This article first appeared on the CATIE website here.
Une version française est disponible ici.
The importance of HIV testing, knowledge of HIV status and early diagnosis of HIV infection cannot be overstated, particularly given recent advancements in our understanding of HIV treatment and prevention.
People who are aware of their HIV-positive status can access care and support services and initiate treatment when they are ready. Advances in treatment mean that people with HIV can live almost as long and as healthy as people who are uninfected. To get the most out of treatment, research suggests it may need to be started soon after becoming infected with the virus. Currently, however, many people in Canada are not learning about their HIV status until late in their disease, when they start to develop symptoms or opportunistic infections. At this point, antiretroviral treatment can help improve their health but not as effectively as when treatment is started earlier.
Knowledge of HIV status is also important for the prevention of HIV transmission. Generally, once people become aware of their HIV infection, they take measures to reduce their risk of HIV transmission. Also, once diagnosed, treatment can be initiated and this can further help reduce the risk of HIV transmission. Research suggests that the majority of HIV transmissions may originate from people who are unaware of their HIV status.
For those who test negative, testing represents an important opportunity to provide HIV prevention information and counselling.
According to 2011 estimates from the Public Health Agency of Canada (PHAC), approximately 25% of people living with HIV in Canada were unaware of their HIV status. Therefore, undiagnosed HIV infection represents a major public health challenge and is undermining HIV treatment and prevention in Canada.
Barriers to testing
There are several barriers to increasing the uptake of HIV testing and reducing the proportion of people who are undiagnosed in Canada. According to a synthesis of the evidence conducted by the European Center for Disease Prevention and Control and published in 2010, these barriers include:
- inability to accurately assess levels of risk for exposure to HIV by some clients and providers
- lack of comfort discussing HIV testing and lack of knowledge about HIV among clients and providers
- provider time constraints for risk assessments and pre- and post-test counselling
- cumbersome consent procedures
- fear of stigma and discrimination associated with risk behaviors and/or testing HIV positive
PHAC guidelines and recommendations
PHAC recently released an HIV Screening and Testing Guide that “seeks to reduce the number of undiagnosed HIV infections in Canada by offering a framework for care providers to explore options that will enhance their ability to provide HIV testing, as well as to better tailor their testing approaches to meet the specific needs of their practice and clients.”
These guidelines include the following recommendations to address the barriers listed above and to improve HIV testing in Canada.
The offer of an HIV test should be made part of periodic routine medical care.The guide acknowledges that targeted testing among populations at highest risk of HIV infection needs to continue but should be complemented with a less targeted testing approach among populations that may be perceived as being lower risk. Research shows that many people at risk for HIV infection (including those who are later diagnosed with HIV) are not requesting, or being offered, an HIV test despite multiple interactions with the health system, likely because of perceived low risk of HIV infection on the part of the client and provider. These interactions represent “missed opportunities” for HIV testing and potential diagnosis of HIV infection.
Therefore, a major recommendation in the guide is that providers take a more active approach and routinely offer HIV testing to clients—whether or not they have asked for a test. Routinely offering HIV testing to patients will help overcome some of the barriers to testing. Also, it may help normalize HIV testing and further reduce stigma and discrimination associated with HIV.
To reduce the fear often associated with an HIV diagnosis, which can be a barrier to testing, the guide recommends that care providers emphasize the benefits of treatment and that HIV is now considered a chronic manageable condition.
Simplify risk assessments.
The guide acknowledges pre-test risk assessments as a potential barrier to HIV testing. Therefore, it states that instead of providing an in-depth comprehensive HIV behavioural risk assessment prior to offering an HIV test, a more brief assessment is sufficient. This assessment should ensure that clients understand the following:
- how HIV is transmitted
- the advantages and disadvantages of HIV testing
- how to interpret the results
After the brief assessment, a client should simply be asked if they want an HIV test. This approach allows the client to assess their own risk without feeling compelled to provide sensitive personal information. This helps to overcome any discomfort the tester and/or client may feel in discussing these issues, which can sometimes be a barrier to testing.
