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1. Overview
The release of the updated HIV testing guidelines—Ontario Guidelines for Providers Offering HIV Testing—represents a progressive step forward in efforts to eliminate new HIV infections in Ontario.
In 2019, the rate of first-time HIV diagnoses was the lowest it has been since 1985. Antiretroviral therapy (ART)—medication a person living with HIV takes to suppress their viral load—is helping more people achieve good health and an undetectable status. As well, more people have access to new prevention tools, such as Pre-Exposure Prophylaxis or “PrEP” (one pill a day that prevents HIV infection) and Post-Exposure Prophylaxis or “PEP” (a course of medication a person can take as soon as possible after an HIV exposure to reduce their risk of infection).
Despite these advances, there were 485 first-time HIV diagnoses in Ontario in 2021. As of 2020, up to 11 per cent of people living with HIV in Ontario may be undiagnosed. Many people currently being diagnosed with HIV are diagnosed late, after the virus has already damaged their immune system and possibly been transmitted to sexual and/or drug using partners.
The updated guidelines reflect the latest in best practices for finding and treating new HIV infections at the earliest possible opportunity. Early detection:
- improves health outcomes for a person infected with HIV
- allows a person diagnosed with HIV to achieve an undetectable status sooner
- minimizes the spread of HIV to other individuals.
Ontario is committed to making new HIV infections rare and to ensuring all people living with HIV are able to lead long, full lives free of stigma and discrimination. The province is also committed to meeting the new 95-95-95 targets set out by UNAIDS. These targets ensure that by 2030:
- 95 per cent of people infected with HIV are diagnosed;
- 95 per cent of people diagnosed with HIV are on treatment; and
- 95 per cent of people on treatment are virally suppressed.
These targets build on previous 90-90-90 targets. In 2020, Ontario made progress (compared to previous years) on the UNAIDS 90s targets:
- 89.0 per cent of people living with HIV were diagnosed (*modelling by PHAC)
- 86.7 per cent of people diagnosed were on treatment (ART); and
- 97.8 per cent of people on ART were virally suppressed.
*Visit the Ontario HIV Epidemiology Surveillance Initiative (OHESI) website for more information on HIV epidemiology in Ontario.
Progress is necessary to ensure more people living with HIV in Ontario are diagnosed and more of those diagnosed are on treatment. The updated guidelines will set Ontario on track to meet our 95-95-95 targets.
2. Four-Pronged Approached to Testing
The guidelines introduce a four-pronged approach to HIV testing, based on symptoms and risks:
- Find new and recent infections: physicians and other testing providers should recognize the signs and symptoms of acute HIV infection and provide testing at appropriate intervals for people who report a possible recent high-risk exposure.
- Find chronic infections: physicians should recognize the indicator conditions most commonly overlooked in people with HIV who are diagnosed late (i.e., with more advanced disease).
- Offer testing to at-risk members of populations with high rates of HIV: physicians and other testing providers should assess members of these populations for factors that may increase their risk and recommend testing when/as appropriate.
- Identify people in other specific care situations who should be tested for HIV: this group includes people seeking pregnancy care and people being treated for conditions that require immunosuppressive therapy (e.g., transplants, treatment with biologics for conditions like rheumatoid arthritis, etc.).
3. Key Takeaways from the Updated Guidelines
A Shorter Testing Window
Advances in testing technologies have allowed the HIV testing “window period” to be reduced from three months to six weeks for laboratory testing (the three-month window period still applies to HIV rapid/point-of-care testing and HIV self/home testing).
The shorter testing window means that within six weeks of a possible HIV exposure a person can know for certain whether they have contracted the virus. This window of time relates to how long it takes for a person’s immune system to generate antibodies to an HIV infection. Newer technology can pick up on fewer antibodies.
Assessing Risk
The guidelines explain that HIV is still concentrated in a small number of Ontario populations, which have higher rates of HIV than the general public. These populations include gay, bisexual, two-spirit, and other men who have sex with men, African, Caribbean and Black communities, Indigenous Communities, people who use drugs, cis and trans women, including those from the communities above, who face systemic and social inequities, and are more likely to be exposed to HIV through a sexual or drug using partner. Providers who serve members of these communities have a unique opportunity to help them assess their risk and identify HIV infection early.
Providing Culturally Appropriate Services
The Guidelines, as well as upcoming training opportunities and resources, will help providers recognize when a person is at higher risk of HIV and create a culturally appropriate pathway to testing, prevention and/or treatment services.
Culturally appropriate testing practices understand and account for cultural difference, which can otherwise create barriers. An understanding of cultural context is paramount to a provider’s ability to build trust, and convey HIV testing as a safe, confidential and important part of caring for oneself and the community.
Encouraging Regular Testing
The guidelines emphasize the importance of encouraging members of populations who are at increased risk of HIV to be tested regularly. Regular HIV testing is critical to both HIV prevention and treatment.
If a person tests positive, they should be linked to care and begin anti-retroviral treatment (ART) as soon as possible, optimally within 72 hours. When people with HIV are diagnosed early, they can be linked quickly to treatment that suppresses the virus (making HIV “undetectable”), leading to improved health outcomes. We know that someone with an undetectable viral load cannot transmit the virus to their sexual partners. This principle is generally summarized as “undetectable equals untransmittable” or “U=U.”
When a person at risk of HIV tests negative, the guidelines specify they should be linked immediately to evidence-based prevention services, including PrEP, PEP and harm reduction resources. These services and resources will protect them and help them stay negative.
Next Steps
The OHTN will work with our partners to get the updated guidelines out to a range of health care provider networks, community-based HIV organizations and organizations that serve members of communities with higher rates of HIV throughout Ontario this spring 2023. Our objective is to ensure that all relevant providers and community-based organizations are aware that the updated guidelines exist, know where to find them, understand their recommendations and recognize that they are the leading resource for HIV testing in Ontario.
As we move into the summer and fall, we will be launching an Education and Capacity Building program to help providers and community-support staff get the training they need to integrate the guidelines’ recommendations into their practices. As part of this program, we are working with Indigenous stakeholders to develop Indigenous testing training videos that will help further unpack best practices for providing culturally appropriate testing for Indigenous Peoples who may be at increased risk of HIV.