Introduction
Of the estimated 71,300 Canadians currently living with HIV, approximately 25% are unaware of their HIV status. Research indicates individuals who are HIV positive but undiagnosed may be the source of a majority of new infections, driving the epidemic in those populations most at risk.(1,2,3) As a result, HIV testing is a key factor in reducing potential for forward transmission and new infections. Early diagnosis is also a primary factor in health and wellness for people living with HIV. People who are unaware of being HIV positive are unable to access lifesaving treatment and support services to significantly improve quality of life. Finally, the cost-benefit of enhanced access to HIV testing and diagnosis provides significant reductions in public health spending.(1,4-8) Enhanced access to HIV testing has a profound impact on both individual and community health outcomes.
HIV Community Link’s Position on Enhanced Access to HIV Testing
HIV testing is an essential strategy to reduce new HIV infections and improve health and wellness for those living with HIV. Based on strong evidence demonstrating the need for enhanced access to HIV testing, HIV Community Link supports the expansion and/or introduction of emerging technologies and practices including: Community-Based Rapid Testing, Routine HIV Screening, Home Testing for HIV, and Anonymous Testing. Opportunities for education, support and linkage to services are best practices in all testing settings. Informed consent and voluntary participation remain foundational tenets of all HIV testing strategies.
Rapid HIV Testing and Community-Based Testing
Standard HIV testing requires a waiting period of one to two weeks and, in most situations, a return trip to the healthcare setting to receive results. In contrast, rapid HIV testing takes approximately 20 minutes including pre and post-test counseling. Access to rapid testing is rare in Alberta and only offered to specific populations or in limited situations at designated healthcare settings.
Rapid HIV testing has been available in Canada for over 15 years. Specificity, sensitivity and cost-effectiveness are well supported by a large body of research. Strong evidence also indicates that: rapid testing is favoured among target populations; availability increases motivation and uptake of HIV testing; and clients are substantially more likely to receive results with rapid testing than with standard HIV testing.(2,9,10)
Based on the evidence, HIV Community Link calls for enhanced access to rapid HIV testing in both traditional healthcare settings and community-based settings such as AIDS service organizations and/or outreach sites. While most commonly performed by health care professionals such as nurses, evidence also supports consideration of community-based rapid HIV testing performed by other appropriately trained personnel.(11,12,13) Examples from the literature include staff or peer volunteers at community organizations. Testing and counseling offered by these groups can be more acceptable and accessible to target populations.
Routine HIV Screening
Routine screening for HIV, also known as routine testing or universal testing, involves offering HIV testing to a wide cross-section of the population. Routine screening can involve offering testing to everybody, but in most cases it is defined as all adults or those between the ages of 15 and 65. As with all testing strategies, informed consent and voluntary participation are imperative.
Routine screening is contrasted with targeted or risk-based approaches, where HIV testing is only encouraged or offered to those identified as most at risk based on behaviour or demographic profile. This often means that if the healthcare provider does not perceive risk, the individual must be aware of and understand personal risk, self-advocate for testing, and be prepared to disclose risk behaviours to their healthcare provider. Risk-based testing can miss a substantial proportion of HIV infections and increase the likelihood of late-stage diagnoses where the immune system is significantly damaged and complicated opportunistic infections have developed.(1,4) Risk-based testing is an important and effective strategy in certain settings, but it must be complemented with broader reaching approaches.
Evidence illustrates numerous benefits of routine screening including avoiding late stage diagnosis, preventing forward transmission, and uncovering advanced HIV infection in individuals considered low-risk.(1,4) Routine testing is highly acceptable when offered and can play an important role in normalizing HIV testing.
Evidence also shows that routine screening strategies significantly exceed the cost effectiveness threshold, meaning significant savings to public health spending.(4-8) In 2012, the Public Health Agency of Canada recommended that “consideration and discussion of HIV testing be made a component of periodic routine medical care”.(14)
Home Testing for HIV
Home testing kits for HIV are currently not approved for sale in Canada. However, with two types of licensed HIV home testing kits available in the United States, it is not difficult for Canadians to access these products cross-border or online.
A number of concerns around home HIV testing exist. Common examples include: the potential for coercive or non-voluntary testing; the lack of support services such as pre and post-test counseling or linkage to care in the case of a positive result; the possibility of false negative results if someone is recently infected and in the window period; and the inability to collect demographic data about HIV incidence.
In careful consideration of potential benefits and concerns, HIV Community Link supports the introduction of HIV home testing in Canada. Home testing is an additional tool to increase testing and diagnosis rates, while normalizing and helping to de-stigmatize all forms of HIV testing. Home testing provides confidentiality, privacy, convenience and access in settings where these concerns may otherwise present barriers.
Home testing also has high acceptability among diverse populations, including key populations for HIV testing such as those most at risk and those who have never been tested.(15-20) As a rights-based approach to prevention and health promotion, home testing reinforces the individual right to make informed personal health decisions and to access resources demonstrated to promote health.
HIV Community Link encourages health authorities to approve the sale of HIV home testing kits. Additionally, we recommend regulation to ensure products available in Canada include appropriate consumer information about local resources for further information, education, support, and timely linkage to care for people who test positive.
Anonymous testing
Anonymous HIV testing is when a health care card or other identifying personal information is not required in order to be tested. Access to anonymous testing is very limited across Alberta. Evidence illustrates the option to be tested anonymously is highly favoured and increases testing uptake, particularly among populations most at risk and those in rural and remote communities.(21-24) Increasing options for anonymous testing will address barriers caused by privacy concerns and enhance access.