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- 1. 11Kai Tiaki Nursing New Zealand * vol 22 no 6 * July 2016 practice Making HIV testing routine New Zealand has a good record of successfully treating people diagnosed with HIV and has a low rate of infection compared to other countries. But reaching the undiagnosed remains a challenge. By James Rice-Davies U ntil there is a cure or a vaccine for the human immunodeficiency virus (HIV), all health professionals have a role in reducing the numbers of people infected with it. The success of agencies such as the New Zealand AIDS Foundation and the Prosti- tutes Collective, and of the Needle Exchange Programme means many health-care workers (HCWs) nowadays may be unfamiliar with HIV or are afraid to suggest testing. HIV testing needs to be normalised to reduce the spread of infection. The HIV test is cheap and easy to carry out, and allows rapid access to treatment. I trained as a mental health nurse, then as a general nurse, in the United Kingdom in the mid to late ‘80s. I began working at the then St Stephen’s Hospital in London in 1987, which had set up a large unit for AIDS care. Emotionally, it was one of the hardest areas I have ever worked, but it also felt a privilege. I am now the clinic nurse specialist for HIV at Capital & Coast District Health Board. One of my main aims is to reduce the barriers that prevent HCWs from thinking about, and recom- mending HIV testing. Caring for patients with HIV HIV care in New Zealand began 30 years ago. There have been more than 4500 cases of HIV infection diagnosed during this time and 1000 deaths recorded. Around 2500 patients are still receiving care.1 Figure 1 on p12 shows the positive effect of antiretroviral (ARV) treatment on one local patient. When he presented to Wellington Hospital in 1998, he had almost no detectable CD4 cells (T Helper cells). Improvement has continued for years on treatment. However, better and quicker immune recovery usually occurs with earlier diagnosis and treatment. This reduces the level of HIV viral load (VL) to undetectable levels in the blood. CD4 cells are the “conductor of the immune system” and unfortunately have the right receptor for the HIV RNA virus to “dock” onto. The virus then uses the DNA inside the CD4 cell to replicate and, in doing so, slowly de- stroys the immune system’s normal function, leaving the patient immunocom- promised. Patients with HIV usually access care via an out- patient setting, such as infectious disease (ID) de- partments or sexual health clinics. This may be part of the reason why HIV has low Peter Saxon on gay men’s health, or men who have sex with men (MSM), estimate that approximately 6.5 per cent of the gay commu- nity in Auckland has HIV and another 1.5 per cent are undiagnosed.3 This indicates one MSM out of every 20 has HIV infection. In Sydney, the number of MSM estimated to have HIV is one in five. I have not discussed HIV testing for intravenous drug users in New Zealand, as this group has more problems relating to hepatitis C infection than HIV infection, but HIV testing should not be forgotten for this group of patients either. Scenarios at Wellington Hospital Recently – on the same day and within 10 minutes of each other – I witnessed two com- pletely opposite scenarios at Wellington Hos- pital. I was waiting in the medical assessment and planning unit (MAPU) to give a positive HIV result to a patient who had had an HIV test added to his initial blood requests. This was because an astute laboratory scientist had suggested to the admitting medical team that become a forgotten infection in some other health-care settings. The advent of effective HIV ARV treatment over the last 15 years gives most patients an almost normal life expec- tancy in developed countries. Many clinical staff are aged under 30 and have never seen a patient with an HIV-related illness. The successful treatment of HIV may have left other HCWs deskilled and lacking knowl- edge and understanding about testing. I have been alarmed when newly-diagnosed patients have told me how the person giving the HIV result informed them, wrongly, that they now had less than five years’ life expectancy. I have also had phone calls from HCWs asking how to protect people sharing the same house as a person with HIV. Those sharing the house were not even sexual partners of that person. This highlights the general lack of HIV under- standing and how it is transmitted. The greatest number of HIV cases in New Zealand is in Auckland, where there are ap- proximately 1000 patients. Studies carried out by University of Auckland senior research fel- Tonya Booker, devoted partner and mother, died from undiagnosed HIV in 2014. She had carried the virus for 12 years and had never once been tested. Earlier this year, the national support organisation for women and families living with HIV and AIDS, Positive Women, launched a cam- paign advocating that HIV testing be included in all routine diagnostic procedures.
