STOP HIV/AIDS
New HIV Recommendations
Dr. Réka Gustafson
Medical Health Officer and Medical Director of Communicable
Disease Control, Vancouver
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
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
2. Evaluation
• Was diagnosis improved?
• Are more people on treatment?
• Did we change the course of the epidemic?
1.
Clinical Rationale for Early
Diagnosis and Treatment
Estimate of Benefits of Early Treatment
Life expectancy as a function of disease stage at
start of treatment
Disease stage at start of
Treatment
Can expect to live to (years)
CD4<100
57.9
CD4 100-199
61.0
CD4 200-350
73.4
BMJ 2011; 343:d6016
IAS-USA Guidelines 2010: When to Start
Asymptomatic Infection
Recommendation
 CD4+ cell count < 500 cells/mm³
 Start HAART
 CD4+ cell count > 500 cells/mm³
 Should be considered*
Initiation of Therapy Recommended Regardless of CD4+ Cell Count
 Symptomatic HIV disease
 Acute Opportunistic Infection
 Older than 50 yrs of age
 HIV-1 RNA > 100,000 copies/mL
 CD4+ cell count Decline >100 cells/mm³/yr
 Active HBV or HCV
 Active or High Risk for Cardiovascular Disease
 HIV-Associated Nephropathy
 Symptomatic Primary HIV infection
 Pregnant Women
 Sero-discordant couples (or High Risk of HIV Transmission)
*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
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
Evidence: HIV Prevention Trials
Network 052 Study
1,763 couples
HIV positive partner with
CD4 350-550
97% heterosexual
N=886
Immediate ART
N=877
ART at CD4 of 250
1 linked transmission
27 linked transmissions
HPTN052 Study Team Prevention of HIV-1 Infection with Early
Antiretroviral Therapy N ENGL J MED 365;6 Aug 11, 2011
So…
 If early diagnosis of HIV benefits the
individual
 and early diagnosis of HIV benefits the
population
 How are we doing?
NOT VERY WELL…
65% of people are diagnosed after they should already be on treatment
First CD4 count (cells/mL) among HIV +ve diagnoses
100%
80%
60%
CD4 350-500
40%
CD4 200-349
20%
CD4 <200
0%
2003
2004
2005
<200
2006
2007
Year of diagnosis
[200, 350)
[350, 500)
2008
2009
2010
500+
Source: VCH public health and BCCFE data linkage project
NOT VERY WELL…..
PHAC
An estimated 26% of HIV infected patients are
unaware of their infection
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
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
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
Contrast: HIV meets ALL WHO Criteria
for a routine screening program
 The condition sought should be an important health problem for the
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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.
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
Uptake in primary care very high
Source: Health Protection Agency, UK, Dec. 2010
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
The barrier is us, not the patient
SITE
Offer
Acceptance
ED
62%
62%
Acute care unit
40%
70%
Dermatology
outpatient
50%
68%
One GP Unit
21%
75%
Medical admissions
unit
40%
91%
http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/HIV/
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
New HIV Testing Recommendations
BCMJ, 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
HOW TO DO ROUTINE HIV
TESTING IN YOUR PRACTICE?
Step 1: Recommend an 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?”
Posters - help start the conversation
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
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
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 Defic Syndr., March 2012
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
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
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
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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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