For all people testing for HIV it is important to promote testing early in the HIV window period (the period from being exposed to HIV to detecting it through HIV testing). People should be advised to test as early as 3 weeks after a high-risk exposure, and if negative, again at 6 weeks, and finally at 3 months. Earlier diagnosis of HIV can result in better health outcomes for HIV positive people, and reducing the level of HIV virus in the body can result in fewer transmissions to others.

For more information on HIV testing in Ontario, visit: www.hivtestingontario.ca

Care providers should respect the cultural, sexual and gender diversities of clients by avoiding judgmental language, behaviours and attitudes. We must be sensitive to the fact that some clients may use drug equipment that could result in transmission of HIV.  It is important for care providers to be acutely aware of the potential effects of stigma and discrimination on clients. Another factor to keep in mind is the degree to which a client’s misperception of their risk for HIV infection may be shaping how they react and behave toward HIV and HIV testing. Where applicable, care providers should offer referrals to local AIDS service organizations and other services/supports to help newly diagnosed clients with the challenges of a new HIV diagnosis, stigma and discrimination.¹ Public Health Agency of Canada. HIV transmission risk a summary of the evidence [Internet]. Ottawa: Public Health Agency of Canada; 2012 [cited 2016 Oct 26]. Available from: http://publications.gc.ca/collections/collection_2013/aspc-phac/HP40-78-2012-eng.pdf For individuals who test HIV negative, it may be appropriate to provide information on PrEP and make referrals.

In addition to standard messages around HIV risk and prevention options, counsellors should be mindful of the following when working with ACB communities: ² AIDS Bureau Ontario. Guidelines for HIV Counselling and Testing [Internet]. 2008. Available from: https://www.catie.ca/sites/default/files/HIV-testing-frequency-guidelines.pdf

• the low rates of HIV testing among people from Africa and the Caribbean, and the importance of affirming an individual’s decision to seek testing
• the high rates of HIV prevalence in these populations, which increases the risk that members of these communities will be exposed to HIV
• the role of HIV-related stigma and discrimination in increasing risk and how it functions as a barrier to voluntary testing and treatment
• the importance of creating an anti-racist and anti-oppressive environment, of making clients feel welcome, valued and respected, and of challenging any stigmatizing attitudes or statements
• the need to train staff to identify racism and other forms of discrimination
• the role of religion in the community and the impact of religious beliefs (e.g., people should not openly discuss sex/sexuality; people who are saved cannot acquire or transmit HIV; HIV is a punishment) on a client’s response to HIV or willingness to be tested
• gender inequities that make it difficult for women to negotiate safer sex, even though they may be able to negotiate other aspects of their lives
• immigration and permanent residency/citizenship status which can make it more challenging for individuals (particularly women) to leave  abusive or dangerous relationships
• the ways in which migration has disrupted family relationships
• the experience of sexual violence in Canada, their country of origin and/or previous countries of residence; this may be linked to conflict situations, particularly for those who migrated to Canada as refugees 
• the role of heterosexism and homophobia, which causes many to view HIV as a “gay disease” and not recognize that they are at risk
• the perception that the risk of acquiring HIV in Ontario/Canada is negligible
• cultural attitudes regarding talking about sex and sexual health education for youth (e.g., sex is a taboo subject)
• cultural attitudes about having multiple sex partners (e.g., in many cultures it is acceptable for men to have many partners)
• cultural practices that can affect risk, such as the rituals of male circumcision and female genital mutilation, where multiple individuals may be cut using the same instrument
• the belief that one is “clean” (i.e., does not have HIV or other sexually transmitted infections [STIs]) and can practice safe sex simply by choosing “clean” partners rather than using condoms
• HIV-related stigma within the community, and the lack of support for people who test positive and who often feel they must keep their status secret
  
  

The following is advice for counsellors who work with men in the African and Caribbean and Black communities: ³ AIDS Bureau Ontario. Guidelines for HIV Counselling and Testing [Internet]. 2008. Available from: https://www.catie.ca/sites/default/files/HIV-testing-frequency-guidelines.pdf

• never assume that men are exclusively either heterosexual or gay
• discuss the risks associated with unprotected sex with multiple partners
• discuss the full range of HIV prevention options without making assumptions about the client’s sexual or drug using activities
• reinforce the message that being in a relationship does not protect against HIV
• explain that in heterosexual relationships, men are twice as likely to transmit HIV and other STIs to their female partners than vice versa, and that the risk of contracting HIV is always greater for the “receiving partner”, whether female or male
• highlight that men can play a unique and valuable role in HIV prevention in their communities by educating themselves and other men
• listen carefully to any objections to HIV testing and prevention and help overcome identified barriers, recognizing that this is an ongoing process
• encourage clients to select and use HIV prevention methods (e.g., using condoms, using pre-exposure prophylaxis [PrEP], using post-exposure prophylaxis [PEP], using treatment as prevention, reducing the number of partners), even if they are in long-term relationships, to protect current and future partners from any risks associated with sexual activity outside the relationship
• for more information on accessing PrEP in Ontario visit, https://ontarioprep.ca/
• help clients to develop a contingency plan in case they engage in sexual activities outside their primary relationship
• recommend regular HIV and other STI testing (e.g., test for HIV at 3 weeks, 6 weeks and 3 months after each and every HIV high risk exposure; for lower HIV risk activities test once a year and when partners change)

Immigrants and refugees undergo HIV testing as part of Canada’s immigration medical examination, either in their country of origin before they arrive in Canada, or after they arrive in Canada and apply for permanent residency. It is important to recognize that the extent of pre- and post-test counselling can be highly variable, with some people not receiving their results at all and assuming that obtaining a visa or clearance to immigrate to Canada meant that they were not HIV‐positive. This reasoning is incorrect, because Canada does not exclude individuals on the basis of their HIV status.⁴ Baidoobonso S, Mokanan H, Meidinger L, Pugh D, Bauer G, Nleya-Ncube M, et al. Final Report from the Black, African and Caribbean Canadian Health (BLACCH) Study. 2012 [cited 2016 Oct 25]; Available from: https://works.bepress.com/shamara_baidoobonso/1/

When caring for newcomer and immigrant populations, physicians and other healthcare providers should consider the effects of biological differences in HIV subtypes on testing. Research suggests that the biological diversity of HIV subtypes may impact results in HIV viral load testing.⁵ O’Bryan T, Jadavji T, Kim J, Gill MJ. An avoidable transmission of HIV from mother to child. Can Med Assoc J. 2011;183(6):690–692.