prevalence Manitoba:.3-.4% Prevalance Sasketchewan: 1%

12 HIDES (HIV Indicator Diseases in Europe Study) Indicator conditions: 1. AIDS-defining conditions (ADC) 2. Conditions associated with increased HIV prevalence (>0.1%) 3.Conditions where failure to diagnose HIV infection may have severe consequences for persons health - Dr. Keith Radcliffe, HIV Europe March 2012, Copenhagen

13 AIDS-defining conditions (ADC) Opportunistic infections – Fungal e.g. Pneumocystis jiroveci, cryptococcosis, histoplasmosis, candidiasis (oesophageal, tracheal, pulmonary) – Bacterial e.g. Tuberculosis (TB), disseminated Mycobacterium avium, recurrent pneumonia or salmonella septicaemia

14 AIDS-defining conditions (contd): Opportunistic (contd): – Parasitic e.g. cerebral toxoplasmosis, cryptospridiosis, microsporidiosis – Viral e.g. CMV retinitis, PML, persistent HSV Neoplasms – Non-Hodgkins lymphoma, Kaposis sarcoma, cervical carcinoma

15 Strongly recommend testing (HIV prevalence >0.1%) Sexually transmitted infections (4.06%)1 Lymphoma (0.29%)1 Anal cancer/dysplasia (2.90%)1 Cervical/anal dysplasia (0.37%)1 Herpes zoster (2.89%)1 Hepatitis B or C (0.36%)1 Mononucleosis-like illness (3.85%)1 Unexplained leucopaenia or thrombocytopaenia, >4 weeks (3.19%)1

16 Strongly recommend testing (HIV prevalence >0.1%), contd: Seborrheic dermatitis or exanthema (2.06%)1 Unexplained oral candidiasis (6-23%) Invasive pneumococcal disease (2.4%) Unexplained chronic fever (3%) Unexplained chronic diarrhoea (10-12%) Pregnancy (0.17%)

17 Consider offering testing: HIV prevalence likely >0.1% Primary lung cancer Lymphocytic meningitis Visceral leishmaniasis Oral hairy leucoplakia Severe or recalcitrant psoriasis Guillain-Barré syndrome Mononeuritis Peripheral neuropathy Subcortical dementia Multiple sclerosis like disease Unexplained weight loss Unexplained lymphadenopathy Unexplained renal failuire

18 Conditions where failure to diagnose HIV infection may have severe consequences: Prior to initiating aggressive immuno- suppressive therapy – Malignancy – Transplantation – Auto-immune disease Primary space occupying lesion of the brain

19 A. HIV RISK ASSESSMENT Case Study 47 year old female (Susan) Aboriginal Recently divorced Dating for last 6 months Sexually active c/o notable change in vaginal discharge & experiencing dysuria

20 A. HIV RISK ASSESSMENT Priority Assessment Type of partners (relationship) # of partnersType of sex Use of barriers Drug/ETOH as a part of sexual experience

21 A. HIV RISK ASSESSMENT 1. Number of partners?

22 A. HIV RISK ASSESSMENT 2. Type of partners/relationship? Known Unknown

23 A. HIV RISK ASSESSMENT 3. Use of barriers? Consistent/inconsistent use

24 A. HIV RISK ASSESSMENT 4. Type of sex? Vaginal Anal Oral Sex toys BDSM Non-penetrative

25 A. HIV RISK ASSESSMENT 5.Drug-use as a part of sexual experience? Drugs: legal/illegal drugs, alcohol

26 A. HIV RISK ASSESSMENT SUSANS RISK FACTORS: Sexually active with multiple partners in past year (6 mos.) with unknown sexual histories Vaginal, oral High and low risk sexual activities Known and anonymous partners Alcohol use as part of sexual experience

27 PERFORMING AN HIV TEST… 1.Point of Care Testing (POCT, rapid testing) 2.Nominal 3.Non-nominal 4.Anonymous

28 PERFORMING AN HIV TEST… 1.POCT Rapid results: within 60seconds to minutes Easy and minimally invasive (finger poke) Convenient in any setting Accurate: >or= 99.6% specificity and sensitivity