HIV testing must remain voluntary and based on informed consent.
The guide states that verbal consent prior to HIV testing is sufficient and written consent prior is not necessary.
Use a flexible approach to pre- and post-test counselling.
The guide encourages care providers to use a flexible approach and tailor the extent of pre- and post-test counselling to each client’s unique needs and situation. While providing extended counselling is preferred, the guide acknowledges that this may be a barrier for both the provider and client, particularly due to time and resource constraints. More specifically, the guide states that shorter counselling may be more appropriate for certain testers, such as pregnant women in labour, well-informed patients and repeat testers. The provision of print, video, mobile and web-based resources can help streamline the pre-test process and inform decisions with regards to HIV testing.
Offer couples testing.
The guide stresses the importance of testing together for those in an ongoing sexual relationship with a regular partner as it allows:
- a common understanding of the risks associated with HIV transmission
- a shared understanding of each other’s HIV status
- an opportunity to make decisions about prevention, treatment and care together
Research studies suggest that couples who test and learn their status together are more likely to adopt preventive measures than those who test alone.
Integrate HIV testing services.
The guide encourages the integration of HIV testing into other services, particularly those that test for infections that can be transmitted the same way as HIV and/or negatively impact the health of people living with HIV.
These services include the following:
- clinical services for tuberculosis (TB), sexually transmitted infections (STIs) and hepatitis C
- antenatal care services
- sexual Health and family planning services
- drug and alcohol treatment services
- newcomer and travel health clinics
- mental illness treatment and psychiatric services
- cancer or oncology clinics
Integrating HIV testing into these other services provides additional opportunities to test for HIV and identify undiagnosed individuals.
While positive results should always be provided in person (preferably by the initial care provider), alternate approaches can be used to provide negative results.
Ideally, negative test results should be provided in person, however, the guide acknowledges that this can be challenging to do for all individuals. Therefore, providers can use a previously agreed upon alternative for those who are unlikely to return for their test results. These alternative approaches may include a secure telephone call, letter or email. The guide emphasizes that effort should be made to ensure that the information is provided confidentially.
It is important that clients are not informed that only HIV-positive results will be provided in person. This may create anxiety when a person is asked to return to get their results in person.
Discuss the window period with those who test HIV negative.
If someone is “in the window period,” there is a chance that even though they may have been infected with HIV, the test won’t be able to detect the infection and will give a negative result. The window period differs for each type of HIV test and also depends on each individual. To ensure that a person was not in the window period at the time the test was performed, the guide recommends that follow-up testing be performed at three weeks and three months following the most recent possible exposure. However, the guide states that additional HIV testing during the window period, particularly following a “high-risk” exposure, may help identify infection earlier.
Discuss frequency of retesting with those who test HIV negative.
The guide recommends that individuals involved in “high-risk practices” be screened for HIV at least once a year. Since many variables determine an individual’s potential risk of HIV infection, the guide does not recommend an exact frequency of HIV testing for different levels of risk. However, when considering the need for retesting, the guide recommends that care providers consider factors such as populations at increased risk for HIV exposure, characteristics of partners and local epidemiology.
Provide information and referrals—regardless of test results—and link newly diagnosed individuals to care.
HIV testing is an important opportunity to educate individuals at risk of acquiring HIV and those who are newly diagnosed and link them to additional services. For example, all people tested for HIV—regardless of their results—should be provided with information and linked to services to help them reduce their risk of acquiring or transmitting HIV. Therefore, in preparation for HIV testing, the guide suggests that providers contact care and support organizations to obtain referral resources to provide to clients.
Research shows that people living with HIV who are linked to and engaged in care have better health outcomes than those who are not. Therefore, newly diagnosed individuals should be referred to an infectious disease specialist who treats HIV. Also, effort should be made to complete baseline testing for CD4 count, viral load, drug resistance and co-infections (hepatitis B and C, STIs, TB) as soon after diagnosis as possible.
For those who test HIV positive, develop a partner notification plan and discuss public health importance of disclosure.
