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AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
HIV testing during the Canadian immigration medical examination: a national survey of designated medical practitioners a
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Jennifer M. Tran , Alan Li
bc
e
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, Maureen Owino , Ken English , Lyndon Mascarenhas & Darrell
abf
H.S. Tan a
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Faculty of Medicine, University of Toronto, Toronto, ON, Canada
b
Committee for Accessible AIDS Treatment, Toronto, ON, Canada
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Regent Park Community Health Centre, Toronto, ON, Canada
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Ontario HIV Treatment Network, Toronto, ON, Canada
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Ontario AIDS Bureau, Ministry of Health and Long-Term Care, Toronto, ON, Canada
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St. Michael's Hospital, Toronto, ON, Canada Published online: 16 Jul 2014.
To cite this article: Jennifer M. Tran, Alan Li, Maureen Owino, Ken English, Lyndon Mascarenhas & Darrell H.S. Tan (2014) HIV testing during the Canadian immigration medical examination: a national survey of designated medical practitioners, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 26:12, 1550-1554, DOI: 10.1080/09540121.2014.936811 To link to this article: http://dx.doi.org/10.1080/09540121.2014.936811
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AIDS Care, 2014 Vol. 26, No. 12, 1550–1554, http://dx.doi.org/10.1080/09540121.2014.936811
HIV testing during the Canadian immigration medical examination: a national survey of designated medical practitioners Jennifer M. Trana, Alan Lib,c,d, Maureen Owinob,c, Ken Englishe, Lyndon Mascarenhasf and Darrell H.S. Tana,b,f* a
Faculty of Medicine, University of Toronto, Toronto, ON, Canada; bCommittee for Accessible AIDS Treatment, Toronto, ON, Canada; cRegent Park Community Health Centre, Toronto, ON, Canada; dOntario HIV Treatment Network, Toronto, ON, Canada; e Ontario AIDS Bureau, Ministry of Health and Long-Term Care, Toronto, ON, Canada; fSt. Michael’s Hospital, Toronto, ON, Canada
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(Received 27 September 2013; accepted 12 June 2014) HIV testing is mandatory for individuals wishing to immigrate to Canada. Since the Designated Medical Practitioners (DMPs) who perform these tests may have varying experience in HIV and time constraints in their clinical practices, there may be variability in the quality of pre- and posttest counseling provided. We surveyed DMPs regarding HIV testing, counseling, and immigration inadmissibility. A 16-item survey was mailed to all DMPs across Canada (N = 203). The survey inquired about DMP characteristics, knowledge of HIV, attitudes and practices regarding inadmissibility and counseling, and interest in continuing medical education. There were a total of 83 respondents (41%). Participants frequently rated their knowledge of HIV diagnostics, cultural competency, and HIV/AIDS service organizations as “fair” (40%, 43%, and 44%, respectively). About 25%, 46%, and 11% of the respondents agreed/ strongly agreed with the statements “HIV infected individuals pose a danger to public health and safety,” “HIV-positive immigrants cause excessive demand on the healthcare system,” and “HIV seropositivity is a reasonable ground for denial into Canada,” respectively. Language was cited as a barrier to counseling, which focused on transmission risks (46% discussed this as “always” or “often”) more than coping and social support (37%). There was a high level of interest (47%) in continuing medical education in this area. There are areas for improvement regarding DMPs’ knowledge, attitudes, and practices about HIV infection, counseling, and immigration criteria. Continuing medical education and support for DMPs to facilitate practice changes could benefit newcomers who test positive through the immigration process.
Keywords: HIV; diagnostic techniques and procedures; counseling; emigration and immigration; Canada
Background Since 2002, HIV testing has been mandatory for individuals aged 15 or older wishing to immigrate to Canada. This testing is factored into an applicant’s assessment for admissibility as part of the Immigration Medical Exam (IME). Pursuant to Section 38(1) of the Canadian Immigration and Refugee Protection Act, an applicant can be found “medically inadmissible” if he/ she (1) is likely to be a danger to public health or public safety or (2) might reasonably be expected to cause excessive demand on health or social services. IMEs are performed by Panel Physicians (formerly, “Designated Medical Practitioners” or DMPs; this terminology was in place during our study and will be used herein). Although HIV pre- and posttest counseling is mandated, the burden of clinical duties borne by DMPs, the resulting lack of time during clinical encounters, and other factors may pose challenges to the optimal provision of IME HIV testing. Some reports suggest that news of a reactive HIV test may not always be delivered appropriately, that pre- and posttest counseling may be limited, and that additional support to DMPs *Corresponding author. Email:
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may thus be of benefit (Committee for Accessible AIDS Treatment, 2008). One study on immigrants from HIV-endemic countries found that patients needed more information about testing and treatment, eligibility for treatment, and limits of confidentiality (Mitra, Jacobsen, O’Connor, Pottie, & Tugwell, 2006). Counseling after a positive result may prevent further transmission, mitigate anxiety and depression, and encourage patients to seek life-saving treatments (Foley, 2005). As such, it is important that the initial test results be delivered with appropriate counseling, even if time constraints only permit this to be brief. We therefore sought to describe the knowledge, attitudes/opinions, practices, and needs of DMPs with regard to HIV infection, counseling, and immigration, and to identify areas for improvement and education.
