HIV in Canada: A primer for service providers

 

New Directions in Program Development

Key Points

  • HIV prevention services are essential to reduce new HIV infections.
  • Effective HIV testing technologies and approaches need to be implemented to help Canada reach the first 90 target.
  • Effective programming to address individual and systems level barriers to care are necessary to reach the second and third 90 targets.

The recent acceleration of biomedical/clinical research in HIV prevention, transmission, testing and treatment; program science; and accumulated experience in addressing HIV at the front-line have provided us with new information to achieve the UNAIDS targets to eliminate the AIDS epidemic by 2030. We now have an understanding of key programming areas to consider moving forward. If we can leverage this knowledge to improve the effectiveness and sustainability of our response, we have the ability to significantly transform our national frontline efforts and end the HIV epidemic. However, awareness of all this new knowledge among at-risk communities, people with HIV and service providers is varied. While some jurisdictions in Canada have integrated this knowledge into their planning many organizations struggle to take up these new developments into their programs, to create new initiatives, and to identify effective programming approaches relevant to their jurisdictions. Canadian service providers, researchers, and policymakers have a role to play in facilitating awareness, access and use of this new knowledge.

Prevention programming is key to reduce the number of new HIV infections in Canada. Expanding knowledge and access of affected communities to highly effective HIV prevention strategies, such as: treatment as prevention, pre-exposure prophylaxis (PrEP), and harm reduction is essential. The convergence of treatment and prevention represents a paradigm shift; earlier approaches tended to differentiate prevention, testing, treatment and care as separate areas of practice. Many new HIV prevention approaches emphasize the importance of frontline responses that integrate new biomedical/clinical knowledge into programming and improve the linkage of clients across these areas of practice. If acted upon, this knowledge can support HIV-negative people to consider newer prevention options (e.g., PrEP), help serodiscordant couples to assess their HIV risk to make informed decisions about prevention and treatment, and help people with HIV to make decisions about when to start treatment.

Canada continues to fall short in reaching the first 90 target: 90% of people with HIV know their status. HIV testing is the gateway to HIV diagnosis and engagement in treatment, care and support for people with HIV. It is also the gateway to enhanced engagement in HIV prevention, care and support for people who test HIV negative but are at ongoing high risk of transmission. HIV testing is an ideal opportunity to identify people at high risk for infection and refer them for enhanced prevention services, such as PrEP and risk reduction counselling. Testing can also serve as a gateway to other, non-HIV specific services for those with and at risk for HIV. 

Improved efforts to reach the undiagnosed in Canada includes the uptake of effective testing technologies and programming approaches, as well as the scale up of evidence-informed linkage to care and partner notification services. An example of an effective HIV testing technology is HIV point-of-care testing (POCT) which has greatly expanded access to and uptake of HIV testing and diagnosis in some Canadian jurisdictions. However, access to HIV POCT varies by province, region, community, and population, a significant challenge in getting ahead of the epidemic in Canada. Although not yet available, home-based HIV testing also has the potential to reach more individuals at high risk for HIV infection.  

An example of effective testing programming approaches includes the use of new settings to reach the undiagnosed through targeted testing strategies. Sometimes these are facilitated by the use of POCT in some jurisdictions. New settings for testing include, but are not limited to, Indigenous health centres, addictions facilities, transitional housing, indoor commercial sex venues, during street outreach, and prisons. These settings allow for reach to populations that may not have had access to HIV testing. Another example is the use of non-regulated and allied health care providers as testers in some jurisdictions. Evidence supports this approach; providers such as pharmacists, social workers, and “peers” are appropriate for the tester role. In some cases, these providers may be more effective at engaging with people at high risk than traditional testers and can expand the availability and uptake of HIV testing services.

Programming that facilitates immediate linkage to care (and treatment) from diagnosis will likely become the standard of care in many high-income countries given that early care and treatment can significantly improve health outcomes. Some jurisdictions in Canada are using this approach with success at getting people immediately engaged in care and on treatment.

