Prevention in Focus

Fall 2013 

Views from the Frontlines: Routine and Targeted Testing

We spoke to people from four organizations about HIV testing strategies:

Thomas Haig

Many health authorities across Canada are trying to expand access to HIV testing. Are there any successful HIV testing approaches or practices from your region you'd like to share?

I guess I’d have to say the SPOT Project which started in 2009. The motivation behind SPOT was to increase access to testing for gay men and other men who have sex with men in Montreal. We know testing works well for some people in a clinical setting. The idea behind SPOT was that we might not be reaching other groups of people who don’t go to a clinic, who are not as comfortable in a clinical setting or for other reasons don’t access testing that way. SPOT allowed us to create a community-based site to offer testing in a more non-medicalized setting. The project is also helping us to reinforce the role that testing can play as a prevention strategy.

One of our innovations was incorporating community workers into the testing team. In Quebec, testing has typically been done only by nurses or doctors. At SPOT we were able to develop a more involved role for the community workers by creating a team approach. The community worker is responsible for the counselling component while the nurses focus mainly on testing. It’s the first time that community workers have taken on this role in Quebec.

SPOT allows us to compare this approach to a model where a nurse works alone. We offered both types of interventions and compared them. We were able to demonstrate that the team approach was at least as effective as a nurse working alone and, for some people, it was more effective. This was especially the case for men whose sexual practices place them more at risk, who were more likely to come back for another test after three months when their initial test was provided by the testing team.

We have also been able to compare a community-based setting for testing with a more typical clinical setting. During the first phase of the project, we were able to offer the same intervention at our community site and in two medical clinics. We learned that doing the work in the community setting was at least as good as offering it in the clinic. For some groups of people, including men under 30 and people born outside of Canada, we were able to more easily attract them to the community site.

Some experts see pre- and post-test counselling as a barrier to testing for some clients, especially in the context of routine testing. What are your thoughts?

I would tend to agree that there’s a need to have a more nuanced approach to counseling instead of a one size fits all approach. However, I have some concerns if the move to streamline testing is motivated by an idea of counselling as a pesky problem that we just want to go away. This could lead to implementing models of routine testing that we don’t necessarily want and that might not work very well.

There are certainly people in the gay community who engage in risky behaviours but are already well-informed about the issues, so there is a case to be made for streamlining counselling for some individuals, especially if we want those people to come back to get re-tested every 3 to 6 months. I think there is value on all sides to see how we can do a better job with counselling. I would like to see this happen in a nuanced way. We also need to break down the assumption that counselling is a problem or something to be avoided.

The SPOT project is allowing us to do research on how to provide better counselling in conjunction with HIV and STI testing. Our main focus for the next phase of research is on evaluating a type of counselling based on motivational interviewing. This approach is more client-focused than standard counselling. The motivational approach involves accompanying people as they identify their own steps and strategies in terms of potential change. We have very preliminary data that suggest motivational interviewing may be more effective than standard counselling and our upcoming research will provide a more complete picture.

Overall, we need to reiterate the value of counselling. At SPOT, what we hear over and over again is that counselling is important. Quite a few people have told us that getting testing at SPOT was the first time they had a chance to have an in-depth talk about personal and sexual health issues with a healthcare provider. This isn’t necessarily what everyone in the community needs, but it seems to be the case for a significant proportion of men.

In some regions, health authorities are recommending that the offer of an HIV test be made part of routine health care for all adults. What do you think about this as an option for your community? What are the benefits and drawbacks?

I can see both benefits and drawbacks and I think one of the benefits is the de-stigmatization HIV. We do need to recognize the issue of how hard it can be to bring up the topic of HIV-related risk, both for patient and provider. So as a way to address this, I think routine testing could be a step in the right direction. But if the goal is simply to remove discomfort that healthcare providers may feel when talking about sexual health, then we would be going in the wrong direction.

We also have to keep in mind the bigger picture of what will happen after a diagnosis. Routine testing has the potential to increase diagnoses but then if people are not properly linked to care or their experience of diagnosis is negative, we run the risk of creating new problems.

I think it’s helpful to broaden the notion of what we mean by “routine testing.” Routine testing has come to refer to systematic testing for the general population, but it may be just as important to strengthen the idea of testing routines as a part of targeted HIV-testing efforts. This would include a community education component that promotes the adoption of testing routines by gay men and MSM whose practices put them at more risk of getting infected. The counselling approaches that we have been developing at SPOT also focus on the capacity of clients to see testing as an important routine in terms of their own health and well-being. For me this is just as important as the more typical ways in which we think about routine testing.

Ken English and Frank McGee

Many health authorities across Canada are trying to expand access to HIV testing. Are there any successful HIV testing approaches or practices from your region you'd like to share?

In Ontario, Toronto’s Hassle Free Clinic made anonymous HIV testing (AT) available to their clients in the late 1980s, as they found demand for it amongst those who were anxious they may be HIV positive. In 1992, the Ontario government introduced a province-wide AT program.

