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Editorial in Canada's Leading Medical Journal Calls for Routine HIV Testing

By Sean R. Hosein

November 30, 2012

The widespread availability of potent combination anti-HIV therapy (commonly called ART or HAART) has greatly decreased deaths from AIDS-related complications in Canada and other high-income countries. The benefits of ART are so profound that doctors estimate that a 20-year-old diagnosed with HIV today who takes his or her medicine exactly as prescribed and who does not have other pre-existing health issues will likely have a near-normal life expectancy.

Unfortunately, not all HIV-positive people in Canada are benefitting from ART in a timely manner. According to the Public Health Agency of Canada, researchers estimate that about 25% of 71,300 HIV-positive people alive in Canada today are not aware of their HIV status. Moreover, a large fraction of such people, because they are unaware of their HIV status, only receives care and treatment when their immune systems are very weak.

There are many disadvantages, at both a personal and societal level, to a late HIV diagnosis, including the following:


Canada

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Routine HIV testing is recommended in Canada in cases of pregnancy and blood donations. Otherwise, HIV testing is primarily done in people who are at or are perceived to be at high risk for this infection. In an editorial for an upcoming issue of the Canadian Medical Association Journal, Vancouver doctors Réka Gustafson and Julio Montaner note that risk-based testing is likely to miss "a substantial proportion of [hidden HIV infections]."


Uncovering HIV

The Vancouver Coastal Health authority conducted a pilot study and found that 60% of HIV-positive people diagnosed late in the course of infection had previously encountered the health care system, as they had at least one of the following experiences three years prior to their diagnosis or last negative test:

Drs. Gustafason and Montaner note that according to recommendations in other high-income countries, such as France and the U.K. and U.S., "these patients should have been offered an HIV test at these earlier encounters, without needing to raise or acknowledge a specific risk." Moreover, public health authorities in these countries now encourage health care professionals to offer HIV testing to a broad age range of people, from teenagers to senior citizens, without taking into account risk factors.


The Pilot Study

As part of Vancouver Coastal Health's pilot project, hospital administrators recommend HIV testing "as part of all medical admissions and emergency department visits," stated Gustafason and Montaner. Preliminary analysis of the pilot project found that 43% of hospital doctors offered the test and 92% of participants consented to be tested for HIV. This project uncovered six new cases of HIV infection per 1,000 tests. Other research has found that even one new case of HIV per 1,000 tests is cost effective. Based on the results from the pilot study, Dr. Gustafason, who is the Medical Health Officer for Vancouver Coastal Health, now recommends offering routine screening for HIV in hospitals and doctors' offices.


Editorial in Canada's Medical Journal

In an upcoming issue of the Canadian Medical Association Journal, based on the success of the BC pilot study, Drs. Gustafason and Montaner encourage other provinces and territories to "implement and evaluate routine HIV testing across Canada." Hopefully such testing will be accompanied by supportive counselling both before and after testing.

This recommendation seeks to normalize HIV testing so that it is routinely done in hospitals and clinics so that undiagnosed cases of HIV can be caught early. Such normalization can help reduce costs, improve personal health and reduce the transmission of HIV.


References

  1. Gustafason R, Montaner J, Sibbald B, et al. Seek and treat to optimize HIV and AIDS prevention. Canadian Medical Association Journal. 2012; in press.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. Haukoos JS, Hopkins E, Conroy AA, et al. Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients. JAMA. 2010 Jul 21;304(3):284-92.
  9. Palfreeman A, Nyatsanza F, Farn H, et al. HIV testing for acute medical admissions: evaluation of a pilot study in Leicester, England. Sexually Transmitted Infections. 2012; in press.
  10. Casalino E, Bernot B, Bouchaud O, et al. Twelve Months of Routine HIV Screening in 6 Emergency Departments in the Paris Area: Results from the ANRS URDEP Study. PLoS One. 2012;7(10):e46437.
  11. Bezemer D, de Wolf F, Boerlijst MC, et al. 27 years of the HIV epidemic amongst men having sex with men in the Netherlands: an in depth mathematical model-based analysis. Epidemics. 2010 Jun;2(2):66-79.
  12. Audelin AM, Cowan SA, Obel N, et al. Phylogenetics of the Danish HIV epidemic: the role of very late presenters in sustaining the epidemic. Journal of Acquired Immune Deficiency Syndromes. 2012; in press.
  13. Wilson DP, Jin F, Jansson J, et al. Infectiousness of HIV-infected men who have sex with men in the era of highly active antiretroviral therapy. AIDS. 2010 Sep 24;24(15):2420-1.
  14. Krentz HB, Gill MJ. Impact of expanded HIV screening. Annals of Internal Medicine. 2007 Jul 17;147(2):146.




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