HIV Australia | Vol. 9 No. 3 | November 2011

LEVINIA CROOKS reports on changes to the new Australian National HIV Testing Policy, tracing its development and exploring some of its aims.

Australia first introduced a formal HIV testing policy in 1998 and revised it in 2006. In approaching the 2011 revision, the Expert Reference Committee asked itself a major question: at this point in time – and looking forward – is there any need for a National HIV Testing Policy?

We believe that there is a clear need for a national policy. A number of issues – including the introduction and treatment of new testing technology – require advice and guidance that a new HIV testing policy can deliver. More importantly, as our understanding of HIV and its management changes, so too does the role of HIV testing.

Although the number of new HIV infections across Australia remains fairly stable, it is our hope that an effective testing policy will make it possible to reduce rates of new HIV infection.

For people living with HIV, the earliest possible diagnosis contributes to both better clinical outcomes as well as reduction in onward transmission¹; the new HIV testing policy facilitates more effective ways of achieving this. From my perspective, it was also vital to create a testing policy resource which was easily accessible to both practitioners and those seeking testing. The review of the testing policy presented an opportunity to put the new policy into an interactive web-based format, in order to effectively promulgate the most up-to-date information to the sector. The web format allows us to provide additional support, so that medical practitioners conveying results can easily access the resources necessary to best assist them, and share these resources with their patients.

Following are a range of considerations and implications relevant to the development of the new testing policy.

Overcoming hurdles to the introduction of point of care (PoC) testing

Traditional pathology tests are those where a sample is taken from the patient and then sent to the laboratory for testing and interpretation, while PoC tests are interpreted on the spot with the patient.

The previous testing policy recommended against the use of PoC testing in Australia, despite them being widely used in many other countries.² This presented a major barrier to the introduction of PoC testing in Australia because without a policy that was at least supportive of evaluating their use in the Australian environment, the Therapeutic Goods Administration (TGA) had no mandate to start accessing the efficacy of PoC tests and producers of the tests had no incentive to lodge applications.

The 2011 National HIV Testing Policy now gives the green light to PoC tests undergoing evaluation. Having this hurdle removed means that producers of PoC tests will not see the policy as hostile and a barrier to their applications. But that still means there is quite a way to go before PoC tests are licensed in Australia. Accommodating PoC tests into the testing process will take some time, as the evaluation process is rigorous and the steps involved getting an approved test into use can take many months.

New concepts

The new policy also introduces some new concepts; the concept of ‘informed consent’ in place of pre-test discussion (formerly pre-test counseling) and ‘conveying a test result’ in place of post-test counseling. Informed consent is what we have always been trying to achieve before initiating a test. These new concepts make this goal explicit. The new policy also allows the concept to span testing for a number of conditions in addition to HIV. We aim to standardise this language across testing for a number of conditions, including HIV, hepatitis C and B and other sexually transmitted infections (STIs).

Educational tools for doctors and patients

In the past we have expected practitioners to be fully up to date with matters relating to HIV at the point they were requesting HIV tests. At the same time data tells us that doctors are only very infrequently called upon to use this knowledge. This is not an effective use of resources, doctors who may have received some training in HIV years ago cannot always rely on their recall. What they need is access to current information relevant to their setting and to be able to talk to a more experienced practitioner if necessary. The new policy approach and our offering of support to new diagnoses can provide this.

We know from existing testing patterns that most practitioners performing HIV testing have little experience of conveying a positive test result. When ASHM reviewed data from a number of jurisdictions we found that many doctors had only conveyed one HIV- positive result in the previous five to eight year period.³

It is not realistic to expect health practitioners to remember training which has never been put into use, so having an accessible and useable policy, and relevant attachments and resources, available online seems a much more rational approach. The provision of online resources will assist in delivering a positive test result by making a range of procedural guidance and information easily available – for both the practitioner and the patient.

The 2011 policy aims to have results conveyed in a clinical setting and to use any result as an opportunity for education. It also recognises that a one-off positive result can require a very tailored response and that people need to be able to readily access accurate information.

