According to the Public Health Agency of Canada, there are an estimated 71,300 HIV-positive people in Canada, 25% of whom do not know their HIV status. It is in this context that expanding opportunities for offering HIV testing should be seen as helpful because they can do the following:
- help uncover undiagnosed HIV infections
- reinforce education about safer sex and substance-using behaviours during the counselling that accompanies HIV testing
- inform newly diagnosed HIV-positive people about the benefits of early treatment and offer avenues for them to explore this
This latter point is important for at least the following reasons:
- Early initiation of potent combination HIV therapy (commonly called ART or HAART) helps to preserve the immune system and places the HIV-positive person on a path to better health. The impact of ART is so profound that a young adult who is diagnosed with HIV today in Canada and similar countries, who has minimal or no co-existing health conditions and who takes ART every day exactly as directed, is expected to live for several decades.
- The other benefit of early initiation of ART is that it can greatly reduce the amount of HIV in the blood (viral load) and genital fluids. This reduces the sexual infectiousness of ART users. If many HIV-positive people take ART, this has the potential to reduce the future spread of HIV in a large city or region.
Using ART to help improve a person’s health and to reduce his or her sexual infectiousness is called Treatment as Prevention (TasP). In Canada, HIV testing and TasP are being offered in British Columbia, where research suggests that this strategy is generally working by reducing the rate of new HIV infections, particularly among injection drug users and heterosexual people. A key part of the BC initiative is the offer of an HIV test.
Barriers to HIV testing
Researchers at Dalhousie University in Halifax, Nova Scotia, have been conducting work on HIV testing. In their latest project, they focussed on the views of users of a sexual health clinic on rapid HIV testing. As part of its work, the Dalhousie team of researchers reviewed scientific publications about HIV testing and reported that those studies have found that some people at high risk for HIV infection do not get tested because of at least the following reasons:
- fear of the testing process
- anxiety about receiving test results
- lack of access to testing
- stigma associated with HIV
About rapid point of care HIV testing
In some parts of Canada, particularly in large urban centres, rapid point of care (POC) HIV testing is available in select locations. This type of test requires a few drops of blood taken from the finger and can be done in almost any community setting. The usual protocol involves counselling clients about the test before the test is done and counselling them about behaviours that commonly lead to HIV transmission. The test result is usually available in a couple of minutes. If it is negative, the client receives the result and further counselling. If the test result is reactive (this is considered a preliminary positive test result), the client receives the result and post-test counselling, including referrals to healthcare providers. After obtaining informed consent, the counsellor can then draw blood for a confirmatory test. Although the rapid POC test has a high level of accuracy (more than 99%), reactive test results need to be confirmed by a central laboratory before someone can be conclusively diagnosed as HIV positive. This confirmatory test can take one to two weeks depending on the laboratory - an anxious time for many people.
The advantages of rapid POC testing include the following:
- it can be done in community settings
- only a few drops of blood are required
- clients can have the same person provide counselling both before and after the test
- the test result is available quickly
Favoured by people at high risk for HIV
As part of their review of scientific publications on rapid POC testing, the Halifax researchers found that “even at sites where rapid POC testing is not the overall preferred method of testing, it tends to be favoured by high-risk clients, such as men who have sex with men and injection drug users.”
Halifax research - Attitudes towards rapid POC testing
The research team at Dalhousie University conducted a study of attitudes toward rapid POC testing among people who were seeking anonymous HIV testing. The team found that rapid POC testing was “highly acceptable” to this population. The team’s report, published in the journal Sexual Health, is important reading for clinics that specialize in screening for sexually transmitted infections (STIs), community-based health centres, and health policy planners, particularly in the Atlantic provinces of Canada. Rapid POC HIV testing can be an important tool to reach busy people and bypass some of the barriers associated with standard HIV testing.
The study took place at a sexual health clinic in Halifax. The clinic’s HIV nurse asked potential volunteers if they were interested in the study’s questionnaire, explained the purpose of the study and other details, and then obtained informed consent from participants. Overall, there were 411 participants who completed surveys over a period of several months in 2011. Participants were all people who sought anonymous HIV testing at the clinic and their basic profile was as follows:
- 53% men, 47% women
- most (78%) were aged 20 to 40 years
- participants self-identified as follows: 72% heterosexual, 19% gay, 9% bisexual
These basic demographic features were similar to those from people who sought anonymous HIV testing at the clinic over the previous five years.
Overall, 90.3% of participants favoured a rapid POC test if it were made available. This result is similar to that of other studies previously done on the same topic in Toronto, New York City and Chicago.