- 2. 12 Kai Tiaki Nursing New Zealand * vol 22 no 6 * July 2016 practice HIV should be added to the other requested tests. The 68-year-old patient had already been discharged after a brief admission, but he agreed to have another test added and the medical team had asked me to be present when they called him back to discuss his results. I was able to offer support to the pa- tient and family, with clear information about a nearly normal life expectancy, with minimal side effects of treatment, and discuss testing of sexual partner(s). Partner notification is an important part of HIV care, in the interest of public health, to reduce spread of infection and enable early access to treatment.5 As I waited in the staff-only area, a nurse, not knowing who I was, or any of the above, suggested to one of the doctors that a young man with a recent history of more than 10kg weight loss, enlarged lymph glands and fatigue, should be screened for HIV as part of his blood work-up. This suggestion was dismissed and the test not carried out, as the registrar said he knew what was wrong with the patient. He then went to “clerk in” the patient, thereby missing an opportunity for HIV screening. I went back to MAPU the next day to discuss the decision not to test the patient and dis- covered the nurse had never cared for anyone with HIV but had thought this might be a dif- ferential diagnosis for the patient. She asked me if her thinking process had been incorrect. I explained why I had been in MAPU and how I believed this type of thinking was so impor- tant. I also asked the medical team that had carried out the HIV test on the other patient, to discuss the case as a team and include the registrar in the discussion, in the hope of rais- ing awareness about the importance of more routine HIV screening. Comparisons with other countries Since the epidemic began, HIV infection rates in New Zealand are half that of Australia and a third less than the United States and Europe. Tangata whenua are under-represented in HIV infection rates, which is a change from their usual health statistics. Saxton has produced several studies around the rate of condom use in gay men in New Zealand and how this has reduced the rates of HIV, with less HIV per capita compared to other developed coun- tries.4 The work of non-government organisa- tions such as Boby Positive, the Prostitutes Collective, INA Indigenous HIV/AIDS Founda- tion, Positive Women and the New Zealand AIDS Foundation, and of the Needle Exchange Programme has helped achieve this low rate. This is something New Zealand can be proud of. Undiagnosed HIV cases There are a number of people in New Zealand with undiagnosed HIV infection who are not seeking testing and who are unknowingly putting others at risk through their sexual behaviour. The number of undiagnosed HIV cases is estimated at 20 per cent.2 This means there are approximately 600 undiagnosed cases of HIV in New Zealand. These people will become unwell from HIV-related conditions and are possibly already attending their GP, or regularly by GPs for almost two years before their AIDS diagnosis. Similarly, a recent Auckland audit looked at the financial cost to the health system over a two-year period of undiagnosed HIV patients presenting several times at ED before eventu- ally being tested for HIV.6 This audit suggests that earlier HIV diagnosis would have saved between $9-14 million by avoiding expensive inpatient care and reducing transmission of infection to others. The auditors advocate that routine HIV screening for everyone present- ing to ED be considered. This approach would take the anxiety and fear out of HIV testing for both staff and patients by normalising HIV screening.6 HIV testing makes HCWs think of the patient’s sexual orientation. However, this subject, like the subject of death and dying, still remains taboo, putting most people in an uncomfortable space and more likely to avoid suggesting HIV testing. Hopefully, the 2013 law reform regarding same-sex marriage will help HCWs become more skilled when taking a sexual history and make it easier for them to ask questions about same-sex relationships and identifying possible risk factors. My recent teaching sessions have high- lighted some of the thinking GPs and ED staff have about HIV testing. There are still several false beliefs about the need to carry out