Manitoba researchers call for changes to help improve opportunities for HIV diagnosis and care

• 27% of new HIV diagnoses in Manitoba in 2016 were in patients with a CD4+ count of less than 200
• Manitoba researchers found that many opportunities for HIV testing were missed
• Better integration of medical care services with public health and community organizations is necessary

The widespread availability of HIV treatment (ART) has led to dramatic declines in AIDS-related infections and deaths in Canada and other high-income countries. ART is so powerful that researchers expect many ART users will have near-normal life expectancy.

However, this rosy forecast is dependent on several sequential steps, including the following:

• timely HIV testing
• swift referral to care for people who test positive
• rapid initiation of ART once people are in care
• achievement and maintenance of viral suppression
• continued engagement in care and treatment

Unfortunately, people can fall out of the system at each of these steps and may not progress to the next step.

In Manitoba

A team of researchers at the University of Manitoba has been studying issues related to HIV testing, care and treatment. They found that “27% of new HIV diagnoses made in 2016 were in patients with CD4+ cell counts [below the 200 cell/mm³ mark].” This low CD4+ count indicates profound immune deficiency and puts people at high risk for developing life-threatening infections and other complications.

There are several issues posed by people who have severe immune deficiency and who are not aware of their HIV status, as follows:

• they are at elevated risk for dying
• as a population, they can inadvertently transmit HIV
• their medical expenses are greater for health systems than those of people who have minimal or no symptoms of HIV (this is also generally the case for other conditions when interventions are postponed or delayed until the situation is dire)

Missed opportunities

In an attempt to find where gaps in HIV testing occurred, a team of researchers at the University of Manitoba conducted a study. They found that two years prior to the diagnosis of HIV infection, people sought care for conditions where testing for HIV should have been discussed, offered and initiated.

To remedy the situation, the Manitoba researchers recommended better integration of healthcare services with public health systems.

Study details

The research team gathered and analyzed health-related information collected through many different databases. As is standard with studies in Canada, information that could identify individuals was removed. In many of the databases, detailed information on patient health was not available. As a result, researchers had to rely on diagnostic codes and phrases used in databases.

The researchers compared information from two groups of people:

• 193 adults who were newly diagnosed with HIV between 2007 and 2011
• 965 adults who did not have HIV during the same period

Data from each HIV-positive person was matched with data from up to five HIV-negative people of the same age, gender and region of residence.

A brief average profile of the people who were diagnosed during this period is as follows:

• age – 38 years
• 66% men, 34% women

Results

Two years prior to their HIV diagnosis, people who were diagnosed with HIV were more likely to have visited a physician for care. During that time the following broad categories of diagnoses were made:

• blood disorders
• infectious conditions
• skin disorders

The researchers stated that these broad diagnostic categories were linked to the following specific conditions (in decreasing frequency):

• blood disorders – iron deficiency anemia; other unspecified blood disorders; other unspecified anemia; bone marrow disorders
• infectious conditions – sexually transmitted infections; head and pubic lice; unspecified viral infections
• skin disorders – bacterial infections; inflammatory conditions

Hospitalization

People with initially undiagnosed HIV infection were more likely to be hospitalized than people who never became HIV positive. 

Prescription drugs

People with initially undiagnosed HIV infection were significantly more likely to have been prescribed the following categories of medicines (in decreasing likelihood):

• antibiotics
• drugs for managing high blood sugar
• drugs for respiratory conditions other than asthma
• drugs for anxiety and other mood disorders
• drugs for asthma

Sexually transmitted infections (STIs)

Researchers focused on two STIs—chlamydia and gonorrhea. They found that people with initially undiagnosed HIV were threefold more likely to have been diagnosed with chlamydia and nearly 12-fold more likely to have been diagnosed with gonorrhea than people who remained HIV negative.

Change is needed

The present study was not designed to uncover the reasons why opportunities for diagnosing HIV were missed. However, the research team is deeply familiar with healthcare and public health systems in Manitoba and made the following comments and recommendations to improve the situation:

1. “More effective coordination between public health and general practitioners can lead to better navigation of the healthcare system and improved delivery of prevention interventions. Without better coordination, those at highest risk of STIs may continue to be denied access to [HIV] testing, and among those that do [access testing], a proportion may continue to fall through cracks in the healthcare system.”

2. “Strengthening community-based prevention efforts, such as outreach to high-risk individuals and other priority populations, and which focus on health promotion, a more enabling environment and addressing other needs such as housing, mental health and addiction issues may also reduce gaps in prevention.”

3. “Our findings illustrating the higher likelihood of […] mental health conditions among individuals with HIV supports prioritization of mental health services.”

The researchers noted that “Community organizations and primary and public healthcare have historically been underfunded in Canada.” The issue of delayed HIV diagnosis also occurs in other parts of Canada and in the U.S. and Europe.

—Sean R. Hosein

REFERENCES:

1. Shaw SY, Ireland L, McClarty LM, et al. Healthcare utilization among persons living with HIV in Manitoba, Canada, prior to HIV diagnosis: A case-control analysis. International Journal of STD and AIDS. 2021 Dec 11:9564624211051615.
2. Nanditha NGA, St-Jean M, Tafessu H, et al. Missed opportunities for earlier diagnosis of HIV in British Columbia, Canada: A retrospective cohort study. PLoS One. 2019 Mar 21;14(3):e0214012.  
3. Powell M, Krentz HB, Eagles ME, et al. Missed opportunities within healthcare for an earlier diagnosis of HIV. International Journal of STD and AIDS. 2020 Oct;31(12):1169-1177.
4. Cayuelas Redondo L, Ruíz M, et al. Indicator condition-guided HIV testing with an electronic prompt in primary healthcare: a before and after evaluation of an intervention. Sexually Transmitted Infections. 2019 Jun;95(4):238-243.
5. Raben D, Sullivan AK, Mocroft A, et al. Improving the evidence for indicator condition guided HIV testing in Europe: Results from the HIDES II Study – 2012-2015. PLoS One. 2019 Aug 13;14(8):e0220108.  
6. Kahn JG, Bendavid E, Dietz PM, et al. Potential contributions of clinical and community testing in identifying persons with undiagnosed HIV infection in the United States. Journal of the International Association of Providers of AIDS Care. 2020 Jan-Dec; 19:2325958220950902.