The study site used a clinic that had a large catchment. According to the researchers, clinic users (and study participants) came not only from Halifax but also from the nearby city of Dartmouth and “several small suburban and rural communities.” Therefore, the results from the present study are likely to reflect the views of urban, suburban and rural people.
Participants were asked if they would be willing to pay a $20 fee for access to rapid POC testing in the future. Although 70% said yes, 27% said no, suggesting that even relatively small user fees can act as a deterrent to HIV testing.
HIV testing sites and knowledge transfer
In its survey, the research team asked participants about services at the sexual health clinic. All participants were in agreement about the clinic’s helpfulness and ability to assist them in understanding issues related to HIV transmission in a clear manner.
According to the study team, 85% of participants “indicated that they learned more about HIV in their testing session than they knew previously, particularly because they were made to feel ‘comfortable in disclosure’ and because staff were able to ‘teach [them] new information and correct misinformation.’”
Based on the Halifax study, it is clear that HIV testing sites can serve as important venues to counsel and (re)educate people about issues related to safer sex and other healthy behaviours. By engaging in this function, such clinics can serve an important educational function.
The research team noted that “several studies have observed that youth sexual health education programs in Nova Scotia sometimes offer only scant coverage of HIV and other sexually transmissible infections, and that there is often a lack of knowledge and topic discomfort among educators, as well as generation gaps between educators and students.” Furthermore, the researchers added that “targeted [HIV] prevention efforts in Nova Scotia have focussed largely on pregnant women, whereas other groups (such as MSM, heterosexual men) may be overlooked.”
The Halifax study provides important insight as to what people at risk of HIV need when it comes to HIV testing opportunities in Atlantic Canada. A major strength of the study is that it engaged participants from both urban and rural areas and was relatively large in size. Rapid POC testing has the potential to reach people at risk for HIV in a variety of settings and can help penetrate traditional barriers to HIV testing. After counselling, people whose reactive POC tests are confirmed can then be swiftly referred to clinics for care and discussion about the initiation of treatment.
A rapid approach to community-based HIV testing – Prevention in Focus
HIV Screening and Testing Guide – Public Health Agency of Canada
Editorial in Canada’s leading medical journal calls for routine HIV testing – CATIE News
U.S. poised to normalize testing – CATIE News
Detecting HIV earlier: Advances in HIV testing – Prevention in Focus
Recently infected individuals: a priority for HIV prevention – Prevention in Focus
- Sean R. Hosein
- Lewis NM, Gahagan JC, Stein C. Preferences for rapid point-of-care HIV testing in Nova Scotia, Canada. Sexual Health. 2013 Apr;10(2):124-32.
- Sabin C. Review of life expectancy in people with HIV in settings with optimal ART access: what we know and what we don’t. In: Program and abstracts of the 11th International Congress on Drug Therapy in HIV Infection, 11-15 November 2012, Glasgow, UK. Abstract O131.
- May M, Gomples M, Sabin C, et al. Impact on life expectancy of late diagnosis and treatment of HIV-1 infected individuals: UK Collaborative HIV Cohort Study. In: Program and abstracts of the 11th International Congress on Drug Therapy in HIV Infection, 11-15 November 2012, Glasgow, UK. Abstract O133.
- Lohse N, Hansen AB, Pedersen G, et al. Survival of persons with and without HIV infection in Denmark, 1995-2005. Annals of Internal Medicine. 2007 Jan 16;146(2):87-95.
- Lohse N, Hansen AB, Gerstoft J, et al. Improved survival in HIV-infected persons: consequences and perspectives. Journal of Antimicrobial Chemotherapy. 2007 Sep;60(3):461-3.
- Søgaard OS, Lohse N, Østergaard L, et al. Morbidity and risk of subsequent diagnosis of HIV: a population based case control study identifying indicator diseases for HIV infection. PLoS One. 2012;7(3):e32538.
- Krentz HB, Gill MJ. Cost of medical care for HIV-infected patients within a regional population from 1997 to 2006. HIV Medicine. 2008 Oct;9(9):721-30.
- Gustafson R, Montaner J, Sibbald B. Seek and treat to optimize HIV and AIDS prevention. CMAJ. 2012 Dec 11;184(18):1971.
- Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral Treatment of Adult HIV Infection: 2012 Recommendations of the International Antiviral Society–USA Panel. JAMA. 2012;308(4):387-402.
- Martin EG, Schackman BR. Updating the HIV-Testing Guidelines - a modest change with major consequences. New England Journal of Medicine. 2013 Mar 7;368(10):884-6.
- Bayer R, Oppenheimer GM. Routine HIV Testing, Public Health, and the USPSTF - an end to the debate. New England Journal of Medicine. 2013 Mar 7;368(10):881-4.