Population and Public Health Population et santé publique 4th Floor; 300 Carlton Street 4e étage; 300, rue Carlton Winnipeg MB R3B 3M9 Winnipeg MB R3B 3M9 Email: [email protected] Email : [email protected]

July 9, 2021

Dear Health Care Provider:

ADDITIONAL INFORMATION Re: New – HIV Medication Coverage, Effective July 12, 2021

In follow-up to the letter sent on July 6, 2021 advising that Manitoba is introducing a new HIV Medication Coverage program, please be advised of the following:  The HIV Medication Program Eligibility Form has been updated, most notably to include a section on the form to be completed by the prescriber, including the prescriber name, signature and contact information. Please ensure you use this new form; the previous version distributed on July 6, 2021 will NOT be accepted. The updated HIV Medication Program Eligibility Form is available online at: https://www.gov.mb.ca/health/publichealth/surveillance/docs/hiv_medication_program_el igibility_form.pdf.  Pharmacies WILL NOT fill a prescription for a client if the client does not have active Manitoba Health coverage at the time they are going to the pharmacy to have their prescription filled. The pharmacist is required to call the DPIN Helpdesk each time they fill a prescription under this program (i.e. maximum of one month supply at a time – if a prescription is for three months, the pharmacist will need to call).  The information available in DPIN ONLY shows the drugs dispensed – NOT prescriptions written if they haven’t been filled. The Department does not have a way to track prescriptions written but not filled.  Pharmacies are NOT required to fill prescriptions under this program – although the department anticipates that most pharmacies will choose to deliver this service to its clients, it is possible that some pharmacies may choose to not participate. A client would then need to seek service at an alternate pharmacy.  Questions about the HIV Medication Coverage program can be emailed to: [email protected]. Please be aware that emails are responded to as quickly as possible, and you can expect to receive a response within two business days. Please share this information with all relevant colleagues in your facility or clinic.

Sincerely, “Original signed by” Richard Baydack, PhD Director Communicable Control

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Population and Public Health Population et santé publique 4th Floor; 300 Carlton Street 4e étage; 300, rue Carlton Winnipeg MB R3B 3M9 Winnipeg MB R3B 3M9 Email: @gov.mb.ca Email : [email protected]

July 6, 2021

Dear Health Care Provider:

Re: New – HIV Medication Coverage, Effective July 12, 2021

Manitoba is introducing a new HIV Medication Coverage program, intended for clients who are actively registered with Manitoba Health who are experiencing significant financial barriers to treatment, and who are not enrolled in an insurance program (e.g., federal drug program, Employment and Income Assistance, private insurance program), other than Pharmacare. Access to this program will facilitate timely access to a prescribed ART regimen and will allow patients and their caregivers more time to explore and establish long-term options for medication coverage. This program is not intended to provide coverage indefinitely.

Please use the HIV Medication Program Eligibility Form to assess client’s eligibility for this program.

Terms of Coverage  Patients in the process of enrolling in Manitoba Pharmacare or enrolling in the Deductible Installment Payment Program - If the patient requires additional time to enroll in Pharmacare or to enroll in the Deductible Installment Payment Program, three months of drug coverage will be provided to the client. Once the client is enrolled in Pharmacare or the Deductible Installment Payment Program, costs that were paid through this coverage program will be put towards the client’s deductible for the first year of treatment. At the start of each fiscal year, the deductible is reset and the client will be provided with information on their deductible installment plan payments. Coverage in this HIV Medication Coverage program is not intended to be indefinite or to replace annual deductibles or installment payment programs.

 Patients cannot enroll in Manitoba Pharmacare - If the patient cannot apply for Pharmacare because of immigration status, new resident, or other factors associated with proof of income or proof of residency issues, one year of coverage for ART is provided and will be reviewed annually.

Please share this information with all relevant colleagues in your facility or clinic.

Sincerely,

“Original signed by”

Richard Baydack, PhD Director Communicable Disease Control

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Communicable Disease Management Protocol

Human Immunodeficiency /Acquired Immunodeficiency Syndrome (HIV/AIDS) Communicable Disease Control Branch

1.0 Definitions • Cervical (invasive) •Coccidioidomycosis (disseminated or 1.1 Human Immunodeficiency Virus extrapulmonary) (HIV) •Cryptococcosis (extrapulmonary) Case Definition • chronic intestinal The case definition of human immunodeficiency (> one month duration) virus (HIV) infection relies on the detection of HIV , nucleic acid or by laboratory •Cytomegalovirus (other than in methods or isolation of HIV in culture. liver, or nodes) 1.1.1 Seroconversion Illness •Cytomegalovirus retinitis (with loss of vision)* Acute self-limited mononucleosis-like illness lasting for one to two weeks occurring within several weeks •Encephalopathy, HIV-related (dementia) to months after infection with HIV. • Herpes simplex: chronic ulcer(s) (> one 1.1.2 Window Period month duration) or bronchitis, pneumonitis or ) The period between initial infection and antibody detection is known as the window period and is • (disseminated or usually two weeks to three months. Rarely, window extrapulmonary) periods lasting years may occur in •Isosporiasis, chronic intestinal (> one immunocompromised persons. month duration) 1.2 Acquired Immunodeficiency Syndrome • Kaposi’s sarcoma* (AIDS) •, Burkitt’s (or equivalent term) Case Definition •Lymphoma, immunoblastic (or equivalent term) Those who meet the case definition for HIV infection PLUS any one of the following indicator •Lymphoma (primary in brain) diseases (based on Case Definitions for Communicable • avian complex or Diseases under National Surveillance, November Mycobacterium kansasii (disseminated or 2009, Public Health Agency of Canada): extrapulmonary)* 1.2.1 Indicator Diseases for Adult and • Mycobacterium of other species or Pediatric Cases unidentified species (disseminated or •Bacterial (recurrent)* extrapulmonary)* • (bronchi, trachea or ) • Mycobacterium (any site, pulmonary* or extrapulmonary, • Candidiasis (esophageal)* disseminated) • CD4+ T- count of < 200 • Pneumocystis jiroveci (formerly cells/µL or CD4+ T-lymphocyte Pneumocystis carinii) pneumonia (PCP)* percentage of total of < 14 (CDC 2008 Surveillance Case •Progressive multifocal Definitions) leukoencephalopathy

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• Salmonella septicemia (recurrent) 2.1.2 Anonymous HIV Testing • of brain* • Anonymous4 test sites are required to report positive test results for HIV or •Wasting syndrome due to HIV HIV antibody to Manitoba Health, 1.2.2 Indicator Diseases that Apply Only to Public Health Surveillance Unit; all Pediatric Cases (< 15 years old) anonymous test results (positive, negative and indeterminate) will be evaluated by •Bacterial (multiple or recurrent, Manitoba Health to monitor service use excluding recurrent bacterial pneumonia) and identify risk groups. •Lymphoid interstitial pneumonia and/or • The Manitoba Health Case Investigation pulmonary lymphoid hyperplasia* Form for Nominal & Non-Nominal * These conditions may be diagnosed Positive Cases does not need to be presumptively; otherwise, definitive diagnosis is completed by the attending health required. Criteria for presumptive and definitive professional when positive test results for diagnoses are provided on the back of the Health HIV are obtained at anonymous testing Canada HIV/AIDS case report form. sites. Instead, the HIV Case Report Form for Anonymous Testing, along with the 2.0 Reporting Requirements1 positive lab confirmation report must be completed and faxed to Manitoba Health, 2.1 Reporting to Manitoba Health Public Health Surveillance Unit. This report form is completely anonymous. 2.1.1 Nominal and Non-Nominal HIV For surveillance purposes, epidemiological Testing data is collected and documented on the •All nominal2 and non-nominal3 positive Anonymous HIV Antibody Testing test results for HIV or HIV antibody are Requisition and submitted to Manitoba reportable by laboratory to Manitoba Health by Cadham Provincial Laboratory Health, Public Health Surveillance Unit as required under the Reporting of Diseases and Conditions Regulation of 1Please see the Manitoba Health document “The Public The Public Health Act (nominal testing Health Act – Reporting Requirements and Powers” for for HIV in Manitoba was introduced in information on reporting requirements when a patient January 2007). refuses treatment for a reportable communicable disease or fails to comply with an order from the Medical • The attending health professional must Officer of Health. complete the Manitoba Health Case 2 Nominal testing: the HIV test is ordered using the Investigation Form for Nominal & Non- name of the person being tested. Nominal Positive Cases and submit it to 3 Non-nominal testing: the HIV test is ordered using a Manitoba Health. This information is code of the person being tested. Only the person completely confidential and will be used ordering the test knows the identity of the person being tested and is able to link the result to that person’s for statistical and program planning health care record. services. 4 Anonymous testing: the HIV test is ordered using a • Contacts of persons infected with HIV unique non-identifying code. The person(s) ordering identified by nominal or non-nominal the test and providing the result do not know the testing should be reported using the identity of the person being tested. Only the person being tested knows the code, so the test result is not Manitoba Health HIV Contact linked to that person’s health care record. Notification Form.

