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

Objectives Why HIV testing remains important Treatment as prevention Discuss advantages/disadvantages of various testing encounters Explore real and perceived barriers to HIV testing in clinical practice Promote normalization of HIV testing as part of comprehensive STI testing approaches

The Issue An estimated 25% of HIV infected persons in Canada are unaware of their status More likely to spread HIV in the population After being notified of their HIV status, newly diagnosed people substantially reduce frequency of unprotected behaviors 64% quoted by Marks G et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005; 39(4): 446-453. Behavior change post diagnosis varies with time but is also being modified by the presence of HAART

The Issue A substantial number of HIV infected persons are diagnosed late in their illness 60% are diagnosed after they should already be on treatment In US (2005), over a third of newly diagnosed cases developed AIDS within a year The Canadian annual incidence rate has remained largely unchanged for the past decade (estimated 2300-4300 per year)

HAART Highly Active AntiRetroviral Therapy makes it harder for the HIV virus to replicate, thus lower level of virus in the body Implications for HIV positive patients: HIV infection is transformed from a death sentence to a chronic, manageable condition If people are otherwise healthy, practicing safe sex, and reducing other risks of transmission it is extremely unlikely they will transmit HIV to another person while on HAART (“treatment as prevention”)

Treatment as prevention Concept pioneered by Dr. Julio Montaner and team at BC Centre for Excellence in HIV/AIDS HPTN 052 (phase 3 clinical trial) Randomized trial involving 1763 HIV discordant couples in 9 countries Due to run until 2015, but interim results led monitoring board to publicly release results in 2011 Demonstrated a 96% reduction in risk of HIV transmission for immediate versus delayed HAART The medial CD4 count at enrollment was higher than WHOs recommendation to start treatment. Hence, HIV positive individuals were asymptomatic, did not require treatment, and certainly would not have been eligible for treatment, according to most national guidelines.

Types of testing encounters Client initiated – client asks for testing based on perceived risk assessment Risk assessment based – provider gathers info on HIV risk factors, determines need for test Routine provider initiated – use of a defined threshold from which to offer HIV testing Standard of care (“opt out”) – patient informed that test will be performed as part of routine screening unless it is specifically declined Opt out testing can help normalize and destigmatize the testing process and has demonstrated greater test acceptance than opt in testing

Why test patients with no risk factors? Everyone who has ever been sexually active is at some risk of HIV Patients don’t always know if they are at risk and they rarely tell their health care providers even if they do know HIV testing is simple, inexpensive, and acceptable to most patients

Types of testing Nominal – normal lab testing with patient identifiers Non-nominal – lab testing using an identity code that is only identifiable to patient and provider Anonymous – only legal use is for HIV testing; only patient knows their true identity; patient does not have access to early therapy or other clinical supports without further identification

Barriers to HIV testing in practice - real and perceived Insufficient time Competing priorities Lack of knowledge and training Burden of consent, counselling requirements Lack of patient acceptance Inadequate reimbursement Paperwork

What about pre-test counselling? Detailed pre-test counselling is increasingly being recognized as a barrier to testing For most patients, offer the test as part of routine care and provide written info for those who have questions Sample statement: “I recommend an HIV test for all my patients, whether or not they think they are at risk.” Separate written consent for HIV testing should not be required.

Moving forward Prevention Education Support

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

Questions/Discussion