Routine testing programs
Could routine testing help reduce the number of people who are unaware they are HIV positive?
In 2011, an estimated 25% of the 71,300 Canadians living with HIV were unaware of their infection.1 People who haven’t been tested and diagnosed are unable to benefit from linkage to care, support and treatment, which improve health and reduce HIV transmissions.
In 2013, the Public Health Agency of Canada released an HIV Screening and Testing Guide2 that “seeks to reduce the number of undiagnosed HIV infections in Canada by offering a framework for care providers to explore options that will enhance their ability to provide HIV testing, as well as to better tailor their testing approaches to meet the specific needs of their practice and clients.” One of the recommendations to improve HIV testing in Canada is to add the offer of an HIV test to periodic routine medical care. Could this help to improve diagnosis of HIV?
Routine testing in New York and New Orleans
Periodic routine testing was implemented in two healthcare settings, in New York City and New Orleans,3 between 2011 and 2013 and was very successful at diagnosing HIV infections and then linking people to care.
In New York, the percentage of people who received an HIV test increased from 8% before the introduction of routine testing to 56% after its implementation. Between 2011 and 2013, 32,534 people were tested for HIV of whom 0.45% tested positive. Of the people who tested positive, 99% received their test result and 81% were linked to care.
There were two routine testing sites in New Orleans. At the first site, the percentage of people who received an HIV test increased from 17% before the introduction of routine testing to 26% after its implementation. At the second site, testing increased from 3% to 17%. In 2012, 11,257 people were tested for HIV of whom 0.94% tested positive. All people who tested positive received their test results and 74% were linked to care.
A Canadian model
Routine testing programs such as those in New York and New Orleans could serve as models for adaptation. However, Canadians don’t need to look that far for examples of routine testing programs. In Vancouver, the routine offer of an HIV test was integrated into family practices and acute care settings as part of the Vancouver STOP project. Routine testing in these settings was just one part of a multi-pronged testing strategy, which continues to include targeted testing for people at ongoing high-risk for HIV infection. In the three acute care settings, for example, 10,102 HIV tests resulted in a positive HIV diagnosis in 0.3% to 0.8% of HIV tests. These rates are quite similar to the rates found in New York and New Orleans. These diagnostic rates are higher than the generally accepted cost-effectiveness threshold of 0.1% in acute care settings.
A promising approach
These results show us that the routine offer of an HIV test in health care, in addition to other testing initiatives, can increase awareness of HIV status among those who may not present for HIV testing on their own. It can also result in high levels of engagement in ongoing care for those who are diagnosed with HIV.
- Public Health Agency of Canada. Summary: Estimates of HIV Prevalence and Incidence in Canada, 2011. Surveillance and Epidemiology Division, Professional Guidelines and Public Health Practice Division, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, 2012. Available at: www.phac-aspc.gc.ca/aids-sida/publication/survreport/estimat2011-eng.php
- Public Health Agency of Canada (PHAC). HIV screening and testing guide. Ottawa: PHAC; 2013. Available from: http://www.catie.ca/sites/default/files/EN_HIV-Screening-Guide-2013.pdf [accessed April 1, 2014]
- Xia Lin X, Dietz PM, Rodriguez V, et al. Routine HIV Screening in Two Health-Care Settings — New York City and New Orleans, 2011–2013. Morbidity and Mortality Weekly Report. 2014 Jun 27:63(25);537–41. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6325a2.htm