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(CPL). This information is completely NOTE: Requisitions and forms are subject to anonymous and will be used for statistical change. Examples of the most recent versions of and program planning services. Cadham Provincial Laboratory requisitions are available in the online Guide to Services at: • Contacts of persons infected with HIV www.gov.mb.ca/health/publichealth/cpl/documents.html. identified by anonymous testing should The most recent versions of the Manitoba Health be reported using the Manitoba Health reporting forms are available at: HIV Contact Notification Form. www.gov.mb.ca/health/publichealth/cdc/protocol/index.html 2.1.3 Point-of-Care (POC) Testing under “Forms.” • Both nominal and non-nominal point-of- 2.2 Reporting to Canadian Blood Services care5 (POC) testing options are currently available in Manitoba (see Section 6.2 (CBS) Testing Options). All reactive and •Manitoba Health, Public Health indeterminate test results obtained from Surveillance Unit reports HIV-positive clinical or point-of-care testing sites are individuals to CBS where the reportable to Manitoba Health, Public investigation form specifies that the Health Surveillance Unit WHEN a individual has received or donated blood. confirmatory standard test is not performed by Cadham Provincial 2.3 Reporting from Canadian Blood Laboratory (CPL) (i.e., patient refuses to Services have a confirmatory standard HIV test •Canadian Blood Services reports HIV- following a reactive or indeterminate positive test results of potential blood point-of-care HIV test result). In these donors to Manitoba Health, Public situations, the attending health Health Surveillance Unit. professional must complete the Manitoba Health HIV Case Report Form for Rapid 2.4 Reporting from Citizenship and HIV Testing and submit it to Manitoba Immigration Canada (CIC) Health. This form does NOT need to be completed for individuals having standard • As of June 2005, CIC refers the names of confirmatory HIV testing at CPL. Where those individuals identified as having an specimens are appropriately procured, sera HIV-positive test result (tested outside of from clients with reactive or Canada) to Manitoba Health. indeterminate HIV antibody or antigen •Manitoba Health will refer cases to the are to be forwarded by clinical operators appropriate regional health authority for in Manitoba to Cadham Provincial case management and follow-up. Laboratory. 2.1.4 Acquired Immunodeficiency Syndrome 5 Point-of-Care (POC) testing refers to when an HIV test (AIDS) is performed outside a designated testing laboratory • The diagnosis of AIDS is reportable by (e.g., in a physician’s office). health professional to Manitoba Health, Public Health Surveillance Unit.

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3.0 Clinical Presentation/Natural syndrome represents the late clinical stage of HIV History infection resulting from progressive damage to the , leading to the opportunistic 3.1 Adults with HIV Infection infections and listed under Section 1.2. In industrialized countries, 80 to 90 per cent of The first stage of HIV infection occurs several weeks untreated patients die within three to five years after to months after infection with HIV (1) and is an AIDS diagnosis (1). The use of highly active associated with high viral titers and widespread antiretroviral therapy (HAART) and prophylactic dissemination (2). Although some individuals in this drugs for the prevention of opportunistic infections stage are asymptomatic (3), many people develop an may prevent, or at least significantly delay, the acute self-limited mononucleosis-like illness lasting development of AIDS, prolonging survival for years, for one to two weeks (seroconversion illness). and perhaps indefinitely. Common symptoms reported during the primary HIV infection include , sore throat, fatigue, 3.3 Infants and Children with HIV weight loss and myalgia (4). Primary HIV infection is often undiagnosed (4). In the second stage of illness, Infection individuals are free of clinical signs and symptoms, Ten to 20 per cent of perinatally-infected children usually for years, before other clinical symptoms who are untreated will present with moderate to develop. A viral load test of over 5,000 copies/mL severely symptomatic disease in the first year of life. obtained during the asymptomatic period is The median time to disease progression of the correlated with an increased risk of more rapid disease remaining 80 to 90 per cent of perinatally-infected progression. The third stage of HIV infection is children is unknown but is likely similar to adults. characterized by the development of opportunistic With treatment, disease progression is delayed. infections and cancers attributable to immune system Diagnosis of HIV infection among children less dysfunction. Without treatment, progression to AIDS than 18 months of age can be complex and requires is highly variable taking between one and detection of the infection by nucleic acid testing approximately 15 years. Onset of clinical illness is (NAT). Management of infants suspected of HIV usually insidious with non-specific symptoms such as infection is best accomplished in consultation with , anorexia, chronic , weight a specialist in HIV care of children. loss, fever and fatigue. However, this constellation of 3.3.1 Clinical Categories for Children with non-specific symptoms is usually not sufficient, by itself, for a diagnosis of AIDS. More than half of all HIV Infection HIV-infected individuals, including children, develop Children who are infected with HIV can be neurologic disease during the course of the infection classified as asymptomatic, mildly symptomatic, (2). The prognosis for HIV infected persons is moderately symptomatic or severely symptomatic, improved with treatment using combination based on their clinical presentation. antiretroviral therapies and/or appropriate prophylaxis A. Asymptomatic: Children who have no against opportunistic infections. It is estimated that signs or symptoms considered to be the over 90 per cent of individuals that are positive for result of HIV infection or who have only HIV will eventually develop AIDS if untreated with one of the conditions listed in Category B. anti-HIV therapy (1). Effective treatment can alter the natural history of HIV infection and slow the B. Mildly Symptomatic: Children with two progression to end-stage disease (AIDS). or more of the conditions listed below, but none of the conditions in C or D: 3.2 Adults with AIDS •Lymphadenopathy AIDS is advanced HIV-related disease. AIDS is a severe, life-threatening clinical condition, first •Hepatomegaly recognized as a distinct syndrome in 1981. This •Splenomegaly

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•Dermatitis D. Severely Symptomatic: •Parotitis •Serious bacterial infections, multiple or recurrent within a two-year period (e.g., •Recurrent or persistent upper respiratory septicemia, pneumonia, ) infection, or otitis media • Candidiasis, esophageal or pulmonary C. Moderately Symptomatic: Children who have symptomatic conditions other than •Coccidioidomycosis, disseminated those listed in B and D that are attributed •Cryptococcosis, extrapulmonary to HIV infection. Examples include but are not limited to: •Cryptosporidiosis or isosporiasis with diarrhea persisting more than one • Anemia month •Bacterial meningitis, pneumonia or •Cytomegalovirus disease with onset of (single episode) symptoms at > one month of age • Candidiasis, oropharyngeal (thrush) •Encephalopathy • Cardiomyopathy • infection causing •Cytomegalovirus infection with onset a mucocutaneous ulcer that persists for before one month of age more than one month, or bronchitis, pneumonitis or esophagitis for any •Diarrhea, recurrent or chronic duration affecting a child > one month •Hepatitis of age •Herpes simplex virus (HSV) stomatitis, •Histoplasmosis, disseminated more than two episodes within one year • Kaposi’s sarcoma •HSV bronchitis, pneumonitis or •Lymphoma (Burkitt’s, B-cell or esophagitis with onset before one unknown immunologic phenotype) month of age •Lymphoma, primary, in brain •Herpes zoster () involving at least two distinct episodes or more • Mycobacterium avium complex or than one dermatome Mycobacterium kansasii, disseminated • Leiomyosarcoma • Mycobacterium, other species •Lymphoid interstitial pneumonia • Mycobacterium tuberculosis, (LIP) or pulmonary lymphoid disseminated or extrapulmonary hyperplasia complex • •Nephropathy •Progressive multifocal • leukoencephalopathy •Persistent fever (lasting more than one •Salmonella (non-typhoid) septicemia, month) recurrent •Toxoplasmosis, onset before one •Toxoplasmosis of the brain with onset month of age at more than one month of age •Varicella, disseminated (complicated •Wasting syndrome chicken pox)

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Refer to •Sexual contact — oral, vaginal, anal and http://aidsinfo.nih.gov/contentfiles/PediatricGuidelines.pdf the sharing of sex toys — with an for more information. individual infected with HIV places individuals at risk for infection. 4. Etiology •Sexual assault – See Manitoba Health’s HIV infection is caused by a human retrovirus, Integrated Post-Exposure Protocol for HIV, usually HIV I, rarely HIV II. HIV infects a wide HBV and HCV: Guidelines for Managing array of cells, but its principal target is the Exposures to Blood and Body Fluids. mononuclear — specifically •Sexual activities that increase risk of and helper T-lymphocytes. Because transmission include but are not limited retroviruses integrate into the target cell genome as to lack of condom use, sexual contact that proviruses, with the viral genome copied during cell induces trauma and multiple partners. replication, the virus persists in infected persons for Intercourse without the use of a condom life (5). Infection with HIV results in the is a high-risk activity for the transmission progressive destruction of CD4+ T lymphocytes of HIV. Use of a condom during making patients more vulnerable to opportunistic intercourse reduces the risk from high to . When the helper T-lymphocyte low, but does not eliminate it (6). population is sufficiently depleted by HIV infection so the body cannot control common subclinical •Individuals with an existing sexually infections and infectious exposures, the patient is transmitted infection, particularly those said to have AIDS. with ulcerative lesions (e.g., syphilis, herpes) are at increased risk of 5.0 Epidemiology transmitting or acquiring HIV. 5.2.2 Transmission Through Injection Drug 5.1 Reservoir Use (IDU) Humans, similar are found in lower • The transmission of HIV through primates. injection drug use is influenced by injection practices and user behaviour. 5.2 Transmission Using non-sterile needles, syringes or There is a higher risk of transmission during the mixing equipment, including water, acute seroconversion illness than during the early constitutes a high risk of transmission. phase of established HIV infection. A high viral load in the infected person increases the potential •From 1997-2008 in Manitoba, for transmission (6). In general, exposing open approximately 19 per cent of HIV wounds to contaminated body fluids can cause infections diagnosed were attributed to IDU transmission of infection. To reduce or prevent as the primary mode of transmission (7). transmission, refer to Section 7.3 on Prevention. •Use of a new and/or sterile needle, syringe For more information on relative risk of and mixing equipment, reduces risk of transmission, see Appendix A and The Canadian HIV transmission through IDU. AIDS Society document HIV Transmission: Guidelines for Assessing Risk, fifth edition, 2005. 5.2.3 Activities Involving Skin Punctures (tattooing, piercing, electrolysis and 5.2.1 Sexual Transmission acupuncture) •Sexual transmission is the major route of • The use of non-sterile equipment for the HIV transmission (3). purposes of tattooing or body piercing places individuals at risk for infection.

