The Atlantic Region Takes Action on Sexually Transmitted Blood Borne Infection Testing

Monday, June 24th, 2019
Halifax, Nova Scotia

The Canadian Institutes of Health Research (CIHR) in collaboration with the Public Health Agency of Canada, Dalhousie University, the Nova Scotia Advisory Commission on AIDS, the Atlantic Interdisciplinary Research Network, Research Nova Scotia, and REACH 2.0

Objectives

In 2018, the “Pan-Canadian Framework for Action: Reducing the Health Impact of Sexually Transmitted and Blood-borne Infections in Canada by 2030” was released. This Best Brains Exchange (BBE) will support the Pan-Canadian Framework for Action by bringing together key public health officials, health researchers, policy makers, industry partners and other key stakeholders to explore how the Atlantic provinces can mobilize to advance Sexually Transmitted Blood Borne Infections (STBBI) testing to help reduce the burden of STBBIs across the Atlantic region by 2030.

More specifically, BBE participants will:

  1. Increase their understanding of the unique characteristics of STBBIs in the Atlantic region including potential barriers and innovative solutions to testing;
  2. Explore collaborative and interprovincial actions to help support increased access to testing, as a key pillar of the Pan-Canadian Framework for Action, in an effort to reach the undiagnosed and expedite access to treatment;
  3. Examine the potential utility of newer STBBI testing technologies and approaches for use in Atlantic Canada; and
  4. Determine potential interprovincial agreements for testing-related actions needed to help reduce the health impact of STBBIs in the Atlantic region.

Policy Context

The rates of STBBIs in the Atlantic region represent an ongoing public health challenge, with increasing rates of infections and recent outbreaks of HIV, HCV and other STBBIs occurring across the region. Specifically, rates of chlamydia in Nova Scotia (NS), New Brunswick (NB), Prince Edward Island (PE) and Newfoundland and Labrador (NL) are 261, 234, 166, and 151 per 100,000 and rates of infectious syphilis in NS, NB, PE and NL were 6.8, 3.6, 6.2 and 4.6 per 100,000 respectively. Further, in NL, Eastern Health reported the first case of lab-confirmed congenital syphilis and 60 cases of lab-confirmed gonorrhea infection in December 2018. While these rates represent important public health data on those who have been tested and provided with a positive test result, it is important to note that these data do not reflect the numbers of those remain untested, undiagnosed and unaware of their infection. Access to and uptake of STBBI testing therefore remains a critical response to the reaching the undiagnosed and referring them to treatment and care. As is currently stands, the Atlantic region does not have access to low-threshold testing innovations such as point of care testing for HIV which was approved by Health Canada in 2005.

The “Pan-Canadian Framework for Action: Reducing the Health Impact of Sexually Transmitted and Blood-Borne Infections in Canada by 2030” was released in July 2018 which outlines four key pillars to an integrated approach to STBBIs which include prevention, testing, initiation of care and treatment, and ongoing care and support. An important element to this integrated approach is focused on equitable access in providing individuals with equal access to appropriate health care services, including testing and care for STBBIs. The Pan-Canadian Framework for Action also provides an important and timely template in response to the recent outbreaks of STBBIs in the Atlantic provinces by offering an opportunity for public health leaders in the provincial ministries of health as well as the various health authorities to examine current STBBI testing policies and approaches across the region.

Need for Evidence

The BBE will provide participants with an interactive platform from which to engage in sharing evidence and knowledge from leading STBBI public health officials, researchers and international experts from other countries on the development of STBBI policies, programs and actions aimed at reaching the undiagnosed. In keeping with the stated objectives for this session, participants will be able to speak to the scaling up of innovative STBBI testing programs and policies from across other jurisdictions.

While the BBE will be held in Halifax, we will be drawing from existing research evidence and policy standards on testing across the Atlantic region to ensure the information shared is the basis for advancing access to and uptake of STBBI testing. For example, while Health Canada approved the use of HIV point of care testing in 2005, none of the Atlantic provinces has access to this testing technology and no billing code currently exists to reimburse health care providers who may wish to add this testing innovation to their clinical practice. The existing research evidence on how this type of testing technology was introduced and integrated into existing provincial STBBI policies and programs elsewhere in Canada would serve as a ‘proof of concept’ for policy action and uptake in the Atlantic region.

Anticipated Outcomes

We anticipate creating interprovincial actions that would support increased accessibility to STBBI testing, diagnoses and linkages to care, treatment and support across the Atlantic region. To achieve this, we will collectively and collaboratively frame interprovincial agreements to refine and advance actions on the proposed solutions to reaching the undiagnosed following the BBE. In addition, we will monitor changes in provincial-level testing policies from the date of the BBE and track this over time to determine the shifts in STBBI testing policy, access and uptake. Following the BBE, we will continue to work closely with our government, community, research and industry partners to determine if the stated actions are gaining traction in the Atlantic region in concert with the Pan-Canadian Framework for Action.