Analysis of testing and positivity rates for the provincial AT program showed AT testing consistently demonstrated significantly higher positivity rates than nominal testing (a rate of about 4 to 1). Based on this, we doubled the number of testing sites to 50 in 2007. Around this time, Health Canada licensed the country’s only rapid point of care (POC) HIV test, and we chose to introduce it into our expanded AT program in 2008. Our decision to introduce POC testing at our AT sites was based on the evidence that the AT program attracts high-risk clients, and we felt that the availability of POC testing would further encourage at-risk clients to test. Our most recent analysis of POC testing shows that the program attracts a greater rate of HIV positives, by about 3 to 1. It’s also important to mention that in Ontario we have made the provision of pre- and post-test counselling a requirement of all of our AT and POC testing sites.

In addition to the provision of AT and POC testing, we have been working with community and stakeholders to promote targeted outreach testing to priority populations, and we’ve been successful at promoting testing to gay men and other men who have sex with men (MSM) and through a correctional facility. The 2011/12 MSM testing blitz, which involved a multi-media campaign and time-limited expanded testing sites over 12 weeks, was successful at attracting over 1,000 testers and successfully obtained a 2% positivity rate. Our correctional facility POC testing initiative was successful at attracting a significant (40%) number of first-time HIV testers.

Some experts see pre- and post-test counselling as a barrier to testing for some clients, especially in the context of routine testing. What are your thoughts?

Interestingly, some of the rationale for streamlined or normalized testing is that it is seen as a barrier for healthcare providers who are either too busy to conduct comprehensive counselling or uncomfortable discussing some aspects of sexual health. Yet, we know that pre- and post-test counselling can be completed in 15–20 minutes, and even shorter if the provider has an ongoing relationship with the client. Regardless, HIV pre- and post-test counselling not only ensures informed consent is obtained prior to testing but, as well, the risk assessment conducted during counselling can help to focus the risk reduction discussion to the most relevant needs of the client – which is especially important when delivering an HIV-positive result. For example, it wouldn’t be very helpful to discuss heterosexual risk reduction with a gay man. As well, in the absence of counselling it might be difficult to ascertain the specific needs of a client and to ensure the appropriate referrals have been made.

Research shows receiving an HIV-positive diagnosis is a pivotal moment in the life of a person with HIV, and has ramifications on the psychological well-being of people living with HIV. Research also shows that this has been done very badly. So, from our perspective in Ontario, we encourage all HIV testers to make use of the Ministry of Health and Long-Term Care pre- and post-test counselling guidelines and, to this end, we distributed them to healthcare practitioners across the province in 2008.

In some regions, health authorities are recommending that the offer of an HIV test be made part of routine health care for all adults. What do you think about this an option for your community? What are the benefits and drawbacks?

Ontario HIV epidemiology has consistently shown that the HIV epidemic is centred in specific at-risk populations (gay/MSM, African, Caribbean, Black Ontarians, Aboriginal populations, people who use injection drugs, and women at greatest risk), so our approach has been to apply our resources to testing where the epidemic exists. In fact, Ontario does a lot of general population testing, mostly through physicians’ offices. We test just under 600,000 people a year to diagnose about 1000 people.

Expanding routine testing presupposes that those at greatest risk regularly seek health care or would somehow begin to do so. Yet we know that these individuals happen to be some of our communities’ most marginalized and have historically had great mistrust of the healthcare system. That’s why our approach has been to promote testing through community clinics and AIDS service organizations and include a strong peer component. Lastly, while there is some research that suggests HIV testing is cost-effective in the long-term in communities where there is a 0.1% positivity rate, the analysis does not account for ramp-up costs associated with expanded testing. For example, had Ontario expanded HIV testing to routine medical examinations (annual medical exams are no longer routinely offered in Ontario), testing infrastructure would have needed to expand to accommodate approximately 3 million HIV tests annually.

Carol Major

Many health authorities across Canada are trying to expand access to HIV testing. Are there any successful HIV testing approaches or practices from your region you'd like to share?

In Ontario, the AIDS Bureau and the Ontario HIV Treatment Network (OHTN) host an annual HIV Testing Conference for those involved in anonymous testing, point-of-care testing or other sexual health or harm reduction service centres that provide HIV counselling and testing. This KTE event provides participants with the latest information on HIV testing, skills building sessions, and opportunities to share local initiatives and best practices. This year one of the highlights was learning about the Niagara Region Public Health outreach to street-involved clients. Stacey Allegro, public health nurse, consulted with more than 50 agencies and her prospective clients to establish an innovative and successful outreach program reaching vulnerable clients. In the first year, she had had more than 2000 client contacts through the mobile van, at drop-in centres, shelters and at client accommodation. Services provided include harm reduction, needle exchange, first aid, vaccinations, HIV/Hep B/Hep C counselling and testing.

Full details of this year’s conference can be found here.

Some experts see pre- and post-test counselling as a barrier to testing for some clients, especially in the context of routine testing. What are your thoughts?