pre- test counselling.7 Some HCWs still believe HIV testing will cause problems with life insurance and question what will happen if the patient is discharged or transferred before the test result is available. If this was the case, health professionals would not order a chest X-ray or a full blood count, as this might be the start of identifying a life-threatening illness, eg cancer. Converse- Figure 1 A simple, cheap and easy HIV blood test would mean earlier access to treatment and avoid- ance of further ill health. after hours services, and will eventually attend emergency departments (EDs) with opportu- nistic infections (OI), such as oral candidiasis, Pneumocystis pneumonia (PCP – now called Pneumocystis jiroveci), B-cell lymphoma, tuberculosis or toxoplasmosis, if they are not offered HIV testing earlier. Twelve people have attended Wellington Hospital’s ED in the last three years with AIDS, due to undiagnosed HIV infection, 10 of whom were men. These patients have been lucky to live through treatment of their OIs and have gone on to start ARV treatment, slowly regain- ing functioning immune systems.4 Conversely, in the last two years in New Zealand, two women and one man did not survive their OI and AIDS diagnosis, leaving their family and friends devastated. This could have been avoided, had they been tested earlier. None of these people were perceived to be at risk from HIV infection, although all had been seen
- 3. 13Kai Tiaki Nursing New Zealand * vol 22 no 6 * July 2016 practice James Rice-Davies, RN, MNSc, is the HIV/ID clini- cal nurse specialist at Wellington Hospital, Capital & Coast District Health Board. ly, a simple, cheap and easy HIV blood test would mean earlier access to treatment and avoidance of further ill health. The only thing needed for an HIV test is informed consent, just as it is for hepatitis B or C testing. How to make testing easier Approximately a third of our newly-diagnosed cases are referred from GPs, usually after pa- tients have attended several times with unex- plained bouts of illness. They are then offered HIV testing as part of a screening-out process, rather than HIV being seen as a possible dif- ferential diagnosis for unexplained weight loss, dry itchy skin, change in bowel motions, or altered blood films, such as neutropenia or low platelet count. When these patients are finally diagnosed with HIV, they often have low im- mune systems, CD4 cells ranging from 50-350 (normal range being 600-1400), indicating that HIV infection has been an issue for these patients, possibly for a number of years. In contrast, referrals from the New Zealand AIDS Foundation have CD4 counts between 400-1000 and patients who are physically well. This allows for earlier access to ARV treatment, which leads to undetectable HIV VL, reducing the spread of infection to others. In the Wellington region, the vast majority of positive HIV test results occur at the New Zealand AIDS Foundation, where a service using HIV Rapid Card takes 20 minutes to get a result. The method used looks similar to a home pregnancy testing device and uses a few droplets of blood on a card. One bar on the card indicates a negative result; two bars, an HIV-positive result.8 This service is obviously attracting an at-risk group who want an in- stant result. The patient is then referred to the ID department for a confirmation HIV antigen/ antibody combination test. An HIV VL is also done via the hospital laboratory. The goal is to test patients at risk of con- tracting HIV, eg MSM or people from countries with high prevalence of HIV who are sexually active, as these groups will be more likely to have HIV infection. They should also be offered re-testing, if they are at ongoing risk of HIV. If HCWs remain uncomfortable about what questions to ask regarding HIV testing when assessing patients, they could either upskill on how to take a sexual history or ask another team member to take a history. What we need to avoid is people presenting in ED acutely unwell with OIs and an AIDS di- agnosis. Of the Wellington regional HIV cohort of 353 cases, more than 70 per cent identify as gay/bisexual or MSM. This group includes 57 women, half of whom were not aware of be- ing at risk of contracting HIV infection before testing. If HIV was regarded as a differential diag- nosis to rule out unexplained symptoms of ill health in service re-attenders, HIV testing would give us more opportunities for ruling out HIV infection in those who may not know they have been at risk of HIV. It would also provide the opportunity to rule out the infec- tion in those who may not disclose risk factors to their GP or ED and currently miss out on being offered