BACKGROUND

Today, HIV infection is a chronic manageable medical condition. Early diagnosis and treatment with antiretroviral therapy (ART) allows HIV infected patients to live long and productive lives, and reduces transmission of the virus.

In British Columbia in 2014, there were an estimated 12,000 people living with HIV. Each year 200-300 people ranging in age from 13 to 81 years old are diagnosed with HIV infection.1

Despite advances in treatment, there continues to be significant and avoidable morbidity and mortality occurring amongst HIV infected individuals, much of which is attributable to late diagnosis. In the last decade in Vancouver, over 60% of diagnoses occurred after patients should already be on treatment.2 In BC up to 17% of patients have advanced disease at the time of diagnosis.3 Data from the United Kingdom 4, United States 5, and Vancouver 6 indicate that people diagnosed late in their infection have had multiple missed opportunities for earlier diagnosis in acute, community, and primary care settings.

This delay in diagnosis has consequences for individuals as well as for the community. For individuals diagnosed late, there is an impaired response to ART, as well as overall increased morbidity and mortality. For the community, late diagnosis contributes to the spread of HIV. It is estimated that 54% of new HIV infections occur via transmission from individuals who are unaware of their HIV status7. However, people who are diagnosed and are on effective treatment are significantly less likely to transmit infection to their partners.

To decrease late diagnoses, many jurisdictions, such as the United States8, 9, the United Kingdom10, and France11, now recommend routine HIV testing in acute and primary care – in addition to existing approaches to HIV diagnosis. This approach recognizes that HIV testing based on the recognition of an individual’s risk factors is insufficient to meet the goal of early diagnosis for all patients. It has been demonstrated to be highly acceptable to patients and health care providers, and effective in reaching and diagnosing patients who were not benefiting from early diagnosis and treatment.12

Health care providers may not perceive a risk or understand an individual to be at risk for HIV, and individuals may not disclose their reasons for testing or their risks for HIV. Requiring patients to disclose a risk to receive an HIV test can be an unintended barrier to testing and a missed opportunity for diagnosis. As such, an HIV test should be ordered whenever an individual requests it.

Experience with antenatal screening has shown that routine testing of a large group of individuals based on demographic factors (and not on risk factors), is considered generally acceptable and is a critical element in effective prevention of transmission of HIV.

These guidelines articulate current HIV testing recommendations for British Columbia. Each component of these guidelines will be evaluated with ongoing monitoring and assessment. As with all guidelines, HIV testing recommendations will evolve over time.