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•Other invasive personal services. •Receipt of blood, blood products, tissue or organs between 1978 and1985, or in •Measures that lessen the likelihood of countries where screening is unreliable or transmission include avoidance of not carried out, poses a risk for tattooing and/or piercing, patronage of transmission. licensed facilities, and consistent observation of infection prevention and 5.2.5 Perinatal Mother-to-Child Transmission control practices (see Infection Prevention •Transmission occurs in utero, intrapartum and Control Practices for Personal Services: or postnatally through . If no Tattooing, Ear/Body Piercing, and anti-HIV treatments are taken during Electrolysis, CCDR 1999; 25S3: 1-73, , there is a 20 to 30 per cent available at: chance of HIV transmission from the www.phac-aspc.gc.ca/publicat/ccdr-rmtc/99pdf/cdr25s3e.pdf). mother to the fetus (6). Maternal antiviral • The risk of HIV transmission is very low prophylactic measures reduce when human biting that causes bleeding transmission risk by two-thirds or more. occurs. •Differences in maternal disease status, 5.2.4 Blood Transfusion, Tissue or Organ mode of delivery, viral phenotype, and Transplantation frequency of breastfeeding all potentially contribute to the observed differences in •In Canada, the risk of HIV transmission transmission rates. from the receipt of donated blood, blood products, tissues or organs is extremely •Principle factors associated with perinatal low, as all donors are screened for HIV. transmission among infected women The use of nucleic acid testing (NAT) by include: Canadian Blood Services and Héma –Increased maternal viral load which Québec reduces the window period still may be associated with recent further, but it is possible for a donor to be infection, development of AIDS, an in a window period of infection at the intercurrent infection, or recent time of donation, and HIV could be discontinuation of antiretroviral transmitted. The estimated risk is less agents. than one per million transfusions. –Low maternal CD4+ counts. •People who have engaged in activities that place them at increased risk for HIV –Vaginal delivery and/or prolonged infection should not donate plasma, rupture of membranes. blood, organs for transplantation, tissue –Dual infection with HIV-1 and 2 or cells (including semen for artificial which is more likely to transmit ). CBS may exclude a blood HIV-1. donation based on information obtained in a donor questionnaire. When a blood –Breastfeeding, as HIV has been sample tests positive for HIV by NAT detected in the milk of lactating and/or antibody testing, CBS will notify HIV-positive women (8-10). the donor, provide appropriate 5.2.6 Occupational Exposure counselling to the individual and discard all the products made from the donation. • The risk of acquiring HIV infection after percutaneous exposure to HIV-infected blood is less than 0.5 per cent (1). Body fluids presenting risk for bloodborne

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disease transmission are blood, semen and protect those who handle HIV-infected vaginal secretions, and possibly cadavers, tissues and fluids from infection. cerebrospinal fluid, synovial fluid, pleural Precautions may involve use of body bags, fluid, pericardial fluid, amniotic fluid, and disposable gloves, and good hygienic peritoneal fluid. Urine, vomitus or feces practice. pose risk only if there is visible blood. 5.2.7 Other Exposures Transmission is more likely to occur in •Exposures to urine, saliva, sweat and tears the occupational setting when: do not pose a risk for HIV infection –Deep parenteral inoculation via a unless the fluid contains visible blood. blood contaminated hollow-bore •Routine social or community contact needle occurs. with an HIV-infected person carries no –A source has a high viral load, such as risk of transmission. Intact skin protects in recent seroconversion or advanced against infection. HIV disease occurs. 5.3 Surveillance –Parenteral inoculation of materials containing a high viral load in a NOTE: Case numbers and their respective laboratory setting. exposure categories, as well as trends, should be interpreted with caution owing to under-diagnosis •Occupational exposures of lesser risk are of cases, underreporting and incomplete reporting those with a small volume, solid bore of anonymous testing, delays in diagnosis and needle, and blood to mucous membrane reporting and the possibility of dual reporting. In or non-intact skin. Risk may be increased addition, the proportion of individuals from in the latter if the volume of blood is particular exposure categories that come forward for large or the exposure prolonged. See testing may differ. Manitoba Health’s Integrated Post- Exposure Protocol for HIV, HBV and 5.3.1 Global HCV: Guidelines for Managing Exposures • The World Health Organization (WHO) to Blood/Body Fluids and the Joint United Nations Programme (www.gov.mb.ca/health/publichealth/cdc/protocol/hiv_postexp.pdf). on HIV/AIDS (UNAIDS) estimated that The Winnipeg Regional Health globally 33.4 million people were living Authority’s Post-Exposure Prophylaxis with HIV by the end of 2008, with 2.7 Protocol (form W-00016) and Exposed million newly infected people in 2008. Worker Package (form W-00019) are WHO/UNAIDS estimated that available through the Health Sciences approximately 2.0 million deaths were Centre print shop at (204) 787-3555. attributable to HIV/AIDS in 2008. Sub- • The risk that tissues and fluids from an Saharan Africa accounts for 71% of all HIV- infected cadaver pose for handling new HIV infections in 2008. providers is extremely small. The use of 5.3.2 Canada appropriate infection control practices (see Infection Control Guidelines •A total of 67,442 HIV-positive cases have Prevention and Control of Occupational been reported to the Public Health Infections in Health Care CCDR 2002; Agency of Canada (PHAC) from 1985 28S1: 1-276 and Routine Practices and (when reporting began) to December 31, Additional Precautions for Preventing the 2008 (11). The number of positive tests Transmission of Infection in Health Care reported to PHAC in 2008 was 2,623, a CCDR 1999; Vol. 25S4) will help to seven per cent increase from 2007 (11).

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Among adults (15 years of age and older) common mode of transmission for in 2008 with reported gender Aboriginals in Manitoba was heterosexual information, 26.2 per cent of all positive activity with person(s) at increased risk of tests were among females. Surveillance HIV (7). Between 1985 and the end of data over time indicates a decreasing 1995, the majority of individuals who proportion of positive test reports among tested positive for HIV in Manitoba younger adults (15-39 years) and an reported as MSM (13). Since 1995, increasing proportion among older adults injection drug use, travel from an HIV (40 years and over) (11). From November endemic country, and male-female sexual 1, 1985 to December 31, 2008, partnering have emerged as significant approximately 0.8 per cent of reported risk factors. The two most likely modes of HIV-positive cases were in children (11). HIV transmission in Manitoba are Where the exposure category is known, unprotected sexual activity and men who have sex with men (MSM) recreational injection drug use. continues to comprise the greatest • AIDS and AIDS-related deaths have been number of new infections (12). The reportable by physicians in Manitoba heterosexual exposure category is since 1985. In 2008, six new cases of increasing in number and proportion of AIDS were reported in Manitoba; the positive HIV tests, surpassing IDU as the total number of AIDS cases reported second largest exposure category (3). The from 1985-2008 is 275 cases (7). major exposure category for children was Seventy-four per cent of individuals perinatal transmission. Aboriginals reported with AIDS have died (7). continue to be over-represented in the Because of delays in the reporting of HIV epidemic in Canada (12). AIDS cases, the number of reported Approximately 27 per cent of people AIDS cases and AIDS-associated deaths living with HIV infection in Canada are may not always reflect the true number of unaware of their HIV status. These cases or deaths. individuals represent the “hidden epidemic” (12). 5.4 Incubation Period 5.3.3 Manitoba For the purposes of this protocol, the incubation • The number of HIV-positive cases period refers to the time period from the date of reported in Manitoba since reporting infection with HIV to the onset of symptoms of began (January 1, 1985) to December 31, AIDS. The window period refers to the time period 2008 is 1,547 cases (7). Of these, 89 were from the date of infection with HIV to the reported in 2008. While females represent development of detectable antibody to HIV. The 25 per cent of all HIV cases reported mean incubation period in some infected children since 1985, comparing the 1985-1995 may be shorter than in adults (1). Without time period to the 1996-2008 time treatment, progression to AIDS is highly variable period, the proportion of newly diagnosed taking between less than one year and 15 years or HIV cases that are female has almost longer (1). Appropriate treatment delays quadrupled (7). In 2008, 40 per cent of progression to AIDS (3). newly diagnosed cases of HIV were self- reported as Aboriginal (7). In Manitoba, 5.5 Period of Communicability Aboriginal people appear to be 10 times While the period of communicability is not known more likely than non-Aboriginals to precisely, it begins early after onset of HIV infection contract HIV (13). In 2008, the most and presumably extends throughout life (1).

