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BASICS OF HIV TESTING: HIV testing in a time-limited setting. - Aleasha Hacault STI/HIV outreach RN - Ida-Lynn Gregan MD, CCFP. N=125. Objectives. Review current HIV testing recommendations, including HIV “indicator” conditions that should trigger testing

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basics of hiv testing hiv testing in a time limited setting

BASICS OF HIV TESTING:HIV testing in a time-limited setting

- AleashaHacault STI/HIV outreach RN

- Ida-Lynn Gregan MD, CCFP

objectives
Objectives
  • Review current HIV testing recommendations, including HIV “indicator” conditions that should trigger testing
  • Perform a basic HIV risk assessment
  • Confidently offer HIV testing (obtaining consent and offer the variety of testing available)
  • Deliver an HIV +ve test result
  • Perform an initial assessment on a newly diagnosed HIV+ve individual
a hiv risk assessment
A. HIV RISK ASSESSMENT

Case Study

  • 47 year old female (“Susan”)
  • Aboriginal
  • Recently divorced
  • Dating for last 6 months
  • Sexually active
  • c/o notable change in vaginal discharge & experiencing dysuria
demographic analysis new patients to care manitoba hiv program 2008 2010
Demographic analysis new patients to care Manitoba HIV program, 2008-2010

35%

35%

35%

*Risk Factors - Multiple responses; totals add up >100%

undiagnosed hiv need to test to diagnose
Undiagnosed HIVneed to test to diagnose!
  • 26% HIV+ in Canada are unaware
    • Undiagnosed estimated to contribute to >50 % of new HIV infections.
    • Being aware of HIV status reduces risk behavior in majority of HIV+
    • Missed benefit of treatment on decreased transmission
benefits of early hiv diagnosis
Benefits of early HIV diagnosis

• Benefits to the infected individual

– Antiretroviral therapy (ART) Reduced mortality &

morbidity (near normal life expectancy)

• Benefits to the public health

–Reduced onward transmission

- Reduction in unsafe sexual behaviour (68%)

- ART-reduced infectiousness ( x 96% in HPTN 0523)

– Reduced health care costs

cost effectiveness of hiv testing
Cost-effectiveness of HIV testing

(2010) Routine HIV Screening in France: Clinical Impact and Cost-Effectiveness. PLoS

ONE 5(10): e13132.

us guidelines opt out
US guidelinesOPT-OUT

September 22, 2006

  • Routine voluntary testing for patients ages 13-64 in all health care settings
  • Persons at high risk should be screened annually
  • No separate consent for HIV
  • Prevention counseling should not be required
  • Objectives
    • Increase screening
    • Foster early detection
    • Identify and counsel persons with unrecognized HIV infection and link them to clinical and preventative services
    • Reduce perinatal transmission
test for hiv
Test for HIV

Unprotected sex (anal or vaginal w/o barrier)

Sex under the influence of ETOH or drugs

Tested +ve for an STI (GC, CT, Hep, syphilis)

Shared needles/drug equipment

Tatooing, piercing, or accupuncture (unsterile)

Blood or blood products prior to Nov 1986

PHAC April 2012

testing only 5 10 of manitobans 07 08 between ages 15 65 yrs
Testing Only 5-10% of Manitobans (07-08) (Between Ages 15-65 yrs)

Prevalence Manitoba: .3-.4%

Prevalance Sasketchewan: 1%

hides hiv indicator diseases in europe study
HIDES (HIV Indicator Diseases in Europe Study)

Indicator conditions:

1. AIDS-defining conditions (ADC)

2. Conditions associated with increased HIV prevalence (>0.1%)

  • Conditions where failure to diagnose HIV infection may have severe consequences for person’s health

- Dr. Keith Radcliffe, HIV Europe March 2012, Copenhagen

aids defining conditions adc
AIDS-defining conditions (ADC)

• Opportunistic infections

– Fungal

e.g. Pneumocystis jiroveci, cryptococcosis, histoplasmosis, candidiasis (oesophageal, tracheal, pulmonary)

– Bacterial

e.g. Tuberculosis (TB), disseminated Mycobacterium avium, recurrent pneumonia or salmonella septicaemia

aids defining conditions cont d
AIDS-defining conditions (cont’d):
  • Opportunistic (cont’d):

