Dr. Marisa Collins (biography and disclosures)
What I used to do
In family practice, I only occasionally recommended an HIV test outside of antenatal care. At the sexual health clinic, I encouraged ‘higher risk’ patients to get tested. But I did not routinely offer and recommend an HIV test to all adults, in either of my practices.
What changed my practice
Routine HIV testing for all adults is now recommended1,2 by Vancouver Coastal Health, Providence Health and the BC Centre for Excellence in HIV/AIDS. The United States3, United Kingdom4, France5 and the World Health Organization6 are among those preceding Canada with guidelines for expanded HIV testing. Specifics of those recommendations vary, but the goal is the same: to reduce the proportion of individuals with HIV infection who remain undiagnosed or present late for care.
It’s estimated that 1/4 of Canadians living with HIV are unaware that they are infected7. That translates to about 3,500 people in British Columbia2,8 who may unknowingly infect others with the virus, and who may benefit from treatment if diagnosed. In BC, about 65% of diagnoses occur after our patients should already be on treatment9, with up to 17% having advanced disease at the time of diagnosis10.
Rationale for routine HIV testing is summarized here in a few key points:
Treatment works
Highly active antiretroviral therapy (HAART) has changed HIV from death sentence to manageable chronic disease. People treated early can live long and productive lives, with lifespans approaching that of the general population11. BC’s HIV treatment guidelines recommend beginning antiretroviral (ARV) therapy earlier in the course of infection – at CD4 count of 500 cells/mm3, sometimes higher12. ARV medication is free in this province.
Treatment as prevention
HIV/AIDS researchers debated whether ARV treatment that effectively suppresses viral replication might also reduce transmission rates13. Then, the HIV Prevention Trials Network (HPTN) announced in May 2011 that the 052 clinical trial had demonstrated a 96% reduction in heterosexual HIV transmission14. “Because of HPTN 052’s profound implications for the future response to the AIDS epidemic”15, the journal Science chose it as 2011 Breakthrough of the Year.
Risk-based testing has fundamental limitations
Consider the Vancouver Mancount study16 in a population with known risk: 20% of gay men had never told a healthcare provider that they had sex with men; only 51 % had been tested for HIV in the previous year; and 23% of the under 30 years olds had never been tested. Improving how, when and who we ask about risk is clearly necessary; but it’s not sufficient. Up to 1/4 of people testing positive report no risk factors17. And even if they know, and we ask, many people still will not disclose their risk behaviors to us.
Expanded testing is cost effective
Evidence supports expanded HIV testing even when the HIV prevalence is as low as 0.5-2 cases per 100018. Estimates19 put Vancouver at 12/1000 diagnosed prevalence, and BC at 2.2/1000. Vancouver may skew BC’s rate estimate, but keep in mind that diagnosed prevalence is tied to testing activity. Therefore, a recommended approach is to begin routine testing and to reassess if no new cases are found after a large number of tests – e.g. if no new cases are identified after 4000 patients are tested, 95% CI for a prevalence of < 0.1% would have been achieved18. I would expect that Public Health will advise us when to stop, but they won’t have the data to do so until we actually start.
By the way, Vancouver’s acute care pilot project, where patients are offered HIV testing upon admission to hospital, has to date resulted in a new diagnosis rate of 10 per 100020 – not only cost-effective, but a rate that may be cost-saving21.
Missed opportunities for timely diagnosis under the old testing paradigm
In the Vancouver acute care pilot20 there have been 18 new diagnoses to date. Half have had CD4 counts of < 200 cells/mm3. Consistent with published research22, many have had multiple encounters with the healthcare system – including family physicians – prior to their diagnosis by consensual routine testing in hospital. These patients are ethnically diverse, one third are > 50 yrs old and most are male. The vast majority of patients offered a test accept20,23, but a much smaller proportion of eligible patients are offered one20.
Imagine if we all adopted a practice of routine HIV testing in both acute and community care – or even just began by ordering a couple more tests per day. We might alter the course of HIV for one of our patients… or perhaps for all of BC.
What I do now
I offer and recommend an HIV test to any adult who has not been tested in the past year:
- whenever other bloodwork is ordered;
- whenever I test for or diagnose a Sexually Transmitted Infection (STI), Hepatitis C or Tuberculosis2; and
- whenever I’m asked for an HIV test.
For patients with identified risk I recommend more frequent testing, e.g. every 3-6 months24. I continue to routinely recommend HIV testing with prenatal bloodwork.
I also:
- Make testing routine: “It is now recommended, and so I ask everyone…”. Normalizing language is destigmatizing, and routinizing the offer also helps me to remember. The majority of patients accept an HIV test when offered one20,23.
- Obtain verbal consent: “May I add an HIV test to your lab work?” As with all medical interventions, consent is required.