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Transmissibility may increase at the onset of •Suggesting to the client that they have infection (with or without symptoms), during someone accompany them to receive the periods of high viral load, worsening clinical status results. and in the presence of other STIs (1). See Appendix B: HIV Pre-test Counselling Guide. 5.6 Susceptibility and Resistance NOTE: Where the testing is being conducted Susceptibility to HIV infection is presumed to be pursuant to an order issued under The Testing of universal. Race, gender and pregnancy status do not Bodily Fluids and Disclosures Act (see appear to affect susceptibility to HIV infection or http://web2.gov.mb.ca/laws/statutes/2008/c01908e.php AIDS. The presence of other STIs, especially genital for more information), it is acknowledged that there ulcers, increases susceptibility (1). Males who are may be no opportunity for sharing the information in uncircumcised are also at increased risk (1, 14). Section 6.1 and Appendix B with the client (Source6) prior to the blood being drawn. The client served with 6. Testing, Diagnosis and an order to submit to testing will be encouraged to seek medical advice as soon as reasonably possible after Interpretation receiving the order and before attending to having the blood drawn. If that is not possible, the Source will be 6.1 Pre-test Counselling encouraged to seek medical advice after having the Pre-test client counselling should be performed prior blood drawn for testing. to HIV testing and will usually include: • explaining the indications for testing as 6.2 Testing Options well as the testing options and procedures; Three HIV testing options are available in Manitoba. It is strongly recommended that health practitioners • indicating that test results will be available discuss the options available to a patient/client before three weeks after the blood is drawn; proceeding with HIV testing. Nominal and non- • discussing consent, reporting and nominal HIV testing should be available at all confidentiality issues such as who will see hospitals, medical clinics and nursing stations. the results and how the paperwork is Anonymous testing will be available at selected sites filed; only. Contact Health Links-Info Sante at 788-8200 or 1-888-315-9257 or the AIDS/STI Information • discussing legal obligations if test result is Line at 945-2437 or 1-800-782-2437 for availability positive (Public Health reporting, of anonymous testing sites. notification of contacts); Anonymous HIV testing is not recommended for • communicating harm and risk reduction prenatal testing as it is not linked directly to care strategies; and pregnant women with HIV infection require •providing pamphlets, condoms, needles, treatment. Non-nominal prenatal HIV testing is etc., where applicable; available if requested by the client. The current prenatal testing practice in Manitoba includes • assessing for stressors, coping skills and , HIV, rubella and syphilis testing unless supports while the client is waiting for the client decides to opt-out7 from results;

• ensuring that the client is linked to 6 The individual whose body the potentially infected resources such as counselling and social blood and/or body fluid originated from. supports during this stressful time. For more information on resources, contact 7 Opt-out: Performing HIV testing after notifying the Nine Circles Community Health Centre patient that 1) the test will be performed and 2) the patient may elect to decline or defer testing. Assent is AIDS/STI Information Line at 945-2437. inferred unless the patient declines testing (15).

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HIV testing. The opt-out option must be clearly by that physician to the Source. If there is no indicated on the appropriate lab requisition if the physician identified by the Source and/or the pregnant client declines HIV testing. Exposed, the test results will be disclosed to the Medical Officer of Health for the region in which Other situations where anonymous HIV testing is the Exposed resides. The Medical Officer of Health not suitable include occupational exposures, will then be responsible for ensuring appropriate refugee/immigration applications, testing for communication of the test results of the Source to insurance purposes, starting HIV treatment, etc. the Source and/or Exposed. Post-test counselling Point-of-Care (POC) HIV testing (both nominal will be done; however, no other personal health and non-nominal) is available at selected sites in information will be disclosed. Manitoba. POC testing refers to an HIV test Health professionals must verify that the performed outside a designated laboratory (e.g., in information on the lab requisition and HIV Case a physician’s office). In Manitoba, POC testing Investigation Form is accurate for epidemiologic involves using a rapid HIV test kit (using purposes. This will facilitate monitoring trends in fingerstick blood, serum, EDTA plasma or EDTA the occurrence of HIV infection in Manitoba, and whole blood) that can provide a preliminary HIV will direct programs and policies. In the case of serostatus result in less than 30 minutes. All non-nominal testing, verify that the unique preliminary reactive results obtained by POC identifier is correct as it is the most reliable means testing will require confirmatory testing at Cadham of distinguishing HIV-positive individuals from Provincial Laboratory (CPL) by standard HIV each other. Use the same patient code for any HIV laboratory testing methods (i.e., venous blood follow-up tests. For anonymous testing, the only sample sent to CPL). Contact Health Links-Info epidemiological information collected is the Santé at 788-8200 or 1-888-315-9257 or the information provided on the lab requisition. AIDS/STI Information Line at 945-2437 or 1-800-782-2437 for POC testing sites. Cadham Provincial Laboratory (CPL) uses an ELISA on serum to detect to HIV as the initial In any HIV testing situation, except where the screening test. Test results may not be available for testing is being done pursuant to an order issued up to three weeks after the blood is drawn if under The Testing of Bodily Fluids and Disclosure confirmation or additional testing is required. Act, informed consent must be obtained prior to testing. Consent may be given verbally rather than Practitioners are responsible for communicating test in writing, but this should be documented. Clients results to the patient/client for nominal and non- should receive pre-test counselling (see Section 6.1 nominal testing. In anonymous testing situations, and Appendix B: HIV Pre-test Counselling Guide) the client is responsible to return to receive test prior to testing and post-test counselling (see results as the testing site has no contact information Section 7.1.2 under Case Management and for the client. Appendix C: HIV Post-test Counselling Guide). 6.3 Test Results for Adults and Children In any HIV testing situation, confidentiality must be maintained to the extent possible. Where the Over 18 Months of Age testing was done pursuant to an order issued under 6.3.1 Positive Test Results The Testing of Bodily Fluids and Disclosure Act, the All positive ELISA test results are confirmed by test results of the Source will be disclosed to the western blot. A positive western blot with an initial 8 physician identified by the applicant (Exposed ) positive screening test is consistent with HIV who obtained the order and will be communicated infection. by that physician to the Exposed. The test results of the Source will also be disclosed to the physician identified by the Source and will be communicated 8 The individual who comes into contact with the potentially infected blood/body fluid.

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6.3.2 Negative Test Results antibody test result. An indeterminate A negative western blot confirmatory test is HIV antibody test combined with a interpreted as no HIV antibody detected even if the positive p24 antigen result in an initial ELISA was reactive. immunocompetent individual may be an indication of early infection. In such NOTE: Although most individuals infected with situations, it is recommended that a HIV develop detectable antibodies within two second blood sample be submitted for weeks to three months after infection (i.e., time HIV antibody testing two to three weeks from infection to development of antibody), there after the original blood sample was taken, may be a more prolonged window period in some to confirm seroconversion. persons. HIV infection may be detected during this period prior to seroconversion by nucleic acid •If the p24 antigen test is negative, the testing (NAT). NAT or p24 antigen testing should patient/client should be retested for HIV be requested for individuals who have antibody as stated above for an mononucleosis-like symptoms consistent with indeterminate antibody test result. seroconversion illness. It is recommended that a patient/client with an indeterminate antibody test result who has a 6.3.3 Indeterminate Test Results suspect seroconversion illness OR risk factors (see An indeterminate result in the western blot cannot Section 5.2 Transmission) for HIV be reassessed be interpreted as either positive or negative and and provirus testing completed. Prior arrangement requires further evaluation based on patient risk. with CPL is required for provirus testing. •A patient/client with an indeterminate •Retesting for HIV antibody is advised HIV antibody test result should be with a positive provirus test to prove the retested in six months. seroconversion. Retesting for HIV •If the second antibody test is antibody will be most sensitive starting indeterminate, antibody testing should be four to six weeks after the implicated high repeated again at 12 months from the risk exposure. Retesting before this time date of the first test. period (window period) may result in false negative/indeterminate results. •If the result is still indeterminate at retesting 12 months after the initial •If the provirus test is negative, the antibody test, in the absence of mitigating patient/client should be retested for HIV factors such as immunocompromise or antibody as stated above for an significant HIV risk factors, the person indeterminate antibody test result. should be considered HIV negative. Consultation with an HIV care specialist 6.4 Test Results for Children 18 Months will likely be warranted. of Age and Under •Recognizing that many patients, 6.4.1 Positive Serologic Test Results regardless of their risk factors for HIV All positive ELISA test results are confirmed by infection, may not be satisfied with these western blot. A positive western blot with an initial long periods between tests, all positive screening test may mean that the child’s indeterminate HIV antibody test results mother was infected and may or may not have are further investigated by testing for p24 transmitted the infection to her child OR that the antigen. child’s infection was acquired postnatally from • The p24 antigen test result will be another source. Therefore ANY child with a reported with the indeterminate HIV positive antibody test requires HIV DNA or RNA nucleic acid testing (NAT) (see Section 6.4.4).

