Evaluating HIV Rapid/Point of Care Testing among Risk Factor Groups in Ontario, 2011 to 2018.

OBJECTIVES: In 2014, Ontario's Point-of-Care (POC) test providers were advised to focus efforts on provincially defined priority populations who experience a greater risk of HIV. Our objective was to describe the POC program before, during and after this change, including tester characteristics, follow-up testing results, positive predictive value (PPV) over time, and trends and characteristics of those with reactive test results without a confirmatory serological specimen. METHODS: Test-level data of POC screening and confirmatory results were extracted from the Public Health Ontario HIV Datamart. Final test results were defined based on results of the confirmatory blood sample, or the POC test for "non-reactive" tests. Testing volumes, percent of total tests, percent positivity and PPV were calculated overall, annually, and by exposure group. RESULTS: Overall testing volumes decreased by 39.8% between 2014 and 2018. The majority of confirmed positive tests were in the men who have sex with men (MSM) exposure category, followed by HIV-endemic and heterosexual - no identified risk (heterosexual-NIR). Overall percent positivity decreased from 0.59% in 2011 to 0.42% in 2015 (change of 0.17%, 95% CI 0.03% to 0.31%), increasing to 0.69% in 2018 (change of 0.27%, 95% CI 0.20% to 0.34%). Increases in percent positivity corresponded with a decrease in the overall proportion of tests conducted in low-risk populations. When compared to the heterosexual-NIR category, PPV was significantly higher for men who have sex with men - people who use injection drugs (MSM-PWID) (52.7% compared to 100%, P < .001), MSM (52.7% compared to 95.4%, P < .001), HIV-endemic (52.7% compared to 91.5%, P < .001), heterosexual - partner with identified risk (heterosexual-PIR) (52.7% compared to 77.3%, P = .042), and people who use injection drugs (PWID) (52.7% compared to 81.3%, P = 0.007). A total of 13.5% of reactive POC results did not have a serological sample submitted. CONCLUSIONS: Targeted testing towards populations at higher risk of HIV improved the overall test performance characteristics of Ontario's POC testing program. While not unexpected, the large discrepancies between PPV in higher-risk, compared to lower-risk populations, suggests the need for greater awareness and messaging of the likelihood of false positive test results in different populations.

HIV testing during the Canadian immigration medical examination: a national survey of designated medical practitioners.

HIV testing is mandatory for individuals wishing to immigrate to Canada. Since the Designated Medical Practitioners (DMPs) who perform these tests may have varying experience in HIV and time constraints in their clinical practices, there may be variability in the quality of pre- and posttest counseling provided. We surveyed DMPs regarding HIV testing, counseling, and immigration inadmissibility. A 16-item survey was mailed to all DMPs across Canada (N = 203). The survey inquired about DMP characteristics, knowledge of HIV, attitudes and practices regarding inadmissibility and counseling, and interest in continuing medical education. There were a total of 83 respondents (41%). Participants frequently rated their knowledge of HIV diagnostics, cultural competency, and HIV/AIDS service organizations as "fair" (40%, 43%, and 44%, respectively). About 25%, 46%, and 11% of the respondents agreed/strongly agreed with the statements "HIV infected individuals pose a danger to public health and safety," "HIV-positive immigrants cause excessive demand on the healthcare system," and "HIV seropositivity is a reasonable ground for denial into Canada," respectively. Language was cited as a barrier to counseling, which focused on transmission risks (46% discussed this as "always" or "often") more than coping and social support (37%). There was a high level of interest (47%) in continuing medical education in this area. There are areas for improvement regarding DMPs' knowledge, attitudes, and practices about HIV infection, counseling, and immigration criteria. Continuing medical education and support for DMPs to facilitate practice changes could benefit newcomers who test positive through the immigration process.

HIV disclosure as practice and public policy.

Responses to the largest surveys of HIV-positive people in Ontario show that most either disclose to or do not have partners who are HIV-negative or of unknown status. Non-disclosure strategies and assumptions are reported by relatively small sets of people with some variation according to employment status, sexual orientation, gender, ethnicity, and having had a casual partner. Interviews with 122 people living with HIV show that disclosure is an undertaking fraught with emotional pitfalls complicated by personal histories of having misread cues or having felt deceived leading up to their own sero-conversion, then having to negotiate a stigmatized status with new people. In gay communities, constructions of the self as individual actors in a marketplace of risk co-exist with the sexual etiquette developed throughout the AIDS era of care of the self and other through safer sex. Among heterosexual populations, notions of responsibility show some divergence by gender. The findings of this study suggest that the heightened pressure of criminal sanction on decision-making about disclosure in personal interactions does not address difficulties in HIV transmission and is unlikely to result in enhanced prevention.