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THE recently released “Screening for HIV: US Preventive Services Task Force Recommendation Statement” represents yet another bold step towards an AIDS-free generation in the US.
Together with initiatives such as making HIV testing more readily available through innovative methods and encouraging the early start of antiretroviral medication — both for the health of the individual and to prevent transmission of the virus — the Task Force recommendations have the real potential to greatly reduce the incidence of HIV in the US.
There have been huge strides in HIV prevention since the old days of “just use a condom every time” for anal and vaginal sex, with more nuanced prevention being the zeitgeist, at least for the gay community in Australia.
Such methods as sero-sorting (endeavouring to have unprotected sex with someone who is the same HIV sero-status), and strategic positioning (where the HIV-negative person takes the insertive role in anal sex) are now de rigueur. Medical interventions such as postexposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) with antiretroviral medications can augment the use of condoms and individual risk-reduction activities.
The US statement calls for clinicians to screen all adolescents and adults between the ages of 15 and 64 years for HIV. This testing can be performed with standard laboratory-based HIV tests, or with rapid HIV tests, which can be performed in the clinic or in community-based settings.
One such rapid test was approved in December 2012 by the Therapeutic Goods Administration for use in Australia and is currently used in some states and territories.
The most recent iteration of the Australian HIV Testing Policy is not as broad as the US in its recommendations for testing, although it does list a large number of contexts where testing is indicated. The question is whether the Australian policy should take on board the US recommendations and recommend screening for all adolescents and adults.
The UK HIV Testing Action Plan recommends an “opt-out” HIV test be offered to patients who use antenatal clinics, sexual health clinics, termination of pregnancy clinics, and in those with tuberculosis, hepatitis B and C, and lymphoma.
It goes further than Australia, recommending opt-out testing for all newly registered patients in general practice and all general hospital admissions in high HIV prevalence areas across the country (ie, areas with two or more HIV-diagnosed persons per 1000 people aged 15–59 years). Pilots of these recommendations showed that such testing was acceptable to patients as well as being cost-effective.
A recent article in The Economist has suggested that it is cost-effective to screen all people in India, where most HIV remains undiagnosed, and where relatively affordable generic antiretroviral medications are available.
In Australia, Victoria has the highest population rate of HIV diagnoses in the country, at 5.7 cases per 100 000 population in 2011.
Generally, diagnosis rates in Australia have been climbing over the past 10 years. Although it is hard to know what we don’t know, it is estimated that around 20% of people with HIV are unaware that they are infected.
So, should Australia follow the lead of the US and recommend HIV screening for all adolescents and adults?
This has the potential to reduce the number of people who are unaware they are infected, to enable early antiretroviral therapy to be offered, and to reduce onward transmission of HIV. It would certainly be possible to do so given Australia’s enviable primary care capabilities, in tandem with established sexual health clinics around the country.
Questions remain, however. Would such opt-out testing be acceptable to patients and, indeed, to GPs? And, of course, would it be cost-effective given Australia’s relatively low (by world standards) HIV prevalence?
Perhaps the time has come to attempt to find the answers to these questions so we can make an informed decision.
Associate Professor Darren Russell is director of Sexual Health at Cairns Base Hospital, Adjunct Associate Professor at James Cook University School of Medicine and Clinical Associate Professor in population health at the University of Melbourne. He is also past-president of the Australasian Chapter of Sexual Health Medicine and the Australian Federation of AIDS Organisations
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I have been a GP for over 20 years, and in the course of my career so far I’ve ordered countless HIV tests, as have my colleagues. In over 20 years I am yet to see a single positive result. I realise that picking up those few cases early with nationwide screening would make an enormous difference to the patients concerned, and to their sexual contacts and babies. But I favour more targeted testing. It is hard to explain to patients at low risk why they should be getting HIV testing. Many find it non-sensical and intrusive. I suspect many would find nationwide opt-out testing a little “big brother”.
– Yes, should be acceptable more to patients, and also GP’S
– Yes, cost-effective to the country, and which also help in reducing HIV prevalence
The Australasian Society for HIV Medicine considered supporting the call to test everyone as did the HIV Testing Policy Committee. It remains an item on our agenda, but is not recommended. Instead it is felt crucial that people test at an approriate rate. That rate changes as a function of the individual’s risk behaviour. The policy list people for whom testing is recommended http://testingportal.ashm.org.au/ and contains resources for doctors and patients.
GPs have a pivotal role in getting patients to understand risk and set realistic testing plans. One test will not be sufficient for many people. HIV predominantly affects men who have sex with men, who account for ~ 80% of Australians with HIV . Some gay men need to test regularly because they continue to take risks. Others need tests less frequently, but should understand risk so if they have a risk event they know to seek testing.
The big question remains is, how frequently to test. We recommend 3 – 6 mthly for most gay men, more regulatly if the patients is having unprotected sex. Behavioural triggers for testing include: having unprotected sex with an HIV+ person; changing sexual partners or sharing injecting drug equipment.
The big challenge is getting people to test for sexual transmissible infections, including HIV. Getting informed consent is simplified in the new testing policy. It is still understandably necessary to get a patient to return for any positive test results, but negative results can also be conveyed by phone or SMS and this should be negotiated with the patient at the time of testing.
Antenatal HIV screening is a win-win situation. Its benefits are obvious & incontrovertible. Women identified HIV+ early in pregnancy will benefit from ART not only in preventing mother-to-child transmission but also with continuation of ART they will avoid presenting later with an AIDS-defining illness. It’s high time HIV was pragmatically viewed as a serious but treatable viral infection without the encumbrances of sociopolitical distractions.