Previous and current partners of newly diagnosed individuals represent a population at high risk of HIV infection. Therefore, notifying previous/current partners and encouraging them to get tested may help identify undiagnosed HIV infections. The guide encourages care providers to develop partner notification plans with newly diagnosed individuals. Also, care providers should inform clients that positive test results will be shared with Public Health, which can help with partner notification while maintaining the client’s anonymity and privacy.
Voluntary disclosure of HIV status to partners has several potential benefits. For example, it may motivate partners to seek testing and/or adopt measures to prevent HIV transmission. Also, it provides an opportunity for the HIV-positive person to receive social support, develop risk-reduction strategies with partners and prevent co-infections. Therefore, the guide states that care providers should emphasize the importance of voluntary disclosure of HIV status to those who are newly diagnosed.
PHAC’s new HIV Screening and Testing Guide contains a series of recommendations to increase the uptake of HIV testing, reduce the proportion of people who are unaware of their HIV infection and diagnose people as early as possible after HIV infection. These goals are critical for improving the health of people living with HIV and for preventing HIV transmissions in Canada. One way the guide seeks to meet these goals is by normalizing HIV testing and making the offer of such testing a routine part of medical care. More nuanced and detailed information can be found in the full guide.
It is important to note that PHAC’s guide is only meant to complement existing efforts and “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. Care providers should comply with local Public Health regulations with conducting HIV testing.”
- James Wilton
HIV Screening and Testing Guide – Public Health Agency of Canada
WHO guidelines encourage couples HIV testing and counselling and use of antiretroviral treatment for prevention – Prevention in Focus
Recently infected individuals: a priority for HIV prevention – Prevention in Focus
Detecting HIV earlier: Advances in HIV testing – Prevention in Focus
A rapid approach to community-based HIV testing – Prevention in Focus
How do you know if you have HIV? – Managing your health
Johnson LF et al. Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLoS Medicine, 10:4. E1001418.
May M et al. Life expectancy of HIV-1-positive individuals approaches normal, conditional on response to antiretroviral therapy: UK collaborative HIV cohort study. Eleventh International Congress on Drug Therapy in HIV Infection, Glasgow, abstract O133, 2012.
Van Sighem AI, Gras LAJ, Reiss P, Brinkman K, De Wolf F. Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. AIDS. 2010 Jun 19;24(10):1527–35.
Nakagawa F, Lodwick RK, Smith CJ, Smith R, Cambiano V, Lundgren JD, et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS. 2012 Jan;26(3):335–43.
Nakagawa F, May M, Phillips A. Life expectancy living with HIV: recent estimates and future implications. Curr. Opin. Infect. Dis. 2013 Feb;26(1):17–25.
Siegfried N, Uthman OA, Rutherford GW. Optimal time for initiation of antiretroviral therapy in asymptomatic, HIV-infected, treatment-naive adults. Cochrane Database of Systematic Reviews. 2010 Mar 17;(3):CD008272.
Althoff KN, Gange SJ, Klein MB et al. Late presentation for human immunodeficiency virus care in the United States and Canada. Clinical Infectious Diseases. 2010 Jun;50(11):1512–20.
Fisher, M. (2008). Late diagnosis of HIV infection: major consequences and missed opportunities. Current Opinion in Infectious Diseases. 21(1):1-3.
Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes. 2005 Aug 1;39(4):446–53.
Cohen MS, Chen YQ, McCauley M et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 2011 Aug 11;365(6):493–505.
Government of Canada Public Health Agency of Canada (2010). HIV/AIDS Epi Updates. Available from: www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/2-eng.php
European Centre for Disease Prevention and Control. HIV testing: Increasing uptake and effectiveness in the European Union. Stockholm: ECDC; 2010.
Government of Canada Public Health Agency of Canada (2013). HIV screening and testing guide. Available from http://www.catie.ca/sites/default/files/EN_HIV-Screening-Guide-2013.pdf
El-Bassel N, Gilbert L, Witte S et al. Couple-based HIV prevention in the United States: advantages, gaps, and future directions. Journal of Acquired Immune Deficiency Syndromes. 2010 Dec;55 Suppl2:S98–S101.