- Provide a print information handout25 to complete the information part of consent. The handout at HealthLink BC 26 is available in 6 languages.
- Chart as for any other tests.
- Manage negative results as for other tests.
Note that for most patients, extensive pre- and post-test counseling is no longer required25. That said, benefit from more discussion with my higher risk patients is expected – no different from other conditions where one assesses pre-test probability of a positive test to be high, or ongoing risk is known.
And when I lapse from the routine, I remind myself of my last HIV diagnosis – a woman in her early 20s. She came in for a PAP, and STI screening was offered because she hadn’t had that since getting together with her current partner. HIV testing was also recommended. Last I heard, she and her partner were both on ARVs and getting on with their lives.
Resources:
- Expanded HIV testing guidelines will improve early diagnosis. STOP HIV/AIDS Update No.3 Spring/Summer 2011 – page 3, for a succinct statement on new HIV testing recommendations. (View)
- Qaseem A, et al. Screening for HIV in health care settings: a guidance statement from the American College of Physicians and HIV Medicine Association. Ann Intern Med. 2009;150:125-131 – a good critical review of US Guidelines- (View with CPSBC). Or in brief: Graham L. ACP releases guidance statement on screening for HIV. Am Fam Physician. 2009;80:405-407. (View)
- Gilbert M, Krajden M. Don’t wait to test for HIV. BCMJ 2010;26:308 – B.C. specific information on testing frequency and window periods. (View)
- CTV News: Interview with Dr. Patricia Daly, Chief Medical Health Officer for Vancouver (View)
- Patient Handout from Health Link BC: HIV and HIV Tests – available in English, Chinese, French, Punjabi, Spanish, Vietnamese. (View)
- Physician Frequently Asked Questions (View)
- It’s Different Now is an award winning social media campaign that may lead your patients to ask you about HIV testing (View)
- Visit hiv.ubccpd.ca for more information and resources
STOP HIV/AIDS* and UBC Division of Continuing Professional Development have partnered to offer a range of educational opportunities about HIV testing, based on what physicians have told us is important. Visit http://hiv.ubccpd.ca for more information; for resources to help you with implementation of routine HIV testing in your practice; and to register for accredited educational offerings – including Webinars, Interactive Workshops, In-practice Support, and Linking Learning to Practice.
* Seek and Treat to Optimally Prevent (STOP) HIV/AIDS is a provincially funded project within Vancouver Coastal Health, Providence Health, Centre for Excellence in HIV & AIDS, and Northern Health – aimed at improving HIV care along the complete continuum, from detection through access and delivery. The HIV Testing Initiative in Family Practice is just one among Vancouver Coastal Health’s STOP HIV/AIDS projects. UBC Division of Continuing Professional Development is leading this initiative for Vancouver’s family physicians, with the aim of increasing HIV testing through physician engagement in quality educational programming.
References: (Note: Article requests require a login ID)
- Gustafson R, Steinberg M. Expanding provider-initiated HIV testing. BCMJ 2011;1: 13,49. (View)
- STOP HIV/AIDS Update No.3 Spring/Summer 2011. (View)
- Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR 2006;55(No. RR-14). (View)
- British HIV Association, British Association for Sexual Health and HIV, British Infection Society. UK national guidelines for HIV testing. September, 2008. (View)
- Haute Autorité de Santé. HIV infection screening in France: Screening Strategies. Executive Summary and Guidelines. October 2009. (View)
- World Health Organization. Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples – recommendations for a public health approach. Switzerland: April 2012. (View)
- Public Health Agency of Canada. Summary: Estimates of HIV Prevalence and Incidence in Canada, 2008. (View)
- BC Centre for Disease Control in Annual Surveillance Report: HIV and Sexually Transmitted Infections, 2010. Note: calculation is based on estimate of undiagnosed HIV 26%7 and Public Health Agency of Canada HIV prevalence estimate8. (View)
- Gustafson R. (Medical Health Officer, Vancouver Coastal Health, Vancouver, BC). BC Public Health Surveillance Unit and British Columbia Centre for Excellence in HIV/AIDS Drug Treatment Program: Data linkage project, 2011. Communication with: MB Collins (Physician Lead, HIV Testing Initiative in Family Practice, S.T.O.P. HIV/AIDS project, Vancouver Coastal Health). 5 July 2012.