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Consultation with CPL and a pediatric HIV is uninfected. Children found to be specialist are recommended if the diagnosis of HIV uninfected by this method should also infection in infancy is suspected. Consultation can have antibody testing between 12 and 18 be arranged through the Children’s Hospital months of age to confirm seroreversion. Infectious Diseases Clinic at 204-789-3619. •Due to the special circumstances and rare 6.4.2 Negative Serologic Test Results nature of this infection, investigation in Manitoba is best conducted through the A negative western blot confirmatory test is Children’s Hospital Infectious Diseases interpreted as no HIV infection even if the initial Clinic (204-789-3619). ELISA was reactive. NOTE: Although most individuals infected with 7.0 Control HIV develop detectable antibodies within two weeks to three months after infection (i.e., time from 7.1 Case Management infection to development of antibody), there may be Public health professionals play an important role a more prolonged window period in some persons. in educating physicians, other health care HIV infection may be detected during this window professionals and patients about: period prior to seroconversion by NAT (see Section 6.4.4). Nucleic acid testing may be necessary for •HIV/AIDS individuals who have mononucleosis-like symptoms • local/regional/provincial resources and consistent with seroconversion illness. supports available 6.4.3 Indeterminate Serologic Test Results • the role of Public Health An indeterminate antibody test result (western blot) •interviewing and post-test counselling cannot be interpreted as either positive or negative and requires further evaluation. The child should • confidential notification of contacts be retested for antibody in six months. • medical follow-up with a physician NOTE: Children lose maternal antibody over a specializing in HIV care variable period of time. Most children lose antibody • advising patients that all Public Health between 15 and 18 months of age. services are strictly confidential 6.4.4 Nucleic Acid Test (NAT) Results • advice regarding legal and ethical issues • Children exposed at birth who acquire concerning the disclosure of HIV status HIV may have no HIV DNA or RNA • assistance to locate the client if the detected by NAT within the first few practitioner/physician has been unable to weeks of life or while on post-exposure do so prophylaxis (PEP). Therefore, HIV DNA or RNA nucleic acid testing is performed 7.1.1 Key Investigations for children born to HIV-positive • Confirm and document that the mothers using a series of three tests, with patient/client has received HIV pre-test the first test conducted at approximately counselling. two weeks of age and the series of tests completed by two-and-a-half months of •Determine whether or not the patient/ age. client has been interviewed for partners. • The purpose of nucleic acid testing is to •Determine how the patient/client plans to identify infected children as soon as notify partners (Public Health, possible and reliably determine if a child practitioner or case initiated).

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•Discuss who will do the post-test •Immunization should be recommended counselling. All HIV-positive persons according to current guidelines (3, 16). should be counselled regarding notifying Generally, there is no contraindication to current and past sex or IDU equipment the use of inactivated or component sharing contacts of their exposure to HIV, vaccines in HIV-positive persons (3, 17). and of the importance of taking The efficacy and safety of the human appropriate precautions with future papillomavirus (HPV) in HIV- contacts. Counselling should also be infected individuals are currently provided concerning legal and ethical unknown (18). issues around disclosure of HIV status to •Offer assistance where necessary to link future partners. the case with resources and supports such •Discuss with the practitioner/physician the as: HIV care and treatment services (HIV role of the Public Health nurse (PHN) in Intake Referral Line 204-940-6089 or counselling, interviewing the person and 866-449-0165), financial and housing providing contact notification. If not assistance, home care, mental health already interviewed, or the interview was supports, and addictions services. not completed, request that the Encourage consultation for assistance in practitioner/physician inform the person of the care of HIV-infected children. the option of being counselled, educated •Recommend testing for: and interviewed by the PHN, and having contacts notified by Public Health. – hepatitis B and C 7.1.2 Post-test Counselling – syphilis While the following post-test counselling –gonorrhea recommendations are directed at the management –chlamydia of HIV-positive clients, post-test counselling services are also available to clients with negative or – cervical dysplasia (HPV) indeterminate test results. See Appendix C: HIV –Cytomegalovirus (CMV) Post-test Counselling Guide. Post-test counselling is a process that is usually achieved in one to six –toxoplasmosis sessions. •Individuals that have tested HIV-positive • Cases should be instructed on precautions should also be screened for tuberculosis to take that will reduce the risk of infection. transmission to current and future sex and •HIV Disclosure – Patients/clients who IDU contacts. The case should begin to test HIV-positive should be informed of use precautions immediately to prevent their obligation to notify all current and transmission and these precautions should future sexual and/or injection equipment- continue indefinitely. sharing partners of their HIV status. •Discuss who will manage the person’s Failing to do so may, in certain medical follow-up. Initial discussions circumstances result in the infected should emphasize counselling, person being charged with a criminal behavioural changes, life adjustments, and offence. HIV-positive individuals, who next steps in medical care and follow-up. fail to disclose their HIV status and/or take appropriate precautions, thereby • Care of the HIV-infected person is continuing to place themselves and others complex and cases should be referred to a at risk for infection, will require special physician specializing in HIV care.

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attention and support. Support is often antiretroviral therapy should be under the achieved through the collaborative efforts direction of a physician specializing in of the attending health practitioners and HIV care. other mental health, family and community agencies. Health practitioners 7.2 Contact Management are referred to The Public Health Agency A “contact” is defined as someone who has been of Canada publication Persons who Fail to exposed, through blood or mucosal exposure, to the Disclose their HIV/AIDS Status: infected blood, , semen or vaginal Conclusions Reached by an Expert secretions or certain other body fluids Working Group (CCDR 2005; 31(5): 53- (cerebrospinal fluid, synovial fluid, pleural fluid, 61). pericardial fluid, amniotic fluid and peritoneal •Verify whether the individual has fluid) of someone that has tested HIV-positive symptoms of or meets the definition of (“index case”). This definition includes sexual and living with AIDS. IDU equipment sharing partners, vertical transmission (in utero, intra-partum, postnatally 7.1.3 Perinatal Case Management and through breastfeeding) from mother to • HIV-positive pregnant women should be child/fetus or occupational exposure. referred to a physician specializing in HIV 7.2.1 Contact Notification care as early as possible in pregnancy, or in labour if not yet being treated. •Notification of contacts regarding their HIV exposure may be Public Health •Pregnant women who are HIV-positive initiated, practitioner/physician initiated should receive antiretroviral therapy or case initiated. Public Health should prenatally and during labour and delivery. ensure that a plan is in place for contact Infants should receive post-partum notification, using at a minimum, one of antiretroviral therapy. All antiretroviral these approaches. therapy undertaken should be under the direction of a physician specializing in •It is preferable that the client agrees to the HIV care. involvement of Public Health and/or practitioners in contact notification. •Pregnant women who are HIV-positive However, if it is believed that there is a should be counselled that in selected significant exposure risk to the contact women, Caesarian section will reduce risk and the client will not inform the contact of transmission to infants. directly, then the case’s practitioner and/or •Breastfeeding is contraindicated for Public Health should inform a contact infants born to HIV-positive women in without obtaining consent from the HIV- Canada. Transmission to the infant positive client. through breastfeeding has been well • All health care practitioners have the legal documented. Safe, culturally accepted and ethical responsibility to assure the replacement feeding is available (8-10). confidentiality of cases and contacts to the •For infants born to HIV-positive mothers extent possible; to ensure that there is a who have not taken antiretroviral plan in place to advise the contacts of prophylaxis, perinatal transmission can their risk for infection; and to assist still be significantly reduced by starting contacts in accessing medical attention if antiretroviral treatment as soon as possible they desire. after birth, preferably within six hours (maximum 48-72 hours) after birth. All

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• Contact notification should generally • The information for each contact must be include sexual and/or injection recorded on a separate Manitoba Health equipment-sharing partners with whom HIV Contact Notification Form and all the client has had contact within the year of the information for each contact must prior to the client’s first HIV-positive be submitted to Manitoba Health as soon laboratory report. If the exposure has as possible for surveillance and public been within three months of the client’s health referral purposes. first positive HIV serology, and the • All of the information for each contact contact has a negative serology test, the will be referred by Manitoba Health to testing of the contact should be repeated the health jurisdiction in which the at least three months after the last contact resides. exposure. Although the recommended interview period is generally not more •Testing of contacts for HIV antibody than one year, there may be situations should be performed as soon as possible. where more distant contact identification and notification may be required 7.2.2 Contact Notification Options depending on the period of infectivity, the 7.2.2.1 Public Health Initiated Contact significance of the exposure, the feasibility Notification of notification and a prioritization of contacts at risk. With this option of contact notification, Regional Public Health notifies the contact(s) of the HIV- Any practitioner involved in contact notification positive client. The region will attempt to notify should use the interaction as an opportunity to contacts within four weeks of receiving the referral educate contacts regarding their activities placing from Manitoba Health. The HIV- positive client them at risk for HIV and to identify strategies for will provide contacts’ names and their locating reducing those risks. The following topics should information to a health professional. The identity be discussed with contacts: of the HIV-positive client will not be disclosed to •Signs and symptoms of HIV infection his/her contacts. •Transmission of HIV 7.2.2.2 Practitioner/Physician Initiated Contact Notification •Prevention and harm reduction The practitioner will notify the contact(s) of the •Pregnancy-related issues HIV-positive client. The HIV-positive client will •Other STIs provide contact names/identifiers and locating information to the practitioner who ordered the • Legal issues concerning disclosure of HIV testing. The practitioner will attempt to notify HIV risk status contacts regarding their exposure to HIV, once •Availability of testing services (including contact information is obtained. It is recommended testing options) that the practitioner notify the contact within four weeks of obtaining contact locating information. • Confidentiality Alternatively, the practitioner can defer contact Regardless of which of the three contact notification to Public Health. The identity of the notification options is chosen: HIV-positive client will not be disclosed to his/her • HIV-positive clients/patients must be contacts. advised that pertinent information about their contacts will be confidentially forwarded to Manitoba Health.

