The Human Immunodeficiency Virus (HIV) causes an infection that affects and attacks the immune system. The immune system is the part of the body that fights off other infections and diseases. Transmission of the virus from one person to another is through body fluids such as blood, breast milk, semen, vaginal and anal fluid. In Canada, estimates indicate that in 2018 just over 62 000 people are living with HIV and the stigma associated with this infection (Haddad et al., 2021; Public Health Agency of Canada [PHAC], 2018; The Ontario Advisory Committee on HIV/AIDS, [OACHA], 2016). The rates have remained stable over the past decade, with only minor fluctuations. The 2019 diagnosis rate was slightly lower than that in 2018. Haddad et al. (2021) suggest that more time and data are needed to determine whether this decrease is the beginning of a continuing trend. Vulnerable populations that account for disproportionate numbers include gay, bisexual, and other men who have sex with men, women, and indigenous people (PHAC, 2018).
Infographic 1
People living with HIV in Canada
(Public Health Agency of Canada, 2018)
To promote health and prevent transmission of HIV, we must shift from a reactive to a proactive approach. Exciting and significant healthcare trends that will impact healthcare and have proven efficacy include rapid point-of-care testing for early detection and the use of treatment to prevent transmission.
These trends have been recognized federally and globally with the Joint United Nations Program on HIV and AIDS (UNAIDS) in their established goals for countries trying to achieve progress in preventing and treating HIV infection. Countries and regions are encouraged to strive to meet these goals, summarized by 90-90-90 (PHAC, -b., 2020).
90% of all people living with HIV will know their HIV status
90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART)
90% of all people receiving ART will have viral suppression (their viral load will be undetectable)
Infographic 2
Canada's progress on 90-90-90 targets
(Canada's Source for HIV and Hepatitis C Information, [CATIE], 2018)
Testing
The overall goal of testing is to identify as many people who have acquired HIV as early as possible and link them to prevention, care and treatment services. Challacombe & Arkell (2019) state engagement is also essential for HIV prevention of people who test negative but are at ongoing risk of acquisition. An estimated 38% of new infections are from undiagnosed people who contribute disproportionately to HIV transmission (Challacombe & Arkell, 2019).
There are two primary ways to test for HIV: standard HIV testing and rapid point-of-care testing. Rapid point-of-care testing was first introduced in Ontario in 2007 and is available in all Public Health Units for anonymous testing (OACHA, 2016). The person receives a result within a few minutes. More recently available in Canada as of November 2020 is HIV self-testing, where a person collects a sample of their blood to perform the test and interpret their results (CATIE, 2020). Traditional point-of-care HIV testing approaches include pre and post-test counselling that provides information about HIV transmission, prevention, and what a person needs to know if they receive a positive diagnosis. The delivery of counselling for self-testing is through print inserts within the kit, telephone hotlines, websites or online videos (CATIE, 2020).
The World Health Organization (WHO, 2016) recommends that HIV self-testing be an additional approach to HIV testing services. It will contribute to global 90-90-90 targets by reaching first-time testers or those with ongoing risk who require frequent testing (WHO, 2016). Furthermore, HIV self-testing can increase access because it offers people who face barriers or do not feel comfortable accessing testing in traditional clinical settings because it ensures confidentiality and provides an opportunity to test privately (CATIE, 2020).
Factsheet 1
Approach to HIV screening
(Public Health Agency of Canada, 2020, -a.)
Despite the potential to reach individuals who may be hesitant to test in a clinical setting, there is some concern that the HIV self-test may provide false-negative results if used immediately before engaging in sexual activity (Walensky & Paltiel 2006; Goldstein, 2005; Harris, 2005; as cited in Vantuneac et al., 2009). Combinative preventative measures for HIV transmission, such as testing and safer sex barriers (i.e. condoms or dental dams), because testing may provide individuals with a false sense of security if not testing outside the window period, providing more accurate test results.