- Rank C, et al. Advanced HIV disease at time of diagnosis in British Columbia,1995-2008. BC Centre for Disease Control Special Report, 2011. (View)
- May M, et al. Impact of late diagnosis and treatment on life expectancy in people with HIV-1: UK Collaborative HIV Cohort (UK CHIC) Study. BMJ 2011;343:d6016 doi: 10.1136/bmj.d6016 (View)
- BC Centre for Excellence in HIV/AIDS Therapeutic Guidelines Committee. Antiretroviral Treatment (ARV) of adult HIV infection. 2011. (View)
- Montaner JS, Hogg R, Wood E, et al. The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic. Lancet 2006;368:531-536. (View with CPSBC)
- Cohen MS, et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. N Engl J Med 2011;365:493-505. (View)
- Cohen J. Breakthrough of the year – HIV treatment as Prevention. Science 2011;334:1628. doi:10.1126/science.334.6063.1628. (View with CPSBC)
- Trussler T, et al. ManCount Sizes-up the Gaps: a sexual health survey of gay men in Vancouver. Vancouver Coastal Health: Vancouver, 2010. (View)
- Chou R, et al. U.S. Preventive Services Task Force. Screening for HIV: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2005;143:55-73. (View)
- Qaseem A, et al. Screening for HIV in health care settings: a guidance statement from the American College of Physicians and HIV Medicine Association. Ann Intern Med. 2009;150:125-131. (View with CPSBC)
- Gustafson R. (Medical Health Officer, Vancouver Coastal Health, Vancouver, BC). Vancouver: number of people known to BCCFE as being linked to care divided by Vancouver’s population; BC: BCCDC prevalence estimates divided by population above 15 years of age. Communication with: MB Collins (Physician Lead, HIV Testing Initiative in Family Practice, S.T.O.P. HIV/AIDS project, Vancouver Coastal Health). 22 June 2012.
- Gustafson R. (Medical Health Officer, Vancouver Coastal Health, Vancouver, BC). Communication with: MB Collins (Physician Lead, HIV Testing Initiative in Family Practice, S.T.O.P. HIV/AIDS project, Vancouver Coastal Health). 5 July 2012.
- Hutchinson AB, et al. Return on public health investment: CDC’s Expanded HIV Testing Initiative. J Acquir Immune Defic Syndr 2012;59:281-6. (View with CPSBC)
- Sullivan AK, et al. Newly diagnosed HIV infections: review in UK and Ireland. BMJ 2005;330:1301-2. (View)
- Health Protection Agency. Time to test for HIV: Expanding HIV testing in healthcare and community services in England. Final report, 2011. [accessed 1 July 2012] (View)
- Gilbert M, Krajden M. Don’t wait to test for HIV. BCMJ 2010;26:308. (View)
- BC Centre for Disease Control. Communicable Disease Control Manual Chapter 5 – Sexually Transmitted Infections, HIV Pre and Post Test Guidelines, September 2011. [accessed 15 June 2012] (View)
- Health Link BC. HIV and HIV Tests. STI Series – Number 08m September 2011. Available in English, Chinese, French, Punjabi, Spanish, Vietnamese. [accessed 13 June 2012] (View)
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I fully agree with this way of offering HIV testing
How often , in a “normal risk” should I repeat the HIV test?
I will adopt same approach as outlined.
good
I am sceptical about blanket HIV testing the whole population – one more cost to bear for the tax payer, to try and make up for good history taking! Screening hi-risk population is a good idea but screening patients you know well in your family practice for years is of doubtful benefit in my opinion. Screening the hi risk population – i.e all patients presenting with STD’s like G.C and Chlamydia Hep B,C for 22 years in a suburban practice of Vancouver in addition to testing everybody who requested HIV testing, without questions asked, has not yielded a single positive, outside one case which was already highly suspected by history. That is my personal experience, for whatever it is worth.
Surely there are some relevant clinical questions to ask. Do statisticians make better physicians than do clinicians?
I have patients concerned about HIV testing being doccumented in their clinical records and the impact it may have on future insurance applications. How valid is this concern?
After reading this I will definitely order more hiv tests.
I work mainly in First Nations Communities where, already when I order blood work I usually ask about and recommend HIV testing. So far, using this approach, I have not diagnosed any new cases, but I will continue to do the testing. I strongly support the study.
RE: Mukhtar Haidar’s question of how often
Right now, in the case of no identified risk, the recommendation is to offer a test if one has not been performed in the past year. Over time, this recommendation may evolve.
RE: b.meetarbhan’s comment “That is my personal experience, for whatever it is worth.” Our personal experiences are worth a great deal, as they inform our impressions of population prevalence in our own practices, and for many conditions we test for that is just about all the info we have on prevalence (which should inform our pre-test probability assessment about value of doing any test).
But don’t be fooled by the rarity of a condition, as that alone doesn’t determine the value of screening for it. Prenatal HIV screening at about 1 positive per 10,000 tests shouldn’t dissuade you from continuing that practice, though you’ve never had a positive. It is a bit of apples with oranges comparison, but both mammogram and pap screening have similarly low rates of positives per 1000 tests (in the general population of eligible women) as HIV screening may have in Vancouver. I expect you will continue to perform pap screening in your practice.