HIV testing earlier. HIV, once diagnosed, can be well controlled by medication, by gaining an undetectable VL. This allows CD4 cells to be reconstituted to a nearly normal immune system. For 80 per cent of our cohort in the Wellington region, current HIV management is six-monthly blood checks to ensure HIV VL is undetectable. This tells us the patient is taking their medication and also monitor for liver and kidney function. The main problem now is patients grow- ing old with HIV and the co-morbidities that often come with advanced age. This is not the specialist area of ID or sexual health clini- cians. In Sydney, HIV care is normalised by a GP-led service, as most patients will never become unwell from HIV, if they take their ARV treatment. This could be the way forward for New Zealand. This makes perfect sense when we now have an aging cohort of people with HIV who need a more generalist approach to their overall health-care needs. Eradicating HIV In the future, it is possible the virus capability to replicate could be switched off altogether, even in sanctuary sites such as memory lymph cells and places such as the cerebrospinal fluid and genital tract.9 This may prove easier than finding a cure or a vaccine. HIV is a poor replicator and therefore similar to the common cold, proving too difficult to find a cure or a drug to eradicate it. Lack of understanding may make HCWs reluctant to offer HIV testing as a routine pro- References 1) University of Otago, Dunedin School of Medicine. (2015). AIDS – New Zealand, 74-June. ISSN 1178-2692. 2) Saxton, P. J., Dickson, N. P., Griffiths, R., Hughes, A. J., & Rowden J. (2012). Actual and undiagnosed HIV prevalence in a community sample of Men that have Sex with Men in Auckland New Zealand. BMC Public Health 12:92. doi: 10.1186/1471-2458-12-92 3) Dickson, N. P., McAllister, S., Sharples, K., & Paul, C. (2010). Late presentation of HIV infection among adults in New Zealand: 2005-2010. HIV Medicine 13(3), 182-189. 4) Saxton. P., & Ludlam, A. (2015). Submission to the Select Committee on Health Public Health (Protection) Amendment Bill. New Zealand. Retrieved from www.fmhs.auckland.ac.nz 5) Deblonde, J., De Koker, P. & Hamers, F. F. et al. (2010). Barriers to HIV testing in Europe: a systematic review. European Journal of Public Health, 20(4), 422-432. 6) Auckland District Health Board. (2015). Potential impact of routinely offering HIV screening at Auckland DHB. HIV Update Day, May. Power- Point presentation. 7) New Zealand AIDS Foundation. (2015). Getting a Rapid HIV Test in 20 minutes. Retrieved from https://www.youtube.com/ watch?v=ToNwta5LBW8 8) Eisele, E. & Siliciano, F. R. (2012) Redefining the viral reservoirs that prevent HIV-1 eradication. Immunity, 37(3), 377-388. 9) Salim, S. & Karim, A. (2015). Overcoming impediments to global implementation of early antiretroviral therapy. The New England Journal of Medecine, 373(875-876). doi: 10.1056/NEJMe1508527 10) Cairns, G. (2015). START trial finds that early treatment improves outcomes for people with HIV. Aidsmap. Retrieved from http://www. aidsmap.com/START-trial-finds-that-early-treatment-improves-outcomes/page/2972328/ cedure. The HIV test is both highly sensitive and specific, with a window of up to 28 days before a positive test result shows (depend- ing on local laboratory testing methods). If a health professional is testing to screen people anxious about a recent sexual situation, a window period and testing at the right time is necessary. What possible harm could happen to the patient who has an HIV test and receives a HIV testing would give us more opportunities for ruling out HIV infection in those who may not know they have been at risk of HIV . . . negative result? I imagine none, except a story to tell friends about how the hospital thought they might have HIV. Meanwhile, those pa- tients ending up diagnosed with HIV infection will have an improved outcome.10 People infected with HIV are part of our working lives and include our work colleagues, people on the bus, neighbours and friends who often hide their diagnosis, due to stigma still associated with this infection. If all HCWs thought about HIV as a differential diagnosis, sooner rather than later, for those with unex- plained symptoms, this would help reduce the spread of infection and late presentation. Until there is a cure or a vaccine for HIV, we all have a role in reducing the numbers of peo- ple becoming infected with HIV. A way to do this is by being more proactive in offering and routinely carrying out HIV testing. This starts with health professionals not being frightened to ask about HIV testing and making it easier for everyone to get a test. •