I was initially reluctant to accept HIV self-testing from my professional experience because pre-test counselling is imperative for preparing individuals for test results. However, early detection and treatment prove to be beneficial and critical components of qualitative living with HIV. Challacombe & Arkell (2019) remind service providers that they still hold an important key role in education through:
Promoting awareness of HIV self-testing
Encouraging frequent testing for those who are at high risk for HIV
Explaining the need to see a healthcare provider for a confirmatory test if the HIV self-test is reactive
Demonstrating how tests work for those who need assistance
Prevention of Transmission Through Treatment
Antiretroviral therapy (ART) treatment is used to prevent transmission of HIV for both those living with HIV and those who are not. Earlier ARV initiation reduces infectivity for those living and managing their HIV (Cohen et al., 2011., as cited in (Cáceres et al., 2015). The ultimate goal of treatment is to achieve and maintain an undetectable viral load (PHAC, 2020, -c.). Today, medications have minimal side effects while suppressing the virus, which means a person can live a long, healthy life and is unlikely to pass the virus onto others when compliant with their treatment to reduce viral loads to an undetectable level. More recent research and campaigns include U=U, which means undetectable viral loads = untransmittable virus.
Picture 1
Undetectable = Untransmittable
(Prevention Access Campaign, n.d.)
Pre-exposure prophylaxis (PrEP) is a Health Canada-approved medication that is an exciting advancement in HIV prevention. It is a medication that can be taken orally by an HIV-negative person and can reduce their risk of getting HIV by up to 99% (Arkell & Herrigan, 2019). The Center for Disease Control and Prevention (CDC, 2020) recommends PrEP for men who have sex with men, heterosexual men and women, and injection drug users. Substantial risk of acquiring HIV infection such as having an HIV-positive partner, a high number of sexual partners, a history of inconsistent or no condom use, sex trade, or sharing of injection equipment (Ozdener-Poyraz, Slugocki, Kalabalik-Hoganson & Han, 2020). The evidence of real-life effectiveness is quickly accumulating for oral PrEP (Cáceres et al., 2015). Amongst many thousands of people now using PrEP globally, studies have shown only a few documented cases of sexual HIV transmission in people adherent to treatment (Arkell & Harrigan, 2019).
Post-exposure prophylaxis (PEP) is a medication that can help prevent the acquisition of HIV by individuals who have had recent HIV exposure (within 72 hours) and reduce the risk of acquiring the virus by up to 80% (PHAC, 2020, -d.). PHAC recommends PEP for those who have had high-risk exposure to HIV in the workplace, individuals who have had high-risk exposure such as condomless sex with an HIV-positive partner who is not on treatment, or a victim of sexual assault (2020, -d.).
Video 1
Carlos' HIV Story
(Healthy Canadians, 2019)
Conclusion
By implementing rapid HIV point-of-care testing, including self- HIV testing for early detection and treatment prevention, we have changed the healthcare approach from reactive to proactive. Consistent medical advancements, advocacy, and dedication to HIV management and prevention have made UNAIDS established goals of 90-90-90 more achievable over the past few decades. We must continue to explore innovative ways to create awareness of testing opportunities available for all people at risk for HIV and overcome barriers of accessibility to allow early HIV detection, a better quality of life and treatment as prevention for those living with and without HIV. I am excited for the future direction of what is to come as health systems work collectively with HIV management and prevention.
