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Materials in this module will help you: 

  • Understand the balance of partners, practices and protections, when assess HIV risk.
  • Ask clients about their reasons for testing and behaviours that may put them at risk of acquiring HIV in a respectful way.
  • Adapt counselling to the needs of the individual testing.
  • Outline Ontario’s guidelines about appropriate frequency of HIV testing.

When Should a Client Be Tested for HIV?

A client should be tested for HIV whenever they have had one or more high-risk exposure(s) to HIV.

To determine if there has been a high-risk exposure consider the three Ps:

Risk assessment is working with clients to understand the balance of the three P’s.

1. Partners

An exposure may be high risk if a client’s sexual partners have HIV (or may have HIV ), and may have detectable levels of HIV; sharing of needles and other equipment should always be considered a risk if the  partner(s) who uses drugs may be HIV-positive. However, people are often uncertain about their partner’s HIV status. In Ontario, HIV is most prevalent in the following priority populations:

  • gay, bisexual and other men who have sex with men, including trans men
  • African, Caribbean and Black communities—including men and women from regions where HIV is endemic
  • Indigenous peoples
  • people (men and women) who inject drugs or share drug equipment
  • women* = cis and trans women, including women from the above populations, and other women who face systemic and social inequities, and are more likely to be exposed to HIV through a sexual or drug using partner

When a client or their partner(s) is a member of a priority population, they should be counselled and assessed for the offer of HIV testing.

Understanding the role of a partner’s HIV status (negative, or undetectable) leads some clients to serosorting (choosing sexual partners based on their perceived status). Particularly for casual partners, this raises challenging questions about how well people know their own status, and how well they can (and are willing to) communicate it. The basic rule: If there is uncertainty about a partner’s negative or undetectable status in an otherwise HIV high-risk practice, recommend testing!

2. Practices

Only five body fluids can contain enough HIV to transmit HIV infection: blood, semen (including pre- cum), rectal fluid, vaginal fluid and breast milk. There is no risk associated with saliva or sweat, urine or tears. Sex and drug use can expose people to another person’s fluids. Activities deemed high risk for transmission of HIV, include::

  • Anal sex – both receptive and insertive
  • Vaginal sex – both receptive and insertive
  • Sharing needles or other equipment to inject or inhale drugs
  • Sharing sex toys inserted into both bodies without washing in between

There are a few other possible ways to transmit these body fluids (tattooing with shared equipment outside a sterile setting, a blood transfusion outside Canada is an environment where blood screening may be sub-standard), however you are much less likely to encounter these. Other sexual activities with properly cleaned sex toys, as well as oral sex, and masturbating together have very low or no risk, regardless of a partner’s HIV status.

More Resources on Transmission Risk:

  • CATIE. Safer Sex Guide. 2016. At: https://www.catie.ca/safer-sex-guide-0
  • CATIE. Putting a number on it: The risk from an exposure to HIV. 2012 At: https://www.catie.ca/prevention-in-focus/assessing-and-addressing-hiv-risk-what-service-providers-need-to-know This document explores the complexities of HIV transmission calculations and is the source of the table included in the slide deck.

3. Protections

Clients can, and do, take action to reduce HIV transmission; sometimes there can be gaps. Asking about gaps helps you more accurately access risk, and may present opportunities to suggest improvement.

During counselling, think about the prevention, harm reduction and support services your clients need and where services are available in your community that may be able to help. You can be a gateway to these services for your clients.

Frequently Used Phrases in HIV Test Counselling

There is no set script for HIV test counselling, it should be driven by the client’s needs and concerns. Start by introducing yourself, confirming that the client is there for an HIV test, and asking why they came in today, then move on to discussing (and potentially expanding on) the concerns and risks that they identify.

Think about mirroring their language. If they talk about their boyfriend (husband, trick), use that language. If they use casual language for sex do that too; if they are more clinical (anal sex), speak as they do.

Here are some phrases that experienced counsellors say they use frequently.