30 2.Nominal Test is ordered using full name of patient Known identity of person being tested Health Care Practitioner ordering test obligated to report positive results to Manitoba Health

31 PERFORMING AN HIV TEST… 3.Non-nominal Test is ordered using patients initials or code Only the person ordering the test knows the person being tested Health care provider ordering the test is responsible for notifying Manitoba Health of positive results Test results is linked and entered in patients chart

32 B. PERFORMING AN HIV TEST 4.Anonymous Test is ordered using a bar code Practitioner performing the test and lab do not know the identity of the person being tested Client returns to clinic to receive results with bar code ID card

33 B. PERFORMING AN HIV TEST Anonymous… If client loses card, no results can be given Anyone can return with found card and access results Paper copies of results are not provided

34 PERFORMING AN HIV TEST… Informed consent is required Verbal consent is required BUT Written consent is not required

35 C. OBTAINING CONSENT 1.Inform that you are performing test 2.Rationale/Indicators for test 3.Limitations 4.Consequences 5.Opportunity for patient to decline

36 CASE STUDY Nominal testing Indication: complete STI screen Limitation: window period Consequences explained Opportunity to decline Plan for follow-up

37 D. Delivering a positive result A.Negative Result Review Safer Sex Practices/Harm Reduction Window period

38 D. Delivering a positive result B.Positive Result Meaning of positive result Natural course of illness Management & treatment – Life expectancy – Quality of life

39 D. Delivering a positive result Coping Supports Prevention Universal precautions Safer sex Issues of disclosure Birth control Partner notification Public health

40 D. Delivering a positive result Safety Acute suicidality Threats of violence to self or others

41 D. Delivering a positive result Linkage to care Manitoba HIV program: P: 940-6089; 1-866- 449-0165 Fax: 940-6003 -HIV care and treatment -Counselling services -Social work; outreach -pharmacist --Dietician -Occupational Therapy

42 Initial Assessment of the HIV +ve individual: Dr. R. Barrios/ BC Centre for Excellence in HIV/AIDS: oads/Final%203- %20R.Barrios%20InitialAssessment_1.pdf

43 Initial assessment of the newly diagnosed HIV+ve patient: Points to cover: – Relevant past med history Recent hospitalizations, recurrent illnesses; past TB/exp; hepatitis – Current stressors and supports How is pt coping with diagnosis Any threats of violence towards pt in context of disclosure Review ability to adhere to safer sex practices Access to supports

44 Initial assessment (contd): Review of systems: – Weight loss, malaise, fever, night sweats (TB, advanced HIV, lymphoma) – Eyes: change in vision (CMV retinitis) – ENT: odynophagia, dysphagia, plaques or ulcers (esophageal candidiasis, HSV esophagitis, syphilis) – Resp: cough, either productive or non; dyspnea, hemoptysis (PCP, TB, recurrent pneumonias) – Cardiac: chest pain, palpns

45 Initial assessment (contd): Review of systems (contd): – GI: N/V, diarrhea (TB, MAC, cryptosporidiosis, advanced HIV) – GU: discharge, ulcers, warts (concurrent STIs, syphilis, HPV) – Obs/gyne: LMP (pregnancy) and pap/previous abn (cervical cancer) – Neuromuscular: peripheral numbness/tingling, or weakness (PML, CMV- associated mononeuropathy multiplex) – CNS: Headache (cryptococcal meningitis); cognitive or behavior changes (HIV-associated dementia, PML – progressvie multifocal leukoencephalopathy)



48 Manitoba HIV Program Structure in 2011 1050 patients: 98% in care – Infectious Disease Physicians – 540 patients at hospital site – 4 nurses – Social worker – Ideal patients for this structure Needs tertiary care services Has a health care provider that can co-manage with us – Family doctors dedicated in HIV Care – 480 patients at Community site – 6 nurses – Social Work – Counselors – Ideal patients for this structure Needs primary care MD in Wpg PHARMACIST dietician Health Promotion and Outreach Education and Prevention Programs

49 Goal: Link patients within 2 weeks

50 Questions???

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