Cristin Muecke, RMOH Nick Scott, ED AIDS NB

 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

 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

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 per year)

 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”)

 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

 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

 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

 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

 Insufficient time  Competing priorities  Lack of knowledge and training  Burden of consent, counselling requirements  Lack of patient acceptance  Inadequate reimbursement  Paperwork

 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.”

 Prevention  Education  Support

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