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7.2.2.3 Case Initiated Contact Notification • The attending practitioner/physician must be contacted by regional Public This is a strategy through which the HIV-positive Health authorities and collaboration client commits to notify his/her contacts regarding sought in identifying the infant and their possible exposure to HIV. The health care family. practitioner should consult with Public Health to agree on a process to confirm that the contact(s) • All infants born to HIV-positive mothers were notified by the case and to discuss any should be referred to a pediatric HIV additional follow-up required. specialist for appropriate follow-up antibody and NAT testing. Positive test The health care practitioner should ensure the case results will be referred to the appropriate is aware of the information that needs to be jurisdiction. communicated to their contacts. The minimum requirement for the HIV-positive client is to inform 7.3 Prevention contacts of their exposure to HIV, their need for HIV testing (either through their own health care •Specific preventive measures should be provider or Public Health) and their need to aimed at vulnerable populations such as contact their own health care provider for follow- individuals engaging in activities that up. The health care practitioner should negotiate a carry a high risk for HIV transmission time period with the HIV-positive client (up to and communities with high HIV four weeks) within which the index case will inform seroprevalence. General population-based their contacts. If the contacts have not been prevention messaging should also occur. notified of their exposure to HIV after the agreed- • HIV counselling and testing should be upon time period, either the practitioner or Public routinely offered to: Health should intervene as determined during the initial consultation process. – all STI cases and their contacts – individuals with tuberculosis 7.2.3 Infant Contact – individuals attending addictions • Children born to a woman known to be treatment programs HIV-positive at time of delivery should be – individuals sharing injection drug- tested for HIV (refer to Section 6 for using equipment testing information). If the mother’s date of seroconversion is unknown, all her – individuals sharing inhalation drug- children should be assessed and use equipment that may cause burns considered for HIV testing. Women (e.g., glass or metal pipes) should be informed that the lack of signs – individuals seeking prenatal care, and symptoms suggestive of HIV family planning or reproductive infection in older children does not services exclude HIV infection. Some perinatally – individuals in correctional facilities infected children can remain –all individuals presenting with an asymptomatic for several years. AIDS-defining illness •To ensure that infants at risk receive 7.3.1 Prevention of Transmission Through appropriate care, Manitoba Health will Blood, Tissues and Organs refer all infants testing positive for HIV antibody to regional Public Health • All donations of blood, tissues and organs authorities, even though this result may are tested for HIV; only donations testing result from maternal antibody transfer negative are used. and not infant infection.

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•Infection Control Routine Practices • The cells of the endocervix in young should be in place for: women are more exposed (cervical ectopy) and allow more efficient – the handling, use and disposal of transmission of HIV (19). Delayed sexual needles or other sharp instruments debut may help to prevent infection. – cleaning of blood, body fluids and •Based on evidence from randomized spills controlled trials, WHO and UNAIDS – direct patient care activities recommend that male circumcision now •Avoid sharing inhalation drug equipment be recognized as an additional important that may cause burns or cracked lips (e.g., intervention to reduce the risk of metal pipes). heterosexually-acquired HIV infection in men in developing countries (20). • HIV post-exposure prophylaxis is available for persons who have experienced an •Public and school health education exposure of concern to blood or body should focus on information, motivation, fluids. The process for determining and behavioural skills for sexual health eligibility for prophylaxis is contained in education. Effective programs have been Manitoba Health’s Integrated Post-Exposure characterized as those that: Protocol for HIV, HBV and HCV: – use social learning theories for Guidelines for Managing Exposures to Blood program development and Body Fluids, available at: – focus on reducing sexual risk-taking www.gov.mb.ca/health/publichealth/cdc/protocol/hiv_postexp.pdf behaviours that may lead to HIV 7.3.2 Prevention of Sexual Transmission infection or STIs, or to unintended •Abstention from oral, vaginal and anal sexual relations is the only certain way of –provide accurate, basic information preventing the sexual transmission of HIV. about the risks of and methods for avoiding unprotected intercourse •Engaging in mutually exclusive sexual – address social and media influences on relations when both persons are known sexual behaviours not to be infected is the next surest way to prevent sexual transmission. – model and practice communication and negotiation skills • Consistent and proper use of male and/or – address factors that interfere with female condoms for anal, vaginal and oral harm reduction efforts such as sex significantly reduces the risk of sexual substance use and mental health transmission of HIV. Oil-based lubricants damage latex condom integrity and 7.3.3 Prevention of Transmission Through should not be used. Water-based Injection Drug Use lubricants should be used instead. •Abstention from IDU is the only certain • There is insufficient evidence to suggest way of preventing transmission of HIV that other proposed harm reduction through IDU. strategies are effective in reducing •Use of a new needle, syringe, and all other transmission risk. injection drug-using equipment (e.g., •Routine use of products containing filters, water, spoon) for each injection nonoxynol-9 should be avoided. significantly reduces the risk of IDU transmission.

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•Harm reduction activities such as needle 8.2 Immigration Considerations exchange, access to drug using equipment HIV testing as part of a Citizenship and that reduces risk of HIV infection and Immigration Canada application is required for: safe injection sites may help to reduce HIV transmission within injection drug • applicants 15 years of age and older; using populations. These activities also • children who have received blood or provide opportunities for further blood products; connections to health services. • children who have a known HIV-positive 7.3.4 Prevention of Mother-to-Child mother; and Transmission • all potential adoptees where a risk factor is •Prenatal HIV antibody screening is identified. recommended for all pregnant women. An ELISA HIV screening test is performed for •In high-risk populations (i.e., individuals HIV 1 and HIV 2. Positive ELISA results are with multiple partners, and/or concurrent confirmed with HIV western blot. It is important genital infections), repeat screening in the to provide applicants having an HIV test with HIV third trimester is recommended for pre-test counselling. pregnant women who initially tested HIV-negative (15, 21). Applicants Who Test Positive for HIV •Appropriate prophylactic antiretroviral •Ensure that applicants who have tested therapy for HIV-infected pregnant positive for HIV receive post-test women. counselling and sign the acknowledgement of HIV post-test •Elective Caesarean delivery for selected counselling form. women. • All HIV-positive migrants granted entry •Avoidance of breastfeeding by HIV- into Canada will receive a Health Follow- infected mothers. up Handout: HIV Infection to assist them •Initiation of antiretroviral therapy in in obtaining medical care in Canada. infants born to HIV-infected mothers as • As of June 2005, CIC refers the names of soon as possible after birth. those individuals identified as having an HIV positive test result (tested outside of 8.0 Other Considerations Canada) to Manitoba Health. Manitoba Health then refers these individuals to the 8.1 Travel Considerations appropriate health authority for case •Pre-travel planning is recommended for management. HIV-infected travelers. Individuals should •It is recommended that repeat HIV consult with their health care providers antibody testing be offered utilizing local and/or a travel medicine specialist at least laboratory services. four to six weeks prior to departure. •Further information on HIV testing •Health care providers should be aware of issues is located in Section 11 of country-specific policies that restrict entry Citizenship and Immigration Canada’s of HIV-infected travelers. Updated Handbook for Designated Medical information for all international travelers Practitioners 2009. is available on the following website: www.cdc.gov/travel

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9.0 Additional Resources •Manitoba Health. Manitoba’s Provincial AIDS Strategy. 9.1 For the Public www.gov.mb.ca/health/aids/strategy.pdf Information on clinics in Manitoba that offer HIV Resources are also available from Manitoba Health, testing and counselling may be obtained by Audiovisual and Publications Department, contacting the following organizations. (204) 945-3000 (fax: (204) 772-7213) •Health Links-Info Santé In Winnipeg, phone: 788-8200 10.0 References Outside Winnipeg: 1-888-315-9257 1. Heymann David L. Acquired •AIDS/STI Information Immunodeficiency Syndrome. In: Control of Nine Circles Community Health Centre Communicable Diseases Manual 19th ed., (NCCHC) American Public Health Association, In Winnipeg, phone: 945-2437, Washington, 2008: 1-9. Fax: 940-6027 2. Cleghorn FR, Reitz Jr MS, Popovic M, Gallo Outside Winnipeg: 1-800-782-2437 RC. Human Immunodeficiency Viruses. In: •Facts of LIFE Line Mandell GL, Bennell JE, Dolin R eds. Sexuality Education Resource Centre Principles and Practice of infectious diseases 6th (SERC) ed. Elsevier, Philadelphia, 2005: 2119-2133. Winnipeg, Phone: 947-9222 or 3. Public Health Agency of Canada. Canadian 982-7800, Guidelines on Sexually Transmitted Infections Fax: 982-7819, e-mail: [email protected] 2006 Edition. Available at: Brandon, MB Phone: (204) 727-0417, www.phac-aspc.gc.ca/std-mts/sti-its/index-eng.php Fax: (204) 729-8364, 4. Schacker T, Collier AC, Hughes J et al. Clinical e-mail: [email protected] and Epidemiologic Features of Primary HIV Website: www.serc.mb.ca Infection. Annals of Internal Medicine 1996; 9.2 For Health Care Professionals 125 (4): 257-264. 5. American Academy of Pediatrics. Human • HIV Intake Referral Line: 204-940-6089 Immunodeficiency Virus Infection. In: or 866-449-0165 Pickering LK ed. Redbook: 2009 Report of the •Manitoba Health (2009). Integrated Post- Committee on Infectious Diseases. 28th ed. Elk Exposure Protocol for HIV, HBV and GroveVillage, IL: American Academy of HCV: Guidelines for Managing Exposures Pediatrics, 2009: 380-400. to Blood and Body Fluids. 6. Canadian AIDS Society, HIV Transmission: www.gov.mb.ca/health/publichealth/cdc/protocol/hiv_postexp.pdf Guidelines for Assessing Risk; A Resource for •Manitoba Health. Provincial Sexually Educators, Counsellors and Health Care Transmitted Diseases Control Strategy Providers, Fifth Edition, Canadian AIDS (August 2001). Available at: Society, 2005. ISBN 0-921906-04-8 www.gov.mb.ca/health/publichealth/cdc/std_strategy.pdf 7. Manitoba Health. Manitoba Health Statistical •Manitoba Health (March 2005). The Update on HIV (in draft): January 1985- Descriptive Epidemiology of Sexually December 31, 2008. Transmitted Infections and Blood-borne Pathogens in Manitoba: 2002-2003. Available at: www.gov.mb.ca/health/publichealth/cdc/surveillance/desti.pdf

