STOP HIV/AIDS

New HIV Recommendations

Dr. Réka GustafsonMedical 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

1. Two pilot sites: Vancouver & Prince George

2. Evaluation

• Was diagnosis improved?

• Are more people on treatment?

• Did we change the course of the epidemic?

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

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…

CD4 200-349

Source: VCH public health and BCCFE data linkage project

65% of people are diagnosed after they should already be on treatment

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 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

Source: Health Protection Agency, UK, Dec. 2010

Uptake in primary care very high

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 RecommendationsBCMJ, 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 careAlready 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 Health604-675-3900 (Vancouver, Richmond, North Shore)

IDC Rapid Expert Advice and Consultation in HIV1-800-665-7677

Oak Tree Clinic604-875-2212

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 PhysiciansAccreditation: Up to 1.5 MainPro M1 Date: Tuesday, April 24, 2012Time: 7:00-8:30pm PST

www.ubccpd.ca/programs/hiv_testing

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