A positive HIV test result may be the result the patient expected or it may come as a complete surprise. Whatever the circumstance, it is a difficult situation for both the patient and the person providing the result. In the past, few people would have reached for the HIV testing policy for practical advice, patient fact sheets, referral information or general advice. With the testing policy being presented as a website with lots of linked resources, we hope that practitioners will reach for the website as a first point of call.

Limitations

Whether any of the above features will reduce HIV transmissions remains the important, but unresolved, question.

We know a number of newly diagnosed infections are being identified in people who acquired their infection outside Australia.⁴ This new policy is likely to have little impact on those numbers. At best it will perhaps allow us to make the HIV diagnosis sooner. Different arms of government look to substantive policy such as this to help them arrange their services. It is particularly important that refugees get access to timely health assessment. This policy, in recognising and stating the benefits of early detection and treatment of HIV, assists in facilitating the timely assessment and management of HIV among refugees and humanitarian entrants.
In the event that a PoC test is evaluated and licensed for use in Australia, we will need to make absolutely sure that those using such a test are aware of its limitations. The tests currently in production (though not licensed for use as PoC tests in the community) cannot detect HIV infection as early as those tests which are performed in the laboratory. So it will be important that those doing the tests and the patients being tested are aware of this.

The future

We know that many people contract HIV from people who have only recently become infected themselves, and thus may be totally unaware of their own positive status; we have seen this data from a range of sources .For instance, data from a Melbourne study by Alisa Pedrana and colleagues indicated that 20% of gay men who tested HIV-positive held an incorrect belief about their HIV-negative status.⁵ We have also seen this from serological studies undertaken by Doris Chibo and Chris Birch who have identified clusters of related recent HIV infections.⁶

How often this occurs is hard to determine because of the lag time between infection and diagnosis. Along with studies looking at PoC testing, I think it would be timely to look more closely at people recently identified as contracting HIV. The more we can find out about these events the better we might be able to assist in driving down new infections.

The testing pendulum has swung from: don’t test there is nothing you can do about it, to test and seek prophylaxis for opportunistic infections, and then access ARV treatment. Frequent testing will identify new infections earlier. Adoption of protective behaviours following infection will stop onward transmission. But no amount of testing will prevent a new infection from occurring when a person is exposed to HIV. The risk of contracting HIV from such an exposure will largely be contingent on the source patient’s HIV viral load; we know this is highest during seroconversion and in early infection. We hope that the new HIV testing policy will help us to more effectively intervene at this crucial early stage.

Please take the time to review the new HIV testing portal: http://testingportal.ashm.org.au.We appreciate your feedback.

References

1 Marks, G., Crepaz, N., Senterfitt, J., and Janssen, R (2005). Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the united States: Implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes, 39(4), 446–453.

2 Pedrana, A., Guy, R., Bowring, A., Hellard, M. and Stoové, M. (2011). Community models of HIV testing for men who have sex with men (MSM): Systematic Review 2011. Report commissioned by ACON.

3 McGuigan, D, Wheeler, E, Bowden, V. (2010). One Year On: Interim Findings from the ‘GP Mentoring at the Time of HIV Diagnosis’ Project. Paper presented at the 2010 Australasian HIV/AIDS Conference, Sydney, 20–22 October 2010.

4 The Kirby Institute. (2011). HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2011. the Kirby Institute, the university of New South Wales, Sydney.

5 Pedrana A, Hellard M, Wilson K, Guy R and Stoové M. (2011) [in press]. High rates of undiagnosed HIV infections in a community sample of gay men in Melbourne, Australia. JAIDS – accepted 22/09/2011.

6 Chibo, D., Kaye, M. and Birch, C. (2011). HIV transmissions During Seroconversion Contribute Significantly to New Infections in Men Who Have Sex with Men in Australia. AIDS Res Hum Retroviruses, Sept. 21 [Epub ahead of print]. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21806486 (accessed 11 October 2011).

Levinia Crooks is the Chief Executive Officer of ASHM, the professional organisation which provides support to the health workforce in HIV, viral hepatitis and sexually transmissible infections. Levinia has worked in the HIV and related diseases area for 25 years and has recently co-chaired the Expert Reference Committee

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