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8. Infectious Diseases and Immunization 17. British HIV Association Immunisation Committee, Canadian Paediatric Society. Subcommittee. Immunisation Guidelines for Maternal Infectious Diseases, Antimicrobial HIV-infected Adults, First edition April 2006. Therapy or Immunizations: Very few Available at: www.bhiva.org/ Contraindications to Breastfeeding, 2006. 18. World Health Organization. Preparing for the Available at: Introduction of HPV Vaccines: Policy and www.cps.ca/English/statements/ID/PIDnote_Oct2006.htm Program Guidance for Countries 2006. 9. Bulterys M, Fowler MG, Van Rompay KK and Available at: Kourtis AP. Prevention of Mother-to-Child www.who.int/reproductivehealth/publications/cancers/RHR_06.11/en/index.html Transmission of HIV-1 Through Breast- 19. HIV Insite, University of California, Feeding: Past, Present and Future. The Journal SanFrancisco. Women and HIV. March, 2004. of Infectious Diseases 2004; 189: 2149-53. 20. World Health Organization. WHO and 10. The Breastfeeding and HIV International UNAIDS Announce Recommendations from Transmission Study Group. Late Postnatal Expert Consultation on Male Circumcision for Transmission of HIV-1 in Breast-Fed Children: HIV Prevention. Press release March 28, 2007. An Individual Patient Data Meta-Analysis. The Available at: Journal of Infectious Diseases 2004; 189: 2154-66. www.who.int/mediacentre/news/releases/2007/pr10/en/index.html 11. Public Health Agency of Canada. HIV and 21. Struik S, Tudor-Williams Gareth, Taylor Graham AIDS in Canada. Surveillance Report to et al. Four Cases of Paediatric HIV Infection due December 31, 2008. to Seroconversion in Pregnancy: Should Partners 12. Public Health Agency of Canada. Estimates of be Tested and/or Repeat Third Trimester HIV HIV Prevalence and Incidence in Canada, Screening be Recommended? (P68) Abstracts of 2005. Canada Communicable Disease Report the 12th Annual Conference of the British HIV 2006; 32 (15): 165-174. Association Brighton, UK 29 March-1 April 13. Manitoba Health. As Long as the Waters Flow: 2006. Available at: www.bhiva.org/ An Aboriginal Strategy on HIV/AIDS (October 10.1 Article 2004). Available at: www.gov.mb.ca/health/aids/waters.pdf Quinn T.C. and Spacek L.A., International Travel: Recommendations for the HIV Infected Patient, 14. Weiss HA, Quigley MA and Hayes RJ. Male Current Infectious Disease Reports 2004, 6: 399- Circumcision and Risk of HIV Infection in 403 Current Science Inc. ISSN 1523-3847 Sub-Saharan Africa: A Systematic Review and Meta-Analysis. AIDS 2000; 14 (15): 2361-70. 10.2 Publications 15. Centers for Disease Control and Prevention. Infectious Diseases and Immunization Committee, Revised Recommendations for HIV Testing of Canadian Paediatric Society and The Committee on Adults, Adolescents, and Pregnant Women in Pediatric AIDS, The American Academy of Health-Care Settings. Morbidity and Mortality Pediatrics. Evaluation and treatment of the human Weekly Report MMWR 2006; 55 (No. RR-14): immunodeficiency virus-1-exposed infant (ID 2004- 1-17. 2). Paediatric Child Health 9: 409-417, 2004. 16. Public Health Agency of Canada. Canadian Citizenship and Immigration Canada. Handbook for Immunization Guide 7th ed. Public Works and Designated Medical Practitioners 2009. Government Services Canada. Ottawa, Ontario 2006.

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Case Reporting and Referral Flow Chart

Client chooses to be tested for HIV

Nominal Testing Anonymous Testing Non-Nominal Testing

Confirmed positive lab result Confirmed positive lab result Confirmed positive lab is reported to Manitoba Health, result is reported to is reported to Manitoba Health, Public Health Surveillance Unit Public Health Surveillance Unit Manitoba Health, for statistical program Public Health Surveillance Unit evaluation purposes only

Manitoba Health reports the positive result to the client’s health region of residence thus initiating case investigation

Either regional public health or the testing physician reports the results of case investigation, including contacts, to Manitoba Health

Manitoba Health reports the contact information to the contact’s RHA for further public health follow-up (e.g., education and testing)

Contact Report and Referral Protocol Flowchart

HIV Case Contact Nominal, non-nominal or anonymous Case identifies on HIV Contact Notification Form Filled by MD/RN or PHN

Send to Manitoba Health, Public Health Surveillance Unit

Surveillance Unit refers contact information to PH Unit in area of residence

PH Unit responsible for contact Counselling and testing of contact See contact management

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APPENDIX A: Levels of Risk (Source – Canadian AIDS Society)

Level of Risk Activity No Risk Kissing (no blood); non-insertive ; receiving unshared sex toys; contact with feces or urine (unbroken skin); injecting with unshared needles; using drugs with new pipe or straw; sadomasochistic activities (with universal precautions); tattooing, piercing, electrolysis and acupuncture with sterilized and new equipment; manicures or pedicures. Negligible Risk Receiving fellatio or cunnilingus; performing fellatio or cunnilingus with barrier; anilingus; fingering; fisting; using shared sex toys with a condom; using disinfected sex toys; sadomasochistic activities; contact with feces or urine (on broken skin); vulva-to-vulva rubbing; docking; taking breast milk into the mouth; using drugs with shared pipe or straw; tattooing, piercing, electrolysis and acupuncture with shared equipment; fighting; sharing toothbrushes and razors. Low Risk Kissing (with exchange of blood); performing fellatio or cunnilingus without barrier; intercourse (penile-anal or penile-vaginal) with barrier; injecting with cleaned needles; tattooing with non- professional equipment; taking blood in the mouth; occupational exposure. High Risk Penile-anal or penile-vaginal intercourse without condom; receiving shared sex toys; injecting with shared needles.

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Appendix B: HIV Pre-test Counselling Guide Purpose of the Counselling Session •Occupational exposure •Time to reflect on individual risk for HIV •Victim of sexual assault •Education regarding transmission/risk Suggestive Symptoms reduction/testing • Asymptomatic •Evaluate if this is a good time to be tested •Prolonged fever Confidentiality/Anonymity •Genital discharge •Testing process (see Testing Options below) •Lymphadenopathy •Use of anonymous code on lab requisition •Fatigue and file (for anonymous testing •Diarrhea situations) • Rash • Charting – storage of results •Physical findings (i.e., Kaposi’s) •Reporting mechanism – All positive HIV •Respiratory symptoms test results are reported to Manitoba Health •Unintentional weight loss • Contact notification for positive test results – contact information reported to •Night sweats Manitoba Health •Other Client’s Reason for Seeking HIV Test – Harm and Risk Reduction Strategies Identify Risk Factors •Review client’s current risk reduction •Pregnancy practices (i.e., sexual, IDU, tattooing) •Sex with men: Number of contacts/year • STI/HBV/HCV testing •Sex with women: Number of contacts/ •No sharing injection/tattooing supplies year (ink, water, cooker, filters) •Sex trade worker •Safer sex practices •Sex with HIV-positive person • Latex condoms •Sex with person at risk for HIV •Use of clean injection equipment •Sex with anonymous contact(s) (needles, syringes, etc.) •Sharing of needles or other injection Knowledge of HIV/AIDS equipment •Assess client’s knowledge of HIV/AIDS –For injection drug use (IDU) •Review HIV/AIDS information specific –For tattooing/piercing to the client’s self-identified risk factors •Recipient of blood/blood products •Basic HIV/AIDS information (i.e., harm •Emigrated from HIV-endemic country reduction practices and medical, psychological, social and legal •Offspring of HIV-positive mother implications)

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Previous HIV Test • The results are confidential and Date of Previous Test documented on the person’s medical chart as it is for any other medical tests. •Test Result: •Health practitioners are able to offer –Positive referrals for support and other services –Negative (nominally). –Indeterminate 3. Anonymous Testing (anonymous code) HIV Testing Procedure • The name of the person being tested is Explain the following: not documented. •Meaning of positive/negative/ • An anonymous code is given to each indeterminate results person being tested. • The presence/absence of antibodies and • The blood for the test is sent to the lab window period using the anonymous code. •Results are available in three weeks • An Anonymous HIV Testing Client Card with code must be presented to obtain Anonymous Testing Situations: The results are test results. only given in person upon presentation of the Anonymous HIV Testing Client Card. There is no •Health practitioners are able to offer possibility for the testing site to contact the person referral for support and other services with test results as contact information is not (nominally). available. • Anonymous test results will not be suitable for prenatal care, refugee/ Testing Options immigration application, occupational 1. Nominal Testing (name-based) exposure, insurance purposes and for starting HIV treatment. • The name of the person being tested is documented as it is for any other medical •It is the client’s responsibility to return for tests. test results as the testing site has no information with which to contact the • The blood for the test is sent to the lab client. using the person’s name. Please contact Health Links-Info Santé or the • The results are confidential and AIDS/STI Information Line for availability of documented on the person’s medical anonymous testing sites and services within chart. Manitoba. •Health practitioners are able to offer referrals for support and other services. 2. Non-nominal Testing (confidential code) • The person’s name is only known by the health practitioner doing the test. • The blood for the test is sent to the lab and identified by code.