Presentation Summaries

The BBE was facilitated by Jean Shoveller (Professor, School of Population and Public Health, University of British Columbia; Fellow, Canadian Academy of Health Sciences; Research Associate, Centre for Gender & Sexual Health Equity; Member, Canadian Institutes of Health Research (CIHR) Governing Council). Here is a summary of the evidence presented by each of the presenters:

Overview of the Pan-Canadian STBBI Framework

Genevieve Tremblay, Director, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada

Testing is one of the four core pillars of the Pan-Canadian Framework for Action – Reducing the Health Impact of Sexually Transmitted and Blood-Borne infections in Canada by 2030, which was jointly released by federal, provincial and territorial governments in June 2018. The Pan-Canadian Framework for Action provides a roadmap for collaborative and complementary actions to reduce the impact of STBBI in Canada and contribute to global efforts to end AIDS, viral hepatitis and sexually transmitted infections as major health concerns by 2030.

The implementation of the Pan-Canadian Framework for Action is guided by a set of principles which include the meaningful engagement of people living with STBBI and key populations; moving towards truth and reconciliation with First Nations, Inuit and Metis Peoples; and taking a human rights and health equity-based approach to addressing these infections.

Implementing the Pan-Canadian Framework for Action in order to reduce STBBI in Canada will require the concerted efforts of all partners and stakeholders working within their respective roles. Facilitating early detection of STBBI through the promotion, normalization and increased availability of testing in a variety of settings, particularly for those at high risk or those who have been previously exposed, will be key to reducing the health impacts of these infections. This presentation will outline opportunities for action on STBBI testing arising from the Framework, focusing on the federal mandate and the levers available at the federal level to improve access to, and uptake of, STBBI testing in Canada.

Innovation in Testing – Dried Blood Spots

John Kim, Chief, Microbiology Laboratory, Public Health Agency of Canada

National Laboratory for HIV Reference Services (NLHRS) at the National Microbiology Laboratory’s JCWilt Infectious Disease Center in Winnipeg, MB. Along with the NLHRS he has extensive experience in testing including reference services for HIV/HTLV, monitoring proficiency in Canadian public health and hospital labs and support for PHAC’s Track surveillance surveys of key populations.

Recently they have engaged with Indigenous communities to increase access to testing opportunities for blood borne infections using dried blood spots. This novel intervention uses a model of engagement and ownership to ensure community uptake and includes Chief/council approval and training of local health care workers in the collection of DBS. This model has helped address empowerment, stigma, racism and reduce health inequities associated with inadequate access to testing.

Innovation in Testing - Community Pharmacy Model

Deborah Kelly, Associate Professor and Special Advisor, Practice Innovation, Memorial University of Newfoundland

The APPROACH study demonstrated the feasibility and high acceptability of HIV testing offered by community pharmacists in urban and rural areas of Newfoundland and Labrador and Alberta. Over 120 tests were conducted over 6 months in this pilot study; 75% of people tested were of moderate to very high risk of HIV infection and this was the first HIV test for 28% of clients. Importantly, one new HIV diagnosis was made and successfully linked with care, demonstrating that testing by pharmacists can boost HIV testing rates and contribute to finding new HIV diagnoses.

In 2019, as part of a larger CIHR HIV/AIDS Biomedical and Clinical research team grant, funding was received to implement APPROACH 2.0 – a study which will expand the pharmacy testing model to include testing for HIV, hepatitis C, and syphilis. This study will take a pragmatic, community-informed approach to develop and expand the pharmacist testing model throughout 3 provinces, including Nova Scotia, Newfoundland and Labrador, and Alberta.

This presentation will propose how community pharmacists can contribute to achieving Canada’s goal to reduce the health impact of STBBIs by 2030, and the next steps required for scalability and sustainability, including: (1) Regulatory and Policy issues; (2) Integration with existing public health systems; and, (3) Financial considerations.

Innovation in Testing – New Testing Technologies

Rick Galli, Chief Technical Officer, BioLytical Laboratories Inc.

