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STOP HIV/AIDS

New HIV Recommendations Dr. Réka Gustafson Medical Health Officer and Medical Director of Communicable Disease Control, Vancouver. STOP HIV/AIDS. Objectives. Identify the indications for HIV testing in primary care

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STOP HIV/AIDS

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  1. New HIV Recommendations Dr. Réka Gustafson Medical Health Officer and Medical Director of Communicable Disease Control, Vancouver STOP HIV/AIDS

  2. Objectives • Identify the indications for HIV testing in primary care • Consider clinical & public health evidence and rationale for treatment as prevention and expanded HIV testing • Identify tools and resources to facilitate implementation of routine HIV testing in primary care practice, and to support care of patients identified with HIV/AIDS

  3. STOP HIV/AIDS Initiative A provincial initiative to enhance early diagnosis and treatment of HIV with the goal of changing the course of the epidemic • Two pilot sites: Vancouver & Prince George • Evaluation • Was diagnosis improved? • Are more people on treatment? • Did we change the course of the epidemic?

  4. Clinical Rationale for Early Diagnosis and Treatment

  5. Estimate of Benefits of Early Treatment BMJ 2011; 343:d6016 Life expectancy as a function of disease stage at start of treatment

  6. IAS-USA Guidelines 2010: When to Start *Unless pt is elite controller or has stable high CD4+ count and low HIV-1 RNA off ART Modified from Thompson M, Aberg J, Cahn P, Montaner J, et al. JAMA. 2010;304;321-333

  7. Public Health Rationale for Early Diagnosis and Treatment 300-400 people a year continue to be diagnosed with HIV in BC Treating an HIV positive person reduces their viral load and renders them 96% less infectious to others Diagnosing and treating HIV infected individuals earlier can reduce community viral load and has the potential to change the course of the epidemic

  8. Evidence: HIV Prevention Trials Network 052 Study HPTN052 Study Team Prevention of HIV-1 Infection with Early Antiretroviral Therapy N ENGL J MED 365;6 Aug 11, 2011

  9. So… • If early diagnosis of HIV benefits the individual • and early diagnosis of HIV benefits the population • How are we doing?

  10. NOT VERY WELL… 65% of people are diagnosed after they should already be on treatment CD4 200-349 Source: VCH public health and BCCFE data linkage project

  11. NOT VERY WELL….. PHAC An estimated 26% of HIV infected patients are unaware of their infection

  12. Why are we diagnosing people late? • Routine in pregnancy only • Identifies mothers early and allows for treatment to be used to prevent transmission • Voluntary Counseling and Testing for Everyone Else • Based on recognition of risk by patient and clinician

  13. How are we doing with diagnosing the high risk? • 50% of those with HCV are tested for HIV within 3 months of diagnosis (M. Gilbert) • In a recent survey of gay men, 23% of those under 30 years of age have never had an HIV test and overall only 51% have had a test in the past year (M-Track) • 2004-2008, 38.6% of individuals with a new HIV positive test had their first known HIV test at the time of diagnosis (M. Gilbert) • Less than 25% of those with an STI diagnosis have an HIV test following their diagnosis • Hep C + patient received a liver without being tested for HIV

  14. Inherent limitations of targeted testing • Requires clinicians to actively think of HIV in the differential diagnosis • Requires patients to recognize and disclose their risk to care provider • Requires clinicians to act on a recognized risk • Fails to recognize changes in epidemiology • Stigmatizes testing • discourages clinicians from offering an HIV test • discourages patients from seeking and/or accepting the test We need to fundamentally change our testing paradigm Opportunistically test everyone in acute and primary care who has ever been sexually active and has not had an HIV test in the past year

  15. Contrast: HIV meets ALL WHO Criteria for a routine screening program The condition sought should be an important health problem for the individual and community. There should be an accepted treatment or useful intervention for patients with the disease. The natural history of the disease should be adequately understood. There should be a latent or early symptomatic stage. There should be a suitable and acceptable screening test or examination. Facilities for diagnosis and treatment should be available There should be an agreed policy on whom to treat as patients. Treatment started at an early stage should be of more benefit than treatment started later. The cost should be economically balanced in relation to possible expenditure on medical care as a whole. Case finding should be a continuing process and not a once and for all project.