We simply haven’t done enough testing yet to learn what the regional differences for estimates of HIV prevalence may be. At an individual practice level, when you have tested 4000 people as part of routine practice, then you can say with 95% confidence that you have no HIV in your practice. In other words, at say 2/1000, most of us won’t diagnose a case. It doesn’t mean we shouldn’t test.
Sounds like you are already doing a bit more testing than many do. Please keep it up, and consider expanding some (e.g. offer an HIV test whenever you do an STI test). Thanks for the great comment, and I encourage you to attend one of UBC CPD’s free accredited education events: http://hiv.ubccpd.ca
RE: K Bazley’s question regarding insurance. You might reassure your patients that it will be documented in their chart as a routine offer of a recommended screening test (and then do that).
Most insurance companies also test for HIV. Also, we don’t refrain from other important screening (diabetes, cancer) because of concerns for insurance.
My anecdotal experience is the patients concerned about insurance are more likely to be at higher risk – those are people more informed of this concern (which historically really was an important issue for people with HIV or at risk for HIV). I explain that HIV is now a manageable chronic disease, but that people respond best to treatment if it is caught early – before symptoms develop. And that too many people are diagnosed late.
In the end though, it is your patients’ right to decline a test, as with any other investigation or intervention we offer.
If you’re in Vancouver, please consider attending one of our workshops, where we’ll go through scenarios such as this one.
http://hiv.ubccpd.ca
I may be biased in that I care for many patients with HIV infection. Many of my patients do not fit the “traditional risk” profile. Some examples: The heterosexual couple in their 80s who are both positive; The young, recently married professional heterosexual couple where one is positive and one negative, hoping to have a family soon (and they can!); The married couple in their 40s, where one is positive and stable on treatment for 10 years and the other partner remains negative- and they have just had a baby; The young single mom who found out she was HIV positive during routine prenatal testing – and her child is negative; The couple who have been together for 16 years and monogamous – so they thought, until one presented with an AIDS defining malignancy.
I have met several heterosexual people living in suburban and rural areas who have risk factors/behaviours unknown to their spouses, families, and GPs – they didn’t disclose this information until after testing positive. Sadly several patients I see have left their GPs because they felt they wouldn’t be treated compassionately and without judgment. I have a colleague with a patient that travels 5 hours for primary care appointments, claiming his original doctor would only see him at the end of the day because he has HIV!!
Clearly HIV is a bigger problem in Vancouver and other big cities, and clearly certain risk groups have higher prevalence. But there is ample research evidence that many patients do not disclose risk to their health care providers, even if clinicians do a good job at identifying these risks and asking – which many do not.
In terms of considering the tax payer, in Vancouver alone the return on cost is about 6-12 times greater than needed for cost effectiveness. Province wide we are above the cost effectiveness threshold in favour of routine testing. Improved regional estimates will only come after a period of expanded and sustained HIV testing.
Lets not forget we do many things in medicine not because they are cost effective, but because it’s the right thing to do, and because the consequences of not doing them are unacceptable. In this case, it’s both cost effective to test, and unacceptable not to.
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In practice, I routinely offer HIV testing to everyone whom I encounter for the first time and when there is no documented recent negative test results, even before the STOP program, mostly because I was aware of the 25-30% of those who are HIV positive not aware of their infection. I have yet to have a positive results.
Also, during my training in the hospital outside of Vancouver (thus not part of the Vancouver Acute Care Pilot Project), a man in his late 70’s who did not fit the “traditional risk profile” was diagnosed with HIV, but only after exhausting almost all the tests you could have ordered while in hospital, and saw numerous specialists after more than 8 weeks stay, without a single HIV test, all because he did not fit the “risky profile”. Only after he was informed of the diagnosis then he disclosed his “risky behaviour”: that he had sex in his younger days.
I fully agree that a good history is, and always will be, the heart of good medicine, but many of us probably have ordered B12, iron and TSH for routine unspecified “fatigue” and “unwell” work up, sometimes even for otherwise healthy screening bloodwork for “demanding” patients, but yet these tests are justified by ourselves and we do not question the burden on our limited healthcare resources. And I am quite sure the cost-effectiveness is much less than the routine screening for HIV.
To me, there is enough evidence to adopt such a practice for public health measures.
After reading the comments, including the ones expressing doubts of the new approach, I am even more convinced about the justification of casting the wide net approach, at least until we get more data to suggest otherwise. The inertia is to remember to add one more thing to the discussion in a regular office visit which is often already packed with other issues. I have already signed up to one of the HIV testing workshops offered by UBC CPD and hope to pick up some suggestions.