Expanding provider-initiated HIV testing

The case for expanding provider-initiated HIV testing is widely supported and has been shown to be cost-effective where prevalence of undiagnosed HIV infection is above 0.1%.[1] 

Motivations include providing timely antiretroviral therapy for im­prov­­ed patient outcome and the opportunity for those who are unaware of their positive HIV status (thought to be approximately 26% of all infected persons in Canada[2]) to enhance their strategies to prevent transmission. 

Continued advancements in testing technologies that have led to reduced window periods[3] and the availability of point-of-care testing[4] also support expanded HIV testing. In recognition of these developments, providers in the Vancouver Coastal Health (VCH) region are being encouraged to expand their testing practices as part of the STOP HIV/AIDS Pilot Project in BC (STOP AIDS).[5] This article provides considerations for clinicians throughout BC looking to expand their HIV testing practices.

Evidence continues to support HIV testing approaches based on clinical assessment. Examples include symptoms of seroconversion illness, opportunistic infections characteristic of AIDS, and risk of exposure to HIV infection. VCH has suggested routinely extending HIV testing to anyone who is being tested for or diagnosed with a sexually transmitted infection, hepatitis C, or tuberculosis, as well as individuals with a past history of a sexually transmitted infection. 

Other individuals with a greater likelihood of HIV infection who should be routinely offered HIV testing include gay, bisexual, and other men who have sex with men; people with a current or lifetime history of use of injection or non-injection drugs, and their sex partners; individuals who trade sex for money or drugs; sex workers and their clients; Aboriginal people; people with mental health disorders; people from HIV-endemic countries and their sex partners; and sexually active adolescents seeking care.

Efforts to expand provider-initiated testing should go hand-in-hand with in­creased efforts to promote HIV testing to encourage client-initiated requests for testing. Additionally, individuals with ongoing risk need to be encouraged to adopt risk event-based testing and to test more frequently. These strategies are also designed to identify HIV infection as soon after infection is contracted at a time when high viral loads, found in acute infection, render individuals far more infectious than during later stages of infection.[6] 

Risk-based approaches to HIV testing remain limited and are unlikely to increase HIV case finding without expanding testing into routine clinical practice. This inability to decrease the proportion of those unaware of their HIV infection supports a pilot phase of routine testing and may lead to recommendations for future screening strategies. 

Equally important, a pilot phase of routine testing affords opportunities for providers to learn directly from their efforts to expand HIV testing within the contexts of their own practice. One approach to a pilot phase of routine testing, suggested by VCH as part of STOP AIDS, asks providers to offer testing to anyone who presents to acute or community care who has ever been sexually active and has not had an HIV test in the past year. 

Expanded HIV testing will likely require more streamlined approaches to pretest counseling. Notwithstanding, patients being offered HIV testing should be made aware through adequate pretest counseling that, as with any other medical intervention, they have the opportunity to refuse testing. Patients should also be inform­ed of the nominal or non-nominal option and that HIV is a reportable condition. These are two of the key elements recommended for inclusion by clinicians in BC during their pre- and posttest counseling interactions.[7] 

Expanding provider-initiated HIV testing is a critical component of an HIV/AIDS prevention and control strategy. Clinicians should increase their offerings of HIV testing to those at risk of infection and explore how to integrate HIV testing into routine clinical practice.

Acknowledgments
The authors thank Ms Elizabeth Elliott and Drs Brian Emerson, Mark Gilbert, Perry Kendall, and Gina Ogilvie for their review of this manuscript.

References

1.  Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the Uni­ted States—an analysis of cost-effectiveness. N Engl J Med 2005;352:586–595.
2. PHAC. Summary: Estimates of HIV Prevalence and Incidence in Canada, 2008. www.phac-aspc.gc.ca/aids-sida/publication/survreport/pdf/estimat08-eng.pdf (accessed 2 Dec 2010).
3. Gilbert M, Krajden M. Don’t wait to be tested for HIV. BC Med J. 2010;52(6):308-309. https://www.bcmj.org/sites/default/files/BCMJ_52Vol6_cdc.pdf (accessed 2 Dec 2010).
4. Gilbert M. Impact and Use of Point of Care HIV Testing: A Public Health Evidence Paper. BC Centre for Disease Control. www.bccdc.ca (accessed 2 Dec 2010).
5. Gustafson R. STOP HIV/AIDS Update for Vancouver Physicians: HIV testing recommendations. Physician’s Update. 30 November 2010. www.vch.ca/about_us/news/physicians__update_-_stop_hiv_aids (accessed 2 Dec 2010).
6. Steinberg M. Understanding HIV infectivity to better HIV prevention efforts. STI, HIV & AIDS Knowledge Exchange (SHAKE), Feb 2008: 1(1). Available online at www.phsanewsletters.ca/.
7. The College of Physicians and Surgeons of British Columbia. Resource Manual—HIV: HIV Infection Added to the Health Act Communicable Disease Regulation Schedule A and B. Updated October, 2009. www.cpsbc.ca/files/u6/HIV-HIV-Infection-Added-to-the-Health_Act-Communicable_Disease-Regulation-Schedule-A-and-B.pdf (accessed 15 Dec 2010).

hidden

This article has not been peer reviewed. 

Dr Gustafson is a medical health officer at Vancouver Coastal Health. Dr Steinberg is a physician epidemiologist, STI/HIV Prevention and Control at BC Centre for Disease Control.