Methods An initial survey was developed using input from HIV physicians, HIV-positive immigrants, AIDS service organizations, and local DMPs. After pilot testing by
AIDS Care
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two DMPs, the final survey consisted of 42 items within five domains: demographics, knowledge, attitudes/ beliefs, practices, and needs. The survey was mailed to all DMPs in Canada using publicly available contact information from the Citizenship and Immigration Canada (CIC) website. Two rounds of follow-up mailings were sent after 3 and 6 months. The initial round was administered in English only; follow-up mailings were in English and in French. Responses were anonymous. Ethics approval was obtained through St. Michael’s Hospital Research Ethics Board. Surveys were coded numerically and missing values were ignored. Responses were summarized using descriptive statistics. Analyses were done using Microsoft Excel 2008 version 12.2.4 and SAS version 9.4. Results Of the 203 surveys mailed, we received 83 responses (41%). Response rates were similar for all regions of Canada. Respondent characteristics are summarized in Table 1. The average number of IMEs performed had a bimodal distribution, with most DMPs performing between 0 and 20 but 17% performing >50/month. Most respondents (86%) reported that HIV diagnoses were rare, at only 0–0.5% of tests performed. When participants rated their levels of knowledge of various issues relevant to their role in HIV testing, only one-third to one-half rated their knowledge as “good” (Figure 1). Knowledge was poorest for pre- and posttest counseling, HIV diagnostic test characteristics, and the prognosis of HIV infection. Participants also rated their agreement with three policy statements related to HIV (Figure 2). Fully 30% (95% CI = 22, 41) agreed/strongly agreed with the statement, “HIV positive immigrants pose a danger to public health and safety,” while this figure was 57% (95% CI = 46, 67) for the statement, “HIV positive immigrants cause an excessive demand on the healthcare system.” In contrast, only 13% (95% CI = 7, 23) of the respondents agreed/strongly agreed that HIV seropositivity is a reasonable ground for denial into Canada. Most respondents reported feeling prepared to perform HIV testing and counseling (80%; 95% CI = 71, 88 agreed/strongly agreed), convey HIV-positive results (85%; 95% CI = 76, 92), counsel about transmission (96%; 95% CI = 89, 99), and counsel about sex/sexuality (84%; 95% CI = 74, 91; Figure 3). However, many (61%; 95% CI = 50, 71) felt that language was often a barrier to effective counseling. Time spent on pretest and posttest counseling was most commonly reported at 1–2 minutes (43%; 95% CI = 33, 53) and ≥5 minutes (76%; 95% CI = 66, 84), respectively (Table 1). Despite being mandatory in the
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Table 1. Participant and practice characteristics. Characteristics
Valuea
Province/territory of practice (n = 78) Yukon 0 (0) British Columbia 13 (16.7) Alberta 9 (11.5) Saskatchewan 4 (5.1) Manitoba 3 (3.8) Ontario 35 (44.9) Quebec 6 (7.7) Newfoundland 1 (1.3) Nova Scotia 3 (3.8) New Brunswick 3 (3.8) Prince Edward Island 1 (1.3) Number of years in practice as DMP 18.0 (15, 20) Number of years since medical school 32.0 (27, 40) graduation Location of medical school training Canada 55 (67.9) USA 1 (1.2) Other 25 (30.9) Missing = 2 Number of IMEs performed per month (n = 81) 0–10 21 (25.9) 11–20 22 (27.2) 21–30 6 (7.4) 31–40 12 (14.8) 41–50 6 (7.4) 51+ 14 (17.3) Proportion of IMEs with HIV+ results (n = 81) 0–0.5% 71 (87.7) 0.5–1% 5 (6.2) 1–2% 4 (4.9) 2–3% 0 (0) 3–5% 1 (1.2) Time spent on pretest counseling 0 minutes 3 (3.7)