– Parasitic

e.g. cerebral toxoplasmosis, cryptospridiosis, microsporidiosis

– Viral

e.g. CMV retinitis, PML, persistent HSV

• Neoplasms

– Non-Hodgkin’s lymphoma, Kaposi’s sarcoma, cervical carcinoma

strongly recommend testing hiv prevalence 0 1
Strongly recommend testing(HIV prevalence >0.1%)

• Sexually transmitted infections (4.06%)1

• Lymphoma (0.29%)1

• Anal cancer/dysplasia (2.90%)1

• Cervical/anal dysplasia (0.37%)1

• Herpes zoster (2.89%)1

• Hepatitis B or C (0.36%)1

• Mononucleosis-like illness (3.85%)1

• Unexplained leucopaenia or thrombocytopaenia, >4 weeks (3.19%)1

strongly recommend testing hiv prevalence 0 1 cont d
Strongly recommend testing(HIV prevalence >0.1%), cont’d:

• Seborrheic dermatitis or exanthema (2.06%)1

• Unexplained oral candidiasis (6-23%)

• Invasive pneumococcal disease (2.4%)

• Unexplained chronic fever (3%)

• Unexplained chronic diarrhoea (10-12%)

• Pregnancy (0.17%)

consider offering testing hiv prevalence likely 0 1
Consider offering testing: HIV prevalencelikely >0.1%

• Primary lung cancer

• Lymphocytic meningitis

• Visceral leishmaniasis

• Oral hairy leucoplakia

• Severe or recalcitrant psoriasis

• Guillain-Barré syndrome

• Mononeuritis

• Peripheral neuropathy

• Subcortical dementia

• Multiple sclerosis like disease

• Unexplained weight loss

• Unexplained lymphadenopathy

• Unexplained renal failuire

conditions where failure to diagnose hiv infection may have severe consequences
Conditions where failure to diagnose HIV infectionmay have severe consequences:

• Prior to initiating aggressive immuno-suppressive therapy

– Malignancy

– Transplantation

– Auto-immune disease

• Primary space occupying lesion of the brain

a hiv risk assessment1
A. HIV RISK ASSESSMENT

Case Study

  • 47 year old female (“Susan”)
  • Aboriginal
  • Recently divorced
  • Dating for last 6 months
  • Sexually active
  • c/o notable change in vaginal discharge & experiencing dysuria
a hiv risk assessment3
A. HIV RISK ASSESSMENT

1. Number of partners?

a hiv risk assessment4
A. HIV RISK ASSESSMENT

2. Type of partners/relationship?

Known

Unknown

a hiv risk assessment5
A. HIV RISK ASSESSMENT

3. Use of barriers?

Consistent/inconsistent use

a hiv risk assessment6
A. HIV RISK ASSESSMENT

4. Type of sex?

Vaginal

Anal

Oral

Sex toys

BDSM

Non-penetrative

a hiv risk assessment7
A. HIV RISK ASSESSMENT
  • Drug-use as a part of sexual experience?

Drugs: legal/illegal drugs, alcohol

a hiv risk assessment8
A. HIV RISK ASSESSMENT

SUSAN’S RISK FACTORS:

  • Sexually active with multiple partners in past year (6 mos.) with unknown sexual histories
  • Vaginal, oral
  • High and low risk sexual activities
  • Known and anonymous partners
  • Alcohol use as part of sexual experience
performing an hiv test
PERFORMING AN HIV TEST…
  • Point of Care Testing (POCT, “rapid testing”)
  • Nominal
  • Non-nominal
  • Anonymous
performing an hiv test1
PERFORMING AN HIV TEST…
  • POCT
    • Rapid results: within 60seconds to minutes
    • Easy and minimally invasive (finger poke)
    • Convenient in any setting
    • Accurate: >or= 99.6% specificity and sensitivity
performing an hiv test3
PERFORMING AN HIV TEST…
  • Nominal
    • Test is ordered using full name of patient
    • Known identity of person being tested
    • Health Care Practitioner ordering test obligated to report positive results to Manitoba Health
performing an hiv test4
PERFORMING AN HIV TEST…
  • Non-nominal
    • Test is ordered using patients initials or code
    • Only the person ordering the test knows the person being tested
    • Health care provider ordering the test is responsible for notifying Manitoba Health of positive results
    • Test results is linked and entered in patient’s chart
b performing an hiv test
B. PERFORMING AN HIV TEST
  • Anonymous
  • Test is ordered using a bar code
  • Practitioner performing the test and lab do not know the identity of the person being tested
  • Client returns to clinic to receive results with bar code ID card
b performing an hiv test1
B. PERFORMING AN HIV TEST

