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HIV and AIDS: For health professionals

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What health professionals need to know about HIV and AIDS

The human immunodeficiency virus (HIV) is a sexually transmitted and blood-borne infection (STBBI). It can be transmitted through exposure to the blood, semen, vaginal fluid, rectal fluid and human milk from a person with HIV. Perinatal transmission can also occur during pregnancy or birth.

Acquired immune deficiency syndrome (AIDS) is a long-term sequela of HIV infection.

Consider and discuss HIV testing as part of routine care with all patients. Early diagnosis and initiation of treatment can lead to reduced morbidity and mortality associated with HIV infections.

HIV-related stigma

Many people living with HIV still experience HIV-related stigma. People living with HIV have diverse life experiences and may also experience overlapping stigmas and other forms of discrimination, including racism, homophobia and ableism.

Stigma is a barrier to healthcare as it can discourage testing and early treatment. Health professionals can ask patients about their situation and the barriers they may face to learn how to best support their health needs. This can also help foster a compassionate and stigma-free healthcare environment and show being mindful of and respecting diverse life experiences.

Prevention

Health professionals play a critical role in improving awareness of the spectrum of HIV prevention methods available. It is essential that health professionals communicate all of the options and work with their patients to identify the method of prevention that works the best for them. By engaging in these discussions openly and proactively, healthcare providers can empower individuals to make informed decisions that work best for them.

Prioritizing a person-centered approach and patient-led care can help start the conversation. This may look like asking patients:

Undetectable = Untransmittable

HIV treatment can also prevent transmission. HIV cannot be sexually transmitted when a person living with HIV is on treatment and maintains a viral load of less than 200 copies of virus per millilitre of blood. To confirm that a person is virally suppressed, their viral load is usually measured every 4 to 6 months as part of clinical care.

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HIV Pre-exposure prophylaxis (HIV PrEP)

HIV pre-exposure prophylaxis (HIV PrEP) is the use of prescription antiretroviral medication by people who are HIV-negative to prevent them from getting HIV. Taken before exposure, the medication interrupts HIV's ability to copy itself in the body and prevents it from establishing an infection.

HIV PrEP is intended for regular use as an ongoing HIV prevention method. It is available as either a daily oral pill or as a long-acting injection received from a health professional. Long-acting injectable HIV PrEP is first given as 2 initiation injections 2 month apart, followed by an injection every 2 months thereafter. HIV PrEP is highly effective when taken correctly.

HIV PrEP should be considered for individuals who don't have HIV and who participate in activities that have increased risk of exposure to HIV. It's reasonable to prescribe HIV PrEP to adults and adolescents who request it as some people may not feel comfortable disclosing their sexual or drug use behaviours to a health care provider.

Any licensed health care provider can prescribe HIV PrEP. Specialization in infectious diseases or HIV medicine isn't required. Any primary care provider with patients who are at higher risk of HIV should consider offering and prescribing PrEP. Refer to the product monographs for prescribing information, including approved indications.

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HIV Post-exposure prophylaxis (PEP)

HIV post-exposure prophylaxis (HIV PEP) is the use of prescription ARV medication by people who are HIV-negative to lower the risk of acquiring HIV following a high-risk exposure.

HIV PEP is intended to prevent HIV transmission from a singular exposure. It should be started as soon as possible after exposure, up to a maximum of 72 hours.

HIV PEP involves taking oral pills daily for 4 weeks (28 days). HIV PEP can be taken on more than 1 occasion, if needed. However, individuals who have taken HIV PEP and are at ongoing risk of HIV exposure should consider taking HIV PrEP.

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Condoms

The most common way to transmit HIV is through sex. Using internal and external condoms can reduce the risk of contracting or transmitting the virus.

If a person living with HIV maintains a low viral load (less than 200 copies per ml measured every 4 to 6 months), HIV can't be sexually transmitted to their partner(s). This means they don't need to use condoms or medicines like PrEP and PEP to prevent HIV transmission during sex.

Condoms also protect against other STBBI, such as:

Harm reduction and safer injection practices

HIV can be passed by sharing equipment used to inject drugs or for tattooing or piercing. It's important that new and sterile equipment is used every time and never shared.

A person can also reduce the risk of acquiring or transmitting HIV by following safer injection practices.

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Progression of HIV infection

The amount of time from initial infection to the development of clinical manifestations is highly variable, as is infection progression.

HIV infection results in the progressive destruction of CD4+ T lymphocytes. These white blood cells are crucial to the normal function of the immune system.

Consequently, people with HIV and subsequent immune suppression are at risk of developing a variety of AIDS-defining conditions, including:

Due to advances in HIV treatment:

Clinical manifestations

Depending on the stage of infection, people with HIV may be asymptomatic or may present with:

Primary acute infection

This is the period from initial infection to development of the full serum antibody profile (seroconversion). The risk of transmission during this stage of infection is high.