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Considerations of HIV Testing •Able to make informed decisions prior to •Decreased anxiety of uncertain HIV a pregnancy to reduce risk of HIV status transmission to unborn child •Increased chance of early HIV detection/ •If pregnant, ability to seek health care and treatment reduce HIV transmission to unborn child •Decreased chance of transmission to •Referral to HIV Specialist others (if positive) •Referral to HIV Support Services • Client has to be tested non-nominally or •If client wishes to remain anonymous, nominally (or re-tested non-nominally or client cannot take advantage of nominally if originally tested services/care anonymously) to take advantage of services/care •Could provide an explanation of client’s current/past symptoms •In anonymous HIV testing situations, testing is client-initiated and client-owned •Decreases the risk of infection to others by prohibiting blood, body fluid, organ Considerations of a Negative or and tissue donation Indeterminate Test Result •Potential legal issues (i.e., HIV disclosure) •False sense of security if result is negative •Some insurance companies have used (i.e., seroconversion/window period) HIV-positive status to demand higher •If the test result is indeterminate, referral rates or deny health coverage for further testing and assessment will be •Potential travel/immigration restrictions required Assess Coping Methods and Social Supports Considerations of Receiving a Positive Test • Thoughts and possible response to a Result positive, negative or indeterminate test • Contact notification to inform partners of result their exposure to HIV (completed by •How the client has dealt with stressful Public Health, health practitioner or the situations in the past client) • Coping strategies, supports available, •Awareness of risk behaviours and harm suicide risk reduction strategies •Resources available in the community •Increase good health practices and prevention of other illnesses Provide Supplies • Early intervention decreases risk of •Pamphlets/information developing severe infections • Condoms, needles, filters, etc. where •Able to incorporate harm and risk applicable reduction strategies to reduce risk of HIV transmission

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Reporting of Test Results consent for HIV testing. The practitioner must • All positive test results will be reported to assess the adolescent’s ability to understand and Manitoba Health under the Reporting of appreciate the nature and consequences of being Diseases and Conditions Regulation of tested for HIV. Adolescents need to have the The Public Health Act. The information is maturity and intellectual capability to understand completely confidential in nominal and critical information about prospective treatment, non-nominal testing situations and and to be able to make important decisions about anonymous in anonymous testing future care (Downie, J. et al., 2002; Rozovsky, LE, situations. The information will be used Rozovsky, FA, 1990). for statistical and program planning Client Card and Phlebotomy (for services. anonymous testing only) Consent for Testing Date Phlebotomy Completed: It is essential that informed consent be obtained ______■ No ■ Yes from the client or their guardian prior to undergoing HIV testing. Pre-test counselling Date Anonymous HIV Testing Client Card Given: provides the opportunity for the client to make an ______■ No ■ Yes informed decision regarding HIV testing. In cases where language interpretation/ translation services Below is an example of an Anonymous HIV are required, the client needs to understand that Testing Client Card. Sites can adapt this card for his/her support person will be privy to confidential their own use or develop their own site-specific information that may be disclosed at the client card. counselling session(s). If the client is unable to comprehend simple explanations, or answer questions related to time, date and place, the practitioner should evaluate the capacity or maturity of the person to provide informed consent before performing HIV testing. In some circumstances, HIV testing may be refused or delayed until the client’s capacity and/or maturity has been reviewed. Adolescents under the legal age of majority (i.e., 18 years of age) who are sufficiently mature (the mature minor) may be able to provide informed PLEASE KEEP THIS CARD SAFE

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APPENDIX C: HIV Post-test Counselling Guide • This information may require more than Positive Result one session Step 1 – The Test Result •Encourage client to return for follow-up •Describe what a positive result means sessions and bring a support person if he/she wishes •Equate to a chronic disease •Emphasize living with HIV Purpose of the Post-test Counselling Session •Provide and explain test results Step 2 – Emotional Support •Assess client’s understanding of test results •Assess client’s psychological reaction and provide immediate support •Encourage client to express feelings/ reactions •Assess client’s support system • Arrange mental health and social support Negative or Indeterminate Result services as available Step 1 – The Test Result • Arrange consultation/counselling as •Describe what a negative or indeterminate required result means Step 3 – Consequences • Schedule future appointments for testing •Health as required •Reproduction •Interpret meaning of result in relation to personal history (i.e., risk behaviours, • Legal window period, need for retest) Step 4 – Behaviours Step 2 – Harm/Risk Reduction •Sex •Review harm/risk reduction strategies •Substance use •Explore client’s commitment to a personal •Rest, nutrition, exercise harm/risk reduction plan Step 5 – Benefits of early medical intervention Step 3 – Support Step 6 – Loss of anonymity with further medical •Provide client with resources, prevention intervention material and referral(s) Step 7 – Medical follow-up and referral Step 8 – Contact notification

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Appendix D: Qualification Criteria for Anonymous Testing Sites Qualification Criteria 3. Experience with HIV/AIDS services and related Facilities wanting to provide anonymous HIV issues. antibody testing shall provide a written request to 4. Ability to provide the required phlebotomy, Manitoba Health (see Appendix F) outlining storage and transport of specimen to Cadham readiness to meet the following criteria: Provincial Laboratory (i.e., safety engineered 1. Delegation of function to allow practitioners to needles, standard practices). perform HIV antibody testing (including 5. Security of documents/records. counselling) and provide the test result must be established, in situations where service is not 6. Ability to offer the same practitioner, as is directly and completely provided by a physician. feasible, throughout the anonymous HIV testing process to each client. 2. Ability and experience in the provision of HIV prevention counselling, pre- and post-test 7. Willingness to participate in an evaluation counselling and referrals. process.

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Appendix E: Telephone Information for Anonymous Testing Services

Staff responding to telephone inquiries regarding •Routine precautions and practices for anonymous HIV testing sites and services should phlebotomy, storage and transport of the ensure that consistent information is provided to blood specimen to CPL are followed. callers and anonymity is assured. •A Client Card with a unique code Inform callers of the following: number will be given at the first appointment. 1. General information: •The test result will only be given to the •The service is free and anonymous. individual upon presentation of the •No Personal Health Identification Anonymous HIV Testing Client Card. Number (PHIN) is needed. • The result is available in three weeks. The • Client-specific identifying information practitioner will discuss with the will not be kept; however, an anonymous individual the date, process and length of code will be assigned. the next appointment. • The onus is on the individual to return • The individual must return for post-test for his or her test result. There is no counselling and test results within three possibility for the testing site to contact months of testing. Individuals returning the person as contact information is not for test results beyond the three month available. period will require re-testing. •Testing sites do not subscribe to call •Practitioners should offer referrals to HIV display. specialists and HIV support services for • Anonymous HIV antibody test results are those testing positive. not accepted by insurance companies. •Referrals to community resources are • Anonymous HIV antibody testing is not available on a nominal basis. recommended for prenatal screening or 3. Locations and schedules: occupational exposure. •Inform the caller of locations and 2. Anonymous HIV testing: schedules regarding anonymous HIV •During the pre-test counselling, a health antibody testing in Manitoba. practitioner provides information •For a listing of anonymous HIV test sites regarding HIV, social/legal implications, in Manitoba or if more information is potential for contact notification and required regarding HIV/AIDS and STI, prevention. refer the individual to the AIDS/STI •If the individual consents to testing Information Line at 945-2437 following pre-test counselling, the blood (1-800-782-2437) or Health Links-Info sample is drawn. Santé at 788-8200 (1-888-315-9257).

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Appendix F: Manitoba Health – Anonymous HIV Antibody Test Site Application Form Please complete the following and forward to Manitoba Health (see address below):

Name of Site/Facility/Organization:______

Address: ______City/Town: ______Postal Code:______Phone: ______Email: ______

Compliance with Guidelines and Procedures for Anonymous Testing Sites (please append supporting documents) 1. Human resources ■ Physician on staff ■ Delegation of function regarding HIV testing and related care ■ Ability to provide the same practitioner (as feasible) 2. HIV Counselling ■ HIV prevention counselling ■ Pre- and post-test HIV counselling ■ Anonymity and confidentiality assured 3. Knowledge/experience ■ Staff with knowledge and experience regarding HIV/AIDS prevention, ■ care, treatment and other related issues ■ Resource material for individuals and service providers 4. Specimen transport ■ Phlebotomy to CPL ■ Storage ■ Transport 5. Documents/records ■ Secure storage of client documents 6. Reporting ■ Reporting of contacts to Manitoba Health 7. Partnerships ■ Agree to meetings with Manitoba Health as required regarding anonymous HIV testing services

Name (please print) ______Signature ______Position ______Date______

Send completed form to: The Communicable Disease Control Branch Manitoba Health 4th floor – 300 Carlton Street Winnipeg, MB R3B 3M9 Confidential Fax: (204) 948-3044

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