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:
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.
- 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.
- 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)