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

2. 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

3. 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 ; 39(4):
Behavior change post diagnosis varies with time but is also being modified by the presence of HAART

4. 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 per year)

5. 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”)

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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.

12. Moving forward
Prevention
Education
Support

13. 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)

14. Questions/Discussion