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2013 HIV Screening and Testing Guide
A guide for care providers developed in response to the need
to reduce the number of undiagnosed HIV infections in Canada
Dr. Robert Gervais, CCDIC
PHPC Continuing Professional Development Day,
Ottawa, June 9th 2013
PHAC HIV Screening and Testing Guide
Foreword
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The HIV Screening and Testing Guide is designed to complement existing
efforts to support care providers involved in HIV testing, including primary
care providers, public health nurses, counsellors, social workers, community
health workers, midwives, community-based service providers and others in
an effort to reduce the number of undiagnosed HIV infections in Canada.
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The guide does not supersede any provincial/territorial legislative,
regulatory, policy and practice requirements or professional guidelines that
govern and inform the practice of care providers in their respective
jurisdictions.
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Care providers should comply with local Public Health regulations when
conducting HIV testing.
PHAC HIV Screening and Testing Guide
Background
HUMAN IMMUNODEFICIENCY VIRUS
HIV SCREENING AND TESTING GUIDE
An Ad Hoc Expert Working Group made up of
representatives with clinical and community
expertise in current HIV testing practices was
established to inform the development of the
Guide.
Further input was obtained through a literature
review, an online public consultation and input
from laboratory experts, STI experts, and
provincial and territorial governments.
The guidelines provide expert opinion and
evidence-informed recommendations reflecting
advances in our ability to detect and treat HIV
infection.
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PHAC HIV Screening and Testing Guide
Context
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An estimated 71,300 people in Canada (58,600-84,000) are currently living with
HIV infection of which an estimated 25% (14,500-21,500) are undiagnosed and
unaware that they are infected
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Evidence demonstrates that many people at “moderate risk” who are outside of
traditional high-risk populations are not being offered HIV testing
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Two recent Canadian surveys of the general population found that only 29% and
37% of respondents reported having ever been tested for HIV
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Conversely, evidence demonstrates that vulnerable populations have a high rate
of ever having been tested, but could benefit from more regular testing
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In spite of many interactions with the healthcare system, some “low-risk” clients
are testing HIV-positive at late stages of their HIV disease and cannot benefit
from available treatment.
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PHAC HIV Screening and Testing Guide
Opportunities
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Fourth generation tests can now detect HIV infection in the acute, and most
infectious, stage of infection - within 15 to 20 days of exposure for most
people
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Undiagnosed cases are a missed opportunity and represent a significant
public health challenge – single greatest contributor to the ongoing
transmission of HIV infection
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The longer people are unaware of their HIV infection the more likely they
are to unknowingly transmit the virus to others
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Every discussion around HIV testing is an opportunity to reinforce risk
reduction messaging for clients
PHAC HIV Screening and Testing Guide
Barriers to HIV Testing
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The literature identifies several barriers to offering HIV testing. The new
guide provides approaches to overcome these barriers.
REPORTED BARRIER
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RECOMMENDATIONS IN THE GUIDE
Inability to accurately assess
levels of risk for exposure to HIV
by some clients and providers
Normalise HIV testing; simplify risk assessments; make the consideration of
an HIV test part of periodic routine medical care.
Lack of comfort discussing HIV
testing and knowledge about HIV
among some clients and
providers
Normalise HIV testing; simplify risk assessments; make the consideration of
an HIV test a part of periodic routine medical care.
Provider time constraints for risk
assessments and pre- and posttest counselling
Simplify risk assessments; streamline the provision of pre-test information
using print, video, mobile and web-based resources; alternate approaches
offered to provide negative results.
Cumbersome consent
procedures
Verbal consent for HIV testing, as with other tests, is sufficient; testing remains
voluntary.
Fear of stigma and discrimination
associated with risk behaviours
and/or testing HIV-positive
Normalise HIV testing and simplify risk assessment to reduce discomfort and
stigma and increase uptake of testing; emphasize HIV as a chronic manageable
condition and the benefits of treatment to reduce fear of HIV diagnosis.
PHAC HIV Screening and Testing Guide
Key Recommendations
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Provider-initiated HIV testing discussion be made a part of periodic routine
medical care, moving away from an exclusive risk-based approach
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Greater integration of HIV testing as part of testing for other sexually
transmitted and blood borne infections, and as part of other related clinical
services such as tuberculosis, antenatal, hepatitis C, and drug/alcohol
treatment
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Flexible streamlined approaches based on the testing situation to make risk
assessment and counselling more time efficient
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PHAC HIV Screening and Testing Guide
Risk Assessment
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HIV testing does not necessarily involve in-depth assessments of sexual
risks or drug use behaviors
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Brief explanation of transmission risks such as:
» “HIV is transmitted primarily through unprotected sex, shared drug equipment
use and from a pregnant mother to her child. Would you like me to order an HIV
test as part of your blood work today?”