Anonymous…

  • If client loses card, no results can be given
  • Anyone can return with found card and access results
  • Paper copies of results are not provided
performing an hiv test5
PERFORMING AN HIV TEST…

Informed consent is required

Verbal consent is required

BUT

Written consent is not required

c obtaining consent
C. OBTAINING CONSENT
  • Inform that you are performing test
  • Rationale/Indicators for test
  • Limitations
  • Consequences
  • Opportunity for patient to decline
case study
CASE STUDY
  • Nominal testing
  • Indication: complete STI screen
  • Limitation: window period
  • Consequences explained
  • Opportunity to decline
  • Plan for follow-up
d delivering a positive result
D. Delivering a positive result
  • Negative Result
    • Review Safer Sex Practices/Harm Reduction
    • Window period
d delivering a positive result1
D. Delivering a positive result
  • Positive Result
  • Meaning of positive result
  • Natural course of illness
  • Management & treatment
    • Life expectancy
    • Quality of life
d delivering a positive result2
D. Delivering a positive result
  • Coping
    • Supports
    • Prevention
      • Universal precautions
      • Safer sex
      • Issues of disclosure
      • Birth control
    • Partner notification
      • Public health
d delivering a positive result3
D. Delivering a positive result
  • Safety
    • Acute suicidality
    • Threats of violence to self or others
d delivering a positive result4
D. Delivering a positive result
  • Linkage to care
    • Manitoba HIV program:

P: 940-6089; 1-866-449-0165

Fax: 940-6003

        • HIV care and treatment
        • Counselling services
        • Social work; outreach
        • pharmacist
        • -Dietician
        • Occupational Therapy
initial assessment of the hiv ve individual
Initial Assessment of the HIV +ve individual:
  • Dr. R. Barrios/ BC Centre for Excellence in HIV/AIDS:

http://www.cfenet.ubc.ca/sites/default/files/uploads/Final%203-%20R.Barrios%20InitialAssessment_1.pdf

initial assessment of the newly diagnosed hiv ve patient
Initial assessment of the newly diagnosed HIV+ve patient:
  • Points to cover:
    • Relevant past med history
      • Recent hospitalizations, recurrent illnesses; past TB/exp; hepatitis
    • Current stressors and supports
      • How is pt coping with diagnosis
      • Any threats of violence towards pt in context of disclosure
      • Review ability to adhere to safer sex practices
      • Access to supports
initial assessment cont d
Initial assessment (cont’d):
  • Review of systems:
    • Weight loss, malaise, fever, night sweats (TB, advanced HIV, lymphoma)
    • Eyes: change in vision (CMV retinitis)
    • ENT: odynophagia, dysphagia, plaques or ulcers

(esophageal candidiasis, HSV esophagitis, syphilis)

    • Resp: cough, either productive or non; dyspnea, hemoptysis (PCP, TB, recurrent pneumonias)
    • Cardiac: chest pain, palp’ns
initial assessment cont d1
Initial assessment (cont’d):
  • Review of systems (cont’d):
    • GI: N/V, diarrhea (TB, MAC, cryptosporidiosis, advanced HIV)
    • GU: discharge, ulcers, warts (concurrent STIs, syphilis, HPV)
    • Obs/gyne: LMP (pregnancy) and pap/previous abn (cervical cancer)
    • Neuromuscular: peripheral numbness/tingling, or weakness (PML, CMV- associated mononeuropathy multiplex)
    • CNS: Headache (cryptococcal meningitis); cognitive or behavior changes (HIV-associated dementia, PML – progressvie multifocal leukoencephalopathy)
manitoba hiv program structure in 2011 1050 patients 98 in care
Manitoba HIV Program Structure in 2011 1050 patients: 98% in care

PHARMACIST

dietician

Health Promotion and Outreach

Education and Prevention Programs

  • Infectious Disease Physicians
  • 540 patients at hospital site
  • 4 nurses
  • Social worker
  • Ideal patients for this structure
    • Needs tertiary care services
    • Has a health care provider that can co-manage with us
  • Family doctors dedicated in HIV Care
  • 480 patients at Community site
  • 6 nurses
  • Social Work
  • Counselors
  • Ideal patients for this structure
    • Needs primary care MD in Wpg
ad