15 responses to “May I add an HIV test to your bloodwork today?”

  1. I fully agree with this way of offering HIV testing

  2. How often , in a “normal risk” should I repeat the HIV test?

  3. I will adopt same approach as outlined.

  4. good

  5. 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.

  6. Surely there are some relevant clinical questions to ask. Do statisticians make better physicians than do clinicians?

  7. 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?

  8. After reading this I will definitely order more hiv tests.

  9. 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.

  10. 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

  11. 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.

  12. 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.

  13. […] Dr. Marisa Collins’ This Changed My Practice article on routine HIV testing. Family physicians can earn 0.25 Mainpro M1 credits for commenting on the […]

  14. 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.

  15. 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.

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