Simple direct questions to determine the extent of the risks people are telling you about:

  • Do you ever have anal sex?
  • (To a man), do you ever have sex with men?
  • When was the last time you had sex without a condom? Who was is with?
  • Do you ever have condomless sex with casual partners?

Questions like these, give permission for the next conversation.

How HIV is transmitted:

  • Are you familiar with the fluids that transmit the virus?
  • There are only five fluids that can transmit the virus: blood, semen (including pre-cum), rectal fluid, vaginal fluid and breast milk. There is no risk associated with saliva or sweat, urine or tears.

Weighing HIV risks:

  • In order for transmission to take place, many factors that have to line up.
  • You are much more likely to get an STI like chlamydia, syphilis, or gonorrhea than you are to get HIV.
  • HIV is not an automatically transmitted virus. You can have sex with someone who has HIV and stay negative.
  • Are you familiar with U=U?

Connect people to other services:

  • Are you familiar with PEP or PreP?
  • Do you know where to get clean drug use supplies?
  • Is your drug use a problem for you? Do you need support?

Consent and the possibility of a positive test:

  • If you are HIV positive, lots of good treatments are now available. I can connect you to a doctor.
  • A reactive result on a POC test will need to be confirmed, but it will likely mean that you have HIV. Are you ready to receive a reactive result?
  • If you have HIV  you will need to tell your past and present partners. I can help you do that anonymously if need be.
  • Do you understand what we have talked about? Are you ready to do the test?

What a negative result will mean:

  • Your test is only yours. It doesn’t tell you what your partner’s status is, they only way they will know is for them to test.

Always ask if there is anything else they are concerned about before doing the test.

Testing Frequency Recommendations

  • When a client has had a high-risk exposure to HIV the optimal approach is to test regularly at three weeks and six weeks (3-6) (lab-based testing) and three months (3-6-3) after the exposure (POC testing only) (More about the scientific basis for this is provided in the training module, The Science and Practice of HIV Testing.
  • If a client has engaged in practices that reduce their risk, or only participated in low risk practices (i.e. oral sex) advise them that their risk is low. If they request testing provide it, however there is no need for follow-up 3-6 or 3-6-3 testing.

Ongoing Testing

  • Clients from priority populations who had any potential exposures (even ones where protections were used) should be advised to return for testing annually; even if they are unaware of a subsequent high-risk practice.
  • If a client is engaging in very frequent high-risk practices, and it does not seem feasible to the client to return after each one, suggest testing as frequently as possible, at least every 3 months; encourage consideration of PrEP.
  • Clients with no risk practices do not require routine testing unless their risk behaviours change.

Useful Ontario-wide Service Resources

Sexual Health Information Line Ontario – Toll-free at 1-800-668-2437 or https://sexualhealthontario.ca/

Assaulted Women’s Helpline – 1-866-863-0511 or TTY 1-866-863-7868 or online http://www.awhl.org/

Ontario Harm Reduction Distribution Program – Find a Needle/Syringe Program https://ohrdp.ca/find-supplies/  

Ontario PrEP website – Find a PrEP provider https://ontarioprep.ca/clinic-finder/

Other Resources for More Information:

Rapid Response Service—A cross-jurisdictional review of HIV testing intervals for population groups at high risk of acquiring HIV. Toronto, ON: Ontario HIV Treatment Network; https://www.ohtn.on.ca/rapid-response-a-cross-jurisdictional-review-of-hiv-testing-intervals-for-population-groups-at-high-risk-of-hiv-infection/

Sexual Assault and Trauma-Informed Care

Trauma Informed Care training – HIV Resources Ontario offers this e-learning module about trauma informed care developed by Alberta Health Services. It is appropriate for anyone providing health services, who wishes to learn more about responding appropriately to clients who have experienced trauma. At: https://www.albertahealthservices.ca/info/page15526.aspx

Women’s College Hospital—Addressing Past Sexual Assault in Clinical Settings. Although this assumes that all clients are women, it is a useful review at http://dveducation.ca/sexualassault/