  16. The Case for Routine HIV Testing in Primary Care 1. Current approach is inadequate: people are being diagnosed too late 2. Routine testing in acute care overcomes identified barriers of targeted approach 3. It’s feasible, acceptable, and it works

  17. Uptake in primary care very high Source: Health Protection Agency, UK, Dec. 2010

  18. Key Findings • The routine offer and recommendation of an HIV test in primary care and hospital settings is feasible and acceptable to both staff and patients • 51 patients were diagnosed via 11,000 tests for an overall positivity rate of 4/1000 • threshold for cost effectiveness is estimated to be approximately 1/1000 new diagnoses

  19. The barrier is us, not the patient http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/HIV/

  20. UK Recommendations • The routine offer of HIV testing in medical admissions should be commissioned as a priority in areas with a diagnosed prevalence of greater than 2/1000 among 15-59 year olds Context : • Diagnosed prevalence in BC is 2.2 per 1000 in the entire population aged over 15 • Diagnosed prevalence in Vancouver is 12/1000 • HIV testing by general practitioners should be widely promoted

  21. New HIV Testing RecommendationsBCMJ, 2011, 53:49 Recommend an HIV test to all adults in your practice who have not had one in the past year • As part of blood work for any other reason in acute and community care • Every time you test for STIs, HCV, tuberculosis If aware of a specific risk, recommend now and more often • Clinical symptoms • Every time you diagnose another STI • Every 3-6 months if you are aware of ongoing high risk Vancouver Coastal Health, PHC, BC Centre of Excellence for HIV/Aids

  22. How to do Routine HIV testing in Your Practice?

  23. Step 1: Recommendan HIV test as part of routine care • Already doing it as part of pre-natal care • Same applies in general practice • “I recommend an HIV test to all my patients now. I'd like to add it to your blood-work today. Is that OK?”

  24. Posters - help start the conversation

  25. Step 2: Pre-test information All other information can be given in writing (BCCDC Sept 2011) Have health file available in waiting room or patient room to answer questions http://www.healthlinkbc.ca/healthfiles/hfile08m.stm

  26. Step 3: Link to care • Local Public Health • 604-675-3900 (Vancouver, Richmond, North Shore) • IDC Rapid Expert Advice and Consultation in HIV • 1-800-665-7677 • Oak Tree Clinic • 604-875-2212

  27. Routine testing in practice • Yield in individual practices likely to be low • Cost effective if yield is 1/1000 tests • Yield of screening in pregnancy is 1/10000 tests • Same efficiency as targeted testing and may be the only way to reach those who remain unaware of or unable to disclose their risk • At the prevalence of Vancouver (1.2%), routine HIV testing every 1-5 years is cost-saving • Hutchinson AB et al. Return on Public Health Investment: CDC's Expanded HIV Testing Initiative J Acquir Immune DeficSyndr., March 2012

  28. Family Physicians can Change this Epidemic • Routine prenatal HIV testing has virtually eliminated perinatal transmission of HIV in BC • 8000 patients see a family physician in Vancouver every day

  29. Summary • Treatment works • Treatment as prevention works • Risk-based testing misses too many, diagnoses too late • Routine testing is not just cost effective, it is cost-saving • You are already doing it in prenatal care • Routine HIV testing de-stigmatizes HIV testing • Routine HIV testing is acceptable to patients

  30. Practice change • Develop a team – get your office colleagues and MOA involved • Delegate set-up to office staff • Program EMR reminders • Highlight HIV test paper lab requisitions • Choose a start date • Set targets; increase each week • Keep it on your radar

  31. Participate in more CPD UBC CPD Free Webinars HIV Testing: What’s Different Now?  Register Now  Target Audience: Family Physicians Accreditation: Up to 1.5 MainPro M1 Date: Tuesday, April 24, 2012 Time: 7:00-8:30pm PST www.ubccpd.ca/programs/hiv_testing

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