In my view, each testing encounter is an educational opportunity and pre- and post-test counselling is essential. After all, most clients will be HIV negative and it is important that they understand what behaviours put them at risk for HIV and how to reduce their risk for HIV.

In some regions, health authorities are recommending that the offer of an HIV test be made part of routine healthcare for all adults. What do you think about this an option for your community? What are the benefits and drawbacks?

At the moment, it seems to me that this approach would not be cost effective in our environment. A better use of resources would be to put additional effort into targeted and outreach programs designed to attract those most at risk for HIV. Through appropriate counselling and testing, we can identify those who have HIV and offer them the care and support they need, and at the same time provide those at risk for HIV the resources and tools they need to prevent HIV infection. The only situation in which “routine” testing might be beneficial is in high-prevalence communities (where the HIV prevalence is greater than 0.2%). However, as these are vulnerable communities, pre- and post-test counselling is particularly important as part of a prevention strategy.

Afshan Nathoo

Many health authorities across Canada are trying to expand access to HIV testing. Are there any successful HIV testing approaches or practices from your region you'd like to share?

As part of the B.C. STOP HIV/AIDS Pilot Project, the city of Vancouver has made considerable efforts to improve access to HIV testing, treatment and support services, with the goal of reducing HIV transmission. In particular, the acute care testing initiative, the first of its kind in Canada, implemented the routine offer of an HIV test to all patients as part of routine hospital blood-work.

The introduction of routine HIV testing in four Vancouver hospitals required the support and active involvement of the medical and operational leaders, support of the laboratories, streamlined consent guidelines, broad and sustained education and a delegated follow-up process. This delegated follow-up was key to offering an HIV test in a setting where physicians do not have ongoing clinical relationships with patients, and ensured that all patients who tested positive received timely linkage to care and support services.

The results from this initiative demonstrate the feasibility of testing in this setting, overwhelming acceptance by patients – with 94% of patients accepting a test when offered by a resident/physician  – and cost-effectiveness, with a yield approximately four-times the cost-effectiveness threshold for routine HIV testing. In addition, the stage of disease at diagnosis for this population of patients ranged from acute infection to late stage disease. As a result, the acute care setting provides an opportunity for testing among patients who have never received testing, but also provides an additional opportunity for patients who regularly access testing.

Some experts see pre- and post-test counselling as a barrier to testing for some clients, especially in the context of routine testing. What are your thoughts?

In B.C., our testing paradigm has remained relatively static despite a changing epidemic and advancements in HIV treatment. If the goal of treatment as prevention is to improve early diagnosis and early treatment, then a shift/expansion of our testing paradigm is an absolute pre-requisite.

A streamlined approach to testing is necessary to address various barriers including: inability to accurately assess risk for exposure to HIV by some clients and providers, time constraints for risk assessments by providers, related fear of stigma and discrimination, and discomfort discussing HIV testing. The importance of early diagnosis cannot be overemphasized. As a result, pre-test counselling should not be a barrier for a life-saving diagnostic test. Verbal consent, as with other medical interventions, should inform patients that an HIV test is being recommended as part of routine care and allow patients the opportunity to decline testing.

This being said, pre-test counselling continues to be an important component of testing in some settings, particularly among key populations known to be at high risk for exposure to HIV infection. As a result, the question is not routine versus targeted testing approaches or pre-test counselling versus no pre-test counselling. Rather, the question is: what is the appropriate framework to enable tailored approaches for both patients and providers based on the needs of the patient? A balance between maintaining the human rights of patients, providing patient-centred care and attending to the time constraints of clinical settings are imperative considerations for the development of testing frameworks.

In some regions, health authorities are recommending that the offer of an HIV test be made part of routine healthcare for all adults. What do you think about this an option for your community? What are the benefits and drawbacks?

Late diagnosis of HIV and multiple missed opportunities for earlier diagnosis are significant concerns in our population. Between 2009 and 2011 in Vancouver, 47% of patients diagnosed with a CD4 count of less than 350 had at least one emergency room, inpatient or outpatient acute care encounter prior to diagnosis. Given this, routine testing for all adults provides an opportunity to improve early diagnosis and minimize missed opportunities for earlier diagnosis of HIV. Routine testing can also help normalize HIV testing and further reduce stigma and discrimination associated with HIV.

HIV infection meets all of the World Health Organization’s guidelines for conditions for which routine screening should be considered. In Vancouver, routine testing is cost-effective, with a diagnosed prevalence of 12.1/1000 which is well above the diagnosed prevalence threshold (2/1000) used by the United Kingdom to determine whether HIV testing should be offered routinely. Still to be determined is the age range and frequency of testing; however, provincial guidelines are being developed in B.C. based on the evaluation of the STOP HIV/AIDS project.

While the expansion of testing is encouraging, increasing the effectiveness of public health follow-up and reducing the significant socioeconomic barriers to adherence in treatment are required as part of an overall HIV/AIDS strategy.

Related article

For more detailed information on testing strategies, see Routine and Targeted Testing.

Do you work in HIV or hep C?
Complete a short survey to evaluate CATIE and enter a draw to win a $250 gift card.