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Allows clients to assess their own risk without feeling obliged to disclose
information they might find sensitive
PHAC HIV Screening and Testing Guide
Who to Test?
• Those who request a test
• Pregnant women and those planning to become pregnant, and their
partners as appropriate
• Individuals presenting with symptoms and signs of HIV infection or with
illnesses associated with a weakened immune system
• Sexually active clients who have never been tested
• Individuals who have shared drug use equipment with a partner whose HIV
status is positive or unknown
• Victims of sexual assault
• Individuals who have had unprotected vaginal or anal intercourse with a
partner whose HIV status is positive or unknown
• Additional factors that can increase an individual’s risk for exposure to HIV
(e.g. multiple partnering, men with a history of sex with men, etc.)
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PHAC HIV Screening and Testing Guide
Frequency of retesting
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Individuals involved in high risk practices should be screening for HIV at
least annually
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Insufficient evidence to provide recommendations for exact frequency of
HIV testing for each scenario due to the number of variables involved with
each individual’s potential for exposure
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Care providers are encouraged to consider the following factors:
» Populations at increased risk (e.g. MSM)
» Characteristic of sexual partnering
» Local epidemiology
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PHAC HIV Screening and Testing Guide
Pre-test Counselling
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A streamlined approach recommends to quickly outline the benefits and
potential disadvantages of being tested for HIV infection including:
» Knowing ones HIV status and risk reduction practices
» Confidentiality vs. reporting positive results to public health
» Partner notification in the event of positive result (e.g. how it would work, public
health benefit)
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Consent does not have to be provided in writing; verbal consent is sufficient
» Clients do need to have a basic understanding of the advantages and
disadvantages of the test and be able to understand the test results
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Including HIV testing as part of a range of tests means that patients can be
told they will be asked to return for results only “if any of the test results are
of concern”
PHAC HIV Screening and Testing Guide
Post-test Counselling
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Negative test results do not have to be provided in person, but any time
results are provided it’s an opportunity to reinforce prevention messages for
people who may be at ongoing risk
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Post-test guidance for positive HIV test results include:
» Reiterating that HIV is a chronic manageable condition
» Discussing the benefits of entering into and being retained in care
» Providing the client with risk reduction information to prevent reinfection and
onward transmission
» Establishing a partner notification strategy
» Connecting clients with support and informational resources as needed
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PHAC HIV Screening and Testing Guide
Role of Public Health
as determined by applicable Public Health Acts
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Public Health will be notified or informed of any positive HIV test results as
per provincial or territorial legislation
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Public Health is recommended as a key resource to care providers needing
to provide local referrals to those newly diagnosed with HIV
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Care providers are encouraged to consult or engage local Public Health to
support with partner notification as appropriate
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The Guide directs care providers to report to Public Health any instance
where the actions or behaviours of an HIV-positive client presents a risk of
infection to others
PHAC HIV Screening and Testing Guide
Opportunities for knowledge transfer and exchange
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At the Family Medicine Forum 2012 of The College of Family Physicians of
Canada, PHAC developed a seminar on HIV/STI Guidelines and conducted a
needs assessment among 207 participants
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2/3 indicated they offered HIV testing to 25% or less of their patients in the past
year
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Following presentation of the Guide recommendations, 83% indicated a
willingness to expand the offer of HIV testing in their practice
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Increasingly preferred electronic formats to inform decision-making and update
clinical knowledge, but traditional methods are still valued
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PHAC HIV Screening and Testing Guide
Suggestions on how to promote uptake of the Guide
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Chief Medical Officers of Health
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MOH in local Public Health Units
» HIV/STI case management group
» Publications, Newsletters, etc.
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Conference and KT events
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Others?
PHAC HIV Screening and Testing Guide
Key Resources
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HIV Screening and Testing Guide & Appendixes
» http://www.catie.ca/en/resources/human-immunodeficiency-virus-screening-andtesting-guide
» http://www.catie.ca/fr/ressources/virus-limmunodeficience-humaine-guidedepistage-diagnostic-linfection-vih
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HIV transmission risk: A summary of the evidence
» http://www.catie.ca/sites/default/files/HIV-TRANSMISSION-RISK-EN.pdf
» http://www.catie.ca/sites/default/files/RISQUE-DE-TRANSMISSION-DU-VIHFR.pdf
HIV Screening and Testing Guide
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Condensed version of the Guide under development