HIV Transmission, HIV Testing, Policy and Practice

1. HIV Transmission, HIV Testing,Policy and Practice Levinia Crooks Chief Executive Officer ASHM

2. Testing policy in Australia • Ongoing need for a policy • Changing role and function of policy • Ongoing need for data and evidence • Changing views and opinions • Policy framework that facilitates new knowledge • Some conundrums

3. Testing policy in Australia • 1st National Strategy in 1989 • 1994 Principles of HIV Testing • 1998 HIV Testing Policy • 2nd HIV Testing Policy 2006 • HIV Testing Policy 2011

4. Evolution of testing • CD4 and P24 antigen • 1st generation antibody tests – slow • Detuned tests - Comparison of 1st and subsequent tests give indication of duration • Combo – Antibody/antigen test faster result • Viral load • Viral sequencing and resistance testing

5. People are most infectious soon after infection • Not all people have a sero-conversion illness • People over estimate frequency or recency of health seeking behaviour • As testing and treatment approaches change clinicians/educators need authoritative advice • Around 30% of people living with HIV are unaware of their status

6. Guidelines & practice • STIGMA guidelines suggest increased testing as a function of potential exposure • Safe sex message has been complex and changing: • Safe sex every time • Responsibility to stay negative and responsibility not to transmit HIV • Strategic positioning • Test, test, trust • Increase frequency of testing

7. Ongoing need for a policy • People are still getting infected • Earlier access to treatment improves health outcomes • Earlier access to treatment reduces infectivity, community viral load and • Earlier access to treatment reduces onward transmission as evidenced by reduced transmission to neonates and in sero-discordant couples

8. Changing role and function of policy • Web-based technology means policy can be set in ether not paper and can thus be more accessible and more responsive to change • In the past HIV Testing policy was reviewed every 5 or so years • Web based policy will be reviewed 6 months • Policy can also be integrally linked to guidelines, resources and discussion forums

9. Ongoing need for data and evidence • Australia has high levels of HIV testing, especially among those most at risk • But ~ 1,000 new HIV infections each year • The make up of that 1,000 people has changed somewhat • Gay men remain the single most impacted group within the Australian society • Need to explore ways to drive that infection rate down

10. Conundrum - epidemic of sero-conversion • If most or even many new infections occur at or soon after sero-conversion are we recommending testing frequently enough • How frequently would we need to test to drive infections down? • Can we do this research without encountering legal barriers or community dissent?

11. Conundrum – point of care testing • If a Point of Care test is licensed how will that change the testing landscape? • If its prioritised for those most at rick, how will we control for early infection? • How will people deal with the knowledge that they might be HIV positive and how will our services accommodate this new status?

12. Conundrum – infectivity & viral load • Can we standardise our assessments of infectivity? • What is more risky: • Unprotected sex with undetectable viral load • Unprotected sex with gay man who thinks negative • EPP by a surgeon with undetectable viral load • Sharing injecting equip with undetectable viral load • Having a baby with undetectable viral load • Why cant we apply assessments across settings

13. http://testingportal.ashm.org.au