Dr. Sarah Stone (biography and disclosures)
Care gaps I have noticed
As a family physician practicing at St Paul’s Immunodeficiency clinic in Vancouver, I have cared for patients living with HIV for over 10 years. Patients who are newly diagnosed HIV positive are often directed to care at our multidisciplinary clinic through a referral from public health nurses or their family physician/care provider. Over the years I have identified two common features of these referrals that can unfortunately have a negative impact on patient care:
- Many patients are referred to the clinic at a stage of disease where treatment would have been beneficial if started earlier.
- Many patients have had several “missed opportunities” with a healthcare provider for an earlier diagnosis.
For example, I saw a young man diagnosed with HIV after profound immunosuppression while undergoing therapy for a malignancy. He was only tested after he developed recurrent thrush. His CD4 at the time of diagnosis was <100.
Another case involves a young female tested as part of a routine STI screen. She has less than 3 sexual partners; however one of those partners did not disclose he was actively having sex outside of their relationship. Her CD4 was 300 at diagnosis.
A final example was a middle-aged male who had been referred to over 3 specialists over 1 year for neurological difficulties. Multiple investigations had been performed until an HIV test was performed and this individual had a severe brain infection and a CD4 <10. Treatment was started very late in his disease; he died from this infection.
Data that should be considered
My own experience is supported by the data. Treatment for HIV is strongly recommended at a CD4 count ≤500 cells/mm3 1. However, in Vancouver from 2009 – 2011, 35% of new diagnoses had a CD4 count of < 350 cells/mm3 at the time of diagnosis; of these, approximately half had at least one prior encounter with a public healthcare provider in the past three years, and a quarter had at least one public lab test in the last three years2.
Late treatment and missed opportunities for earlier diagnosis occur partly as a result of risk-based HIV testing. As healthcare providers, we are not always aware of a patient’s ‘risk’3; from my experience we often find out about an individual’s risk for acquiring HIV only after the diagnosis.
The limitations of risk-based testing, combined with the fact that an estimated 26% of people with HIV are unaware they are infected4, have led to recommendations for routine HIV testing from Vancouver Coastal Health, Providence Health and the BC Centre for Excellence in HIV/AIDS5&6. This spring, the Public Health Agency of Canada issued new guidelines for HIV testing, recommending that an HIV test be considered and discussed as part of routine medical care7.
In Vancouver, opportunistic routine HIV testing has been recommended and implemented in primary care since July 2011. In this time testing has increased 58%; there have been 86 new positive diagnoses and a 0.4% positivity8. New diagnoses as a result of routine testing include patients who had been previously missed by their healthcare providers on many occasions.
When we start treatment earlier, patients have the opportunity to live long, healthy lives9. Our current HAART regimens are often between 1-3 pills daily and are typically well tolerated. In addition, HAART lowers HIV viral loads to a range that is undetectable, drastically reducing the likelihood of transmission10. As a result of appropriate testing and treatment, many of my patients have productive careers, healthy sexual relationships and healthy families. Conversely, late diagnosis and treatment limits the efficacy of treatment: life expectancy is significantly lower9. These patients are at risk of life threatening opportunistic infections and malignancies, and their battered immune systems take longer to recover.
We can only start treatment early when patients are diagnosed early. The estimated prevalence of HIV in BC is 2.6 per 1000*. Considering family physicians’ large daily patient loads, collectively we can play a vital role in reducing missed opportunities for diagnosis.
In terms of cost-effectiveness, evidence supports routine HIV testing even when prevalence is as low as 0.1%11. In the US, routine HIV testing is recommended until diagnostic yield is found to be below 0.1%11. BC’s estimated prevalence of HIV is 0.26%. Our diagnostic yield can only be determined through increased HIV testing.
* Estimated prevalence of HIV per 1000 calculated based the estimated number of people currently infected with HIV in BC12 over the population of BC13 (11,700/4,576,577=0.0026)
What I recommend now for all family physicians in BC
Family physicians can reduce the late diagnosis of HIV. I recommend that all family physicians integrate routine HIV testing into their practice, in accordance with the recommendations from Vancouver Coastal Health, Providence Health and the BC Centre for Excellence in HIV/AIDS5&6. Specifically, I recommend that an HIV test is offered to all adults who have not been tested in the past year. The following are good opportunities to offer an HIV test:
- when you order bloodwork for any reason
- when you test for or diagnose a sexually transmitted infection (STI)
- when you test for or diagnose Hepatitis C or Tuberculosis
- every time a patient requests an HIV test
- when patients present with diagnoses, signs or symptoms that may be related to HIV infection (which are broad and non-specific, see link below)
Patients with an identified risk may benefit from more frequent testing, e.g. every 3-6 months and an HIV test should continue to be ordered routinely with prenatal bloodwork.