To reach the second and third 90 targets, services need to address barriers to care for people with HIV. This includes both individual- and systems-level barriers to engagement in care, treatment, and adherence. Effective programming that addresses barriers to care, such as multidisciplinary care teams, peer navigation services for people with HIV and adherence support programming, is necessary to provide support to address ongoing barriers to clinical services.

Resources

A Pan-Canadian Framework for Action: Reducing the Health Impact of Sexually Transmitted and Blood-Borne Infections by 2030 – Public Health Agency of Canada

Ending the HIV Epidemic in Canada in Five Years: It’s Time to ACT – Members of the National Working Group on HIV/AIDS Research

National Deliberative Dialogue on Reaching the HIV Undiagnosed: Scaling up effective programming approaches to HIV testing and linkage to prevention and care: Meeting report - CATIE

CATIE Forum 2013: New Science, New Directions in HIV & HCV: Final Report

Practice Guidelines in Peer Health Navigation for People Living with HIV – CATIE

Health Navigation in HIV Services: A review of the evidencePrevention in Focus, Fall 2018.

PrEP for understudied populations: Exploring questions about efficacy and safetyPrevention in Focus, Fall 2018.

Health navigationProgramming Connection package

Health promotion case managementProgramming Connection package

Linkage to careProgramming Connection package

Multidisciplinary programs in biomedical HIV preventionProgramming Connection package

Multidisciplinary programs in HIV careProgramming Connection package

Non-clinic based testingProgramming Connection package

Routine HIV testingProgramming Connection package

Public health follow upProgramming Connection package

Testing campaignsProgramming Connection package

Sources

  1. Sherman EM, Elrod S, Allen D, Eckardt P. Pharmacist testers in multidisciplinary health care team expand HIV point-of-care testing program. Journal of Pharmacy Practice. 2014 Dec;27(6):578–581.
  2. Lazarus L, Patel S, Shaw A, et al. Uptake of community-based peer administered HIV point-of-care testing: Findings from the PROUD Study. PLoS ONE. 2016;11(12): e0166942. Available from: https://doi.org/10.1371/journal.pone.0166942.
  3. World Health Organization. Consolidated Guidelines on HIV Testing Services. Geneva, Switzerland: World Health Organization (WHO); 2015 Jul. Available from: http://apps.who.int/iris/bitstream/10665/179870/1/9789241508926_eng.pdf?ua=1&ua=1
  4. BC Centre for Disease Control. Point of Care HIV Test Guidelines for Health Care Settings. In: Communicable Disease Control Manual, Chapter 5. BC Centre for Disease Control; 2014 May..
  5. CATIE. National Deliberative Dialogue on Reaching the HIV Undiagnosed: Scaling up effective programming approaches to HIV testing and linkage to prevention and care: Meeting report. 2017. Available from: http://www.catie.ca/en/resources/national-deliberative-dialogue-reaching-hiv-undiagnosed-scaling-effective-programming-appr
  6. CATIE. National Deliberative Dialogue on Integrated Approaches to HIV Treatment and Prevention: Meeting report. 2013. Available from: http://www.catie.ca/sites/default/files/National-Deliberative-Dialogue-on-Integrated-Approaches-to-HIV-Treatment-and-Prevention_05312012.pdf.
  7. CATIE. CATIE Forum New Science, New Directions in HIV and HCV – meeting report. 2013. Available from: http://www.catie.ca/sites/default/files/CATIE-Forum-Report-Final-Nov-2013.pdf.
  8. CATIE. Shifting the paradigm: The history of the Vancouver STOP HIV/AIDS Project. 2013. Available from: http://www.catie.ca/sites/default/files/stop_EN_2013_10_07.pdf
  9. CATIE. Health Navigation in HIV services: A review of the evidence. Prevention in Focus, Fall 2018. Available from: http://www.catie.ca/en/pif/fall-2018/health-navigation-hiv-services-review-evidence

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