Despite progress in improving HIV and other STBBI testing rates over time, concern has been raised that conventional, public, facility-based testing has several weaknesses, including long waiting time, the identification of HIV negative people within testing programs without a subsequent effective prevention message, and the inability to reach key and vulnerable populations. It is estimated that in 2017 over 9000 persons living with HIV in Canada remain undiagnosed. Point of Care (POC) HIV testing has been available in Canada since 2006 yet POC testing accounts for <5% of all HIV diagnostic testing. Dried blood spot testing greatly facilitates remote sample collection with centralized multiplex testing of HIV and other STBBI, yet implementation remains limited. Self- or home testing for HIV (“HIVST”) is not yet available in Canada, but is an emerging approach with the potential to increase the uptake of HIV testing, to be high impact, low cost, and empowering for those who may not otherwise test, notably in key populations and other people at high risk for HIV infection.

My presentation will outline novel complementary biomedical and clinical/public health implementation strategies to reach the undiagnosed including :1) accuracy, usability and acceptance of HIV self-tests, 2) HIV self-testing strategies in clinic and community-based settings using innovative App technology; 3)community-based testing interventions with peers to diversify HIV testing for key populations; 4) non-traditional approaches for test delivery including pharmacy-based HIV testing and integration with existing infrastructure.

Innovation Implementation – Lessons learned from Ontario

Ken English, Senior Program Consultant, AIDS and Hepatitis C Programs, Ministry of Health and Long Term Care (Ontario)

Ontario launched an HIV rapid/point-of-care (POC) testing program in 2008. The program operates out of over 50 sites, including local public health offices, community health centres, and independent sexual health clinics. Ontario’s program has been successful at reaching out to the province’s HIV high-risk priority populations, and has an HIV positivity rate that is four times higher than standard HIV testing. In this session, we will discuss some of the planning and implementation considerations associated with establishing an HIV-POC program, including program oversight and quality assurance, and review the success of Ontario’s program in contributing to the objectives of the province’s HIV prevention, engagement and care cascade.

Recommended Readings

  1. Shabnam Asghari, Alexa Minichiello, Alison Maybank, Michelle Swab, Zack Marshall, Jacqueline Gahagan, Aurélie Hot, Michael Schwandt, and Sonia Gaudry, HIV point-of-care testing in Canadian settings: A scoping review.
  2. Jacqueline Gahagan, Brian Condran, Mohammad Hajizadeh, HIV Point-of-Care Testing (POCT) in Canada: Action Plan 2015-2020. Halifax, NS: Dalhousie University, 2015.
  3. Jacqueline Gahagan, Brian Condran, Sowmya Sharma, Todd Hatchette, HIV point-of-care-testing in Nova Scotia: A pilot study final report. July 31, 2015.
  4. Jacqueline Gahagan, Alexa Minichiello, Michelle Swab, Zack Marshall, Kellee Hodge, Sonia Gaudry, Shabnam Asghari, Michael Schwandt, HIV point-of-care testing in non-urban settings: A scoping review. The Canadian Journal of Human Sexuality, Volume 27, Number 1, 2018, pp.12-20.
  5. Amanda Giacomazzo, BLOG: Bring testing to the people (April 2, 2019).
  6. Government of Canada, Reducing the health impact of sexually transmitted and blood-borne infections in Canada by 2030: A pan-Canadian STBBI framework for action (July 9, 2018).
  7. Christine Hughes, Deborah Kelly, Jason Kielly, Stephanie Hancock, Hyungu Kang on behalf of the APPROACH study team, Findings from the APPROACH study: a pharmacy-based point-of-care testing model for HIV in two provinces. Memorial University of Newfoundland and University of Alberta.
  8. Deborah Kelly, Jason Kielly, Christine Hughes, Stephanie Hancock, Hyungu Kang on behalf of the APPROACH study team, Client and provider satisfaction with a pharmacist-administered HIV point of care testing program — the APPROACH study. Memorial University of Newfoundland and University of Alberta.
  9. Jason Kielly, Deborah V. Kelly, Christine Hughes, Kristine Day, Stephanie Hancock, Shabnam Asghari, Jacqueline Gahagan, Carlo Marra, Hai Nguyen, Adaptation of POCT for pharmacies to reduce risk and optimize access to care in HIV, the APPROACH study protocol: Examining acceptability and feasibility. Pilot and feasibility studies 4.1 (2018): 59.
  10. National Working Group on HIV/AIDS Research, Ending the HIV epidemic in Canada in five years: It’s time to act. October 23, 2018
  11. PRESENTATION DECK: AIDS Bureau, Ministry of Health and Long-Term Care Quality Assurance of HIV Rapid Tests. 2015

    NOTE: some of these processes and results, are dated; Ontario is currently updating their training materials.

  12. BACKGROUNDER: HIV Epidemic in Ontario.
  13. BACKGROUNDER: HIV/AIDS Strategy document that was developed by the Ontario Advisory Committee on HIV/AIDS under a previous government (2016).
Date modified: