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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


Basics of hiv testing hiv testing in a time limited setting

N=125


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 assessment2

A. HIV RISK ASSESSMENT


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 test2

PERFORMING AN HIV TEST…


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


Goal link patients within 2 weeks

Goal: Link patients within 2 weeks


Basics of hiv testing hiv testing in a time limited setting

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