References
Arkell., C & Harrigan, M. (2019). Oral pre-exposure prophylaxis (PrEP). Canada's source for HIV and hepatitis C information. Retrieved April 5, 2021, from http://www.catie.ca/en/fact-sheets/prevention/pre-exposure-prophylaxis-prep
Canada's Source for HIV and Hepatitis C Information. (2018). Canada's progress on 90-90-90 targets [Infographic]. Retrieved March 6, 2021, from http://www.catie.ca/sites/default/files/CATIE-Cascade-Infographic-ENG-Final-WEB.pdf
Canada's Source for HIV and Hepatitis C Information. (2020, November 4). Health Canada licenses HIV self-testing. Retrieved March 25, 2021, from http://www.catie.ca/en/catienews/2020-11-04/health-canada-licenses-hiv-self-testing
Cáceres, C., Koechlin, F., Koechlin, P., Sow, P., Mayer, K., & Godfrey-Faussett, P. (2015). The promises and challenges of pre‐exposure prophylaxis as part of the emerging paradigm of combination HIV prevention. Journal of the International AIDS Society, 18. 1-9. https://doi.org/10.7448/IAS.18.4.19949
Center for Disease Control & Prevention. (2020). Deciding to take PrEP? Retrieved March 25, 2021, from http://www.cdc.gov/hiv/basics/prep/prep-decision.html
Challacombe, L., & Arkell, C. (2019, November 11). Reaching the first 90: how HIV self-testing can help us end the HIV epidemic. CATIEBLOG. Retrieved March 25, 2021, from http://www.blog.catie.ca/2019/11/11/reaching-the-first-90-how-hiv-self-testing-can-help-us-end-the-hiv-epidemic/
Haddad, N., Weeks A., Robert A., & Totten S. (2021). HIV in Canada—surveillance report, 2019. Canada Communicable Disease Report, 47(1), 77–86. https://doi.org/10.14745/ccdr.v47i01a11
Healthy Canadians. (2019). Carlos' HIV story [Video]. Youtube. Retrieved March 25, 2021, from http://www.youtube/watch?v=i6amcMZ0JqE
Prevention Access Campaign. (n.d.). U=U news [Picture]. Retrieved March 25, 2021, from http://www.preventionaccess.org
Özdener-Poyraz, A., Slugocki, M., Kalabalik-Hoganson, J., & Han, J. (2020). Pre-exposure prophylaxis (PrEP) in the prevention of HIV: Strategies, target populations and upcoming treatments. HIV/AIDS, 12. 283-293. 10.2147/HIV.S216024
Public Health Agency of Canada. (2018). People living with HIV in Canada [Infographic]. Retrieved March 25, 2021, from http://www.canada.ca/content/dam/hc-sc/documents/services/publications/diseases-conditions/vih-canada/hiv-infographic-en.pdf
Public Health Agency of Canada. (2020, -a.). Approach to HIV screening [Factsheet]. Retrieved March 25, 2021, from http://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/hiv-factsheet/hiv-factsheet-types-hiv-screening-tests.pdf
Public Health Agency of Canada. (2020, -b.). Estimates of HIV incidence, prevalence and Canada's progress on meeting the 90-90-90 HIV targets, 2018. Retrieved March 5, 2021, from http://www.canada.ca/content/dam/hc-sc/documents/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-canadas-progress-90-90-90/national-hiv-estimates-report-2018-en.pdf
Public Health Agency of Canada. (2020, -c.). HIV factsheet U=U for health professionals [Factsheet]. Retrieved March 25, 2021, from http://www.canada.ca/en/public-health/services/publications/diseases-conditions/hiv-factsheet-undetectable-untransmittable-health-professionals.html
Public Health Agency of Canada (2020, -d.). HIV factsheet. Biomedical prevention of HIV – PrEP and PEP [Factsheet]. Retrieved March 25, 2021, from http://www.canada.ca/en/public-health/services/publications/diseases-conditions/hiv-factsheet-biomedical-prevention-prep-pep.html
The Ontario Advisory Committee on HIV/AIDS. (2016). HIV/AIDS Strategy to 2026: Focusing our efforts – changing the course of the HIV prevention, engagement and care cascade in Ontario. Retrieved March 5, 2021, from
Vantuneac, A., Carballo-Diéguez, A., Lui., C., Levin, B., Bauermeister, J., Woodman-Maynard, E., & Giguere, R. (2009). Use of a rapid HIV home test to screen sexual partners: An evaluation of its possible use and relative risk. AIDS Behav, 13 (4). 731–737. 10.1007/s10461-009-9565-7
World Health Organization. (2016). WHO recommends HIV self-testing. Policy Brief. Retrieved March 15, 2021, from http://www.apps.who.int/iris/bitstream/handle/10665/251549/WHO-HIV-2016.21-eng.pdf;jsessionid=735635B899F2B71753A7E1E5903A5CD7?sequence=1
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