Following a positive diagnosis
Even with routine HIV testing many family physicians will not encounter an HIV positive diagnosis. However, if you do diagnose a patient with HIV I recommend that you:
- Utilize the resources at hiv.ubccpd.ca (see below for a list)
- Contact local Public Health Nurses for advice
- Reassure your patient – treatment is effective, HIV is a manageable chronic disease
- Complete initial blood work – an example pre-filled lab requisition is included below
- Consider the options for shared care and referral so that you and your patient can make the optimal choice for their care
Resources
Routine HIV Testing
- Tools for implementing routine HIV testing in family practice, including a checklist, summary information sheets, FAQ, and tracking sheets. (View)
- Patient materials, including posters, HealthLink BC handouts and the public media campaign (View)
- Signs and symptoms that may be related to HIV infection (View)
HIV Positive Result
- One page flow sheet on referral options for a positive HIV result. (View)
- Who to contact if you have a positive result: (View)
- Prefilled Lab Requisition for the recommended bloodwork following an HIV positive diagnosis. (View)
- BCCDC guidelines on post-test discussion following a positive result. (View)
- Summary of ‘SPIKES’ protocol for breaking bad news for family physicians to use as a framework for delivering an HIV positive result to a patient. (View)
Upcoming Education
HIV Testing Workshop (3 Mainpro-C credits)
- Vancouver, Nov 26, 6-9PM (View)
- North Shore & Richmond – coming in early 2014 (email hiv.cpd@ubc.ca for information)
References
- BC Centre for Excellence in HIV/AIDS Therapeutic Guidelines Committee. Antiretroviral Treatment (ARV) of adult HIV infection. 2013. (View)
- Demlow E, MacDonald L, Nathoo A, Chu T, Sandhu J, Gustafson R. Missed Opportunities for HIV Diagnoses in Vancouver. 2013; Can J Infect Dis Med Microbiol.Vol 24 Suppl A. Spring . (Request print copy)
- Trussler T, et al. ManCount Sizes-up the Gaps: a sexual health survey of gay men in Vancouver. Vancouver Coastal Health: Vancouver. 2010. (View)
- Public Health Agency of Canada. Summary: Estimates of HIV Prevalence and Incidence in Canada. 2008. (View)
- 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)
- Public Health Agency of Canada. HIV Screening and Testing Guide. 2013. (View)
- BC Centre for Disease Control. HIV Test Volumes from selected clinics/hospitals in VCH, Quarterly Report (2007 – 2013). 2013
- 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)
- Cohen MS, et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. N Engl J Med. 2011;365:493-505. (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 or UBC)
- BC Centre for Disease Control. HIV in British Columbia: Annual Surveillance Report. 2012. (View)
- Statistics Canada. Population Estimate in 2011 for British Columbia: Annual Population. 2012 (View)
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nice summary.
I offer HIV, HCV and syphilis testing every time I test for G & C but often the patient declines. The difficulty working in an ED setting is ensuring adequate follow up and counselling, which in our current system is sometimes difficult to do.
This is a challenge for me. My 25 years of sporadic but not insignificant screening has yielded not a single positive result, my only case moved here after diagnosis, and as my practice ages the returns are unlikely to increase. I will try to screen more extensively but glucose, FIT, Mammo, Pap, depression, alcohol, and lipids seem more relevant in my catchment.
Will definitely change practice but the resources are Vancouver Lower mainland centric and need to be expanded to include the rest of the province!
I took the course on universal testing for HIV several months ago and was keen to start it at my Hospital the next day. (I am part of a large Hospitalist group in Fraser Health). However, I was asked not to do this as the sudden change in testing patterns would have overwhelmed our system. I am still waiting to be told that we can do universal testing; my threshold for testing is much lower than it used to be.
Thank you for your feedback.
As for the follow up in the ER, we recognized this could be a challenge in Vancouver when we implemented routine testing in Acute Care. A delegate follow-up process was created to avoid any concerns re: increased workload, or post testing follow-up. If you want to contact us, we can discuss this process with your MHO/Health authority etc.
With respect to increasing testing in a population where HIV prevalence is assumed to be low, I have 2 comments.
1. We will never know the true prevalence of HIV in a population of practice unless we test, and our current recommendations suggest we should test until we determine prevalence is below 0.1%. Within the doctors that have implemented routine testing, some never see 1 positive and others have unexpectedly found 2 or 3.
2. With an increasingly mobile society, and increased social media based sexual networks, people that are at risk of acquiring HIV are very difficult to pin down geographically. People can easily move from areas of high prevalence to low, and many people are engaged in high risk activity that of which their practitioners are unaware.
With respect to expansion to the rest of the province, resources are currently highest, in areas where prevalence is known to be high. However the “Hope to Health” initiative describes permanent funding which is being given to all the health authorities in the province to expand HIV testing, treatment and additional resources. Perhaps is you have an interest in this area, we can link you to some of this new work in your region.