Up to 90% of people in the acute infection stage are symptomatic, though these symptoms may be unrecognized.

Acute HIV infection can resemble other viral syndromes, including influenza and mononucleosis. Health professionals should consider acute HIV infection as part of the differential diagnosis for patients presenting with acute non-specific symptoms, including:

If present, symptoms:

Chronic HIV infection

In this stage of infection, viral replication and plasma viremia are more controlled by the immune response represented by the level of CD4+ T cells

Some individuals may be asymptomatic, while others may experience non-specific symptoms, including:

Non-specific laboratory findings may also be detected, including:

Many individuals living with HIV are in this stage of infection.

Acquired Immunodeficiency Syndrome

In this stage, the infection is characterized by:

Viral replication depletes the CD4+ T cells to the level of profound immunosuppression, leading to opportunistic infections.

Diagnosis

Different types of HIV tests are licensed for use in Canada. Type and availability can vary by jurisdiction.

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Approach to testing

Health professionals should offer screening for STBBI, including HIV, as part of their clinical prevention and control strategies.

Before offering an HIV screening test, conduct an assessment and ensure the individual understands:

Normalizing screening can reduce barriers to screening and testing, and the stigma associated with HIV.

It's also important to recognise that some patients at risk of contracting HIV may have faced other forms of stigma and previous negative experiences in healthcare settings. Using non-stigmatizing language and following up HIV testing and diagnosis with patient support materials is important to reduce fear and build trust.

To learn more about approaches to testing and barriers to accessing screening, take the free online STBBI Barriers to Screening course:

Additional resources:

Standard HIV Testing

In Canada, all laboratories performing HIV screening use fourth generation HIV tests, also known as combination tests, which detect both HIV antibodies and the HIV p24 antigen. These screening tests perform better in acute infection than those that only detect antibodies because the p24 antigen is detectable earlier than antibodies. With fourth generation screening tests, some people will have a reactive (positive) result as early as 15 to 20 days after HIV exposure. While most people will have an accurate test result 3 to 6 weeks after exposure, for a small number of people the window can be up to 12 weeks. If an HIV screening test indicates a reactive result, the laboratory will conduct specialized confirmatory testing to ensure correct diagnosis of an HIV infection.

In certain circumstances, qualitative nucleic acid amplification tests (NAAT) and/or quantitative NAAT (viral load testing) can be used to detect the virus itself. Genotyping and phenotyping are used to detect and monitor HIV drug resistance.

Rapid HIV Testing

Rapid HIV test kits licensed in Canada for point-of-care (POC) testing or self-testing require a few drops of blood from a finger prick and provide results within several minutes. Because rapid screening tests are third generation tests that only detect HIV antibodies, they generally have a longer window period than standard fourth generation HIV screening tests. While some people may have a reactive result as early as 20 to 30 days after HIV exposure, the window period can be up to 12 weeks. Reactive results are considered "preliminary" and should be confirmed with standard laboratory testing for the diagnosis of HIV infection.

Where available, rapid HIV test kits for POC testing or self-testing can facilitate uptake of screening. In addition, rapid HIV testing provides an option for people who face barriers accessing testing in healthcare settings, such as:

Treatment

HIV is treated with antiretroviral therapy (ART), which is a combination of medications that can:

Early diagnosis and treatment reduce the morbidity and mortality associated with HIV and infection progression.

Treatment of HIV infection is a complex area, with changes in recommended regimens occurring as new research and evidence becomes available. If ART is being considered, consult a colleague experienced in HIV care or an infectious diseases specialist. Local public health authorities will have a listing of these health professionals.

Summary: HIV antiretroviral medication coverage in Canada (report)

Surveillance

HIV and AIDS are both nationally notifiable diseases. National notification is voluntary and data are reported by provincial or territorial public health authorities.

Provinces and territories have legislation for the reporting of priority infectious diseases within their jurisdictions. All provinces and territories collect data on diagnosed HIV infections and report to the Public Health Agency of Canada annually. However, not all provinces and territories have mandatory reporting of AIDS.

Provinces and territories report cases to the Public Health Agency of Canada if they meet the national case definition for HIV or AIDS.

The Public Health Agency of Canada, in partnership with provinces and territories, regional and/or local public health partners, coordinates the Tracks enhanced surveillance system at sentinel sites across Canada. The Tracks system monitors trends in the prevalence of HIV and hepatitis C and associated risk factors in key populations.

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Reporting on HIV in Canada

Information at a glance

Technical reports

Guiding resources

Reporting on Canada's progress towards HIV elimination

Information at a glance

Technical reports

Guiding resources

Reporting on HIV interventions

Information at a glance

Technical reports

Related links

Canada Communicable Disease Report

External resources

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