Fenton

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Sustaining HIV Prevention: HIV Testing in Health Care Settings Kevin A. Fenton, MD, PhD, FFPH Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention The International AIDS Society–USA

Sustaining HIV Prevention: HIV Testing in Health Care Settings: 

Kevin Fenton, MD, PhD, FFPH Director National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention Sustaining HIV Prevention: HIV Testing in Health Care Settings

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Overview Epidemiologic background Rationale for revising recommendations 2006 Recommendations Moving forward in implementing revised recommendations Summary

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Year of diagnosis or death N o . o f c a s e s a n d d e a t h s ( i n t h o u s a n d s ) 0 90 10 20 30 40 50 60 70 80 1985 Note. Data have been adjusted for reporting delays. Estimated Number of AIDS Cases, Deaths, and Persons Living with AIDS--United States, 2001-2005

Race/Ethnicity of Persons with HIV/AIDS Diagnosed during 2005, 33 States: 

Race/Ethnicity of Persons with HIV/AIDS Diagnosed during 2005, 33 States African American, 49% White, 31% Hispanic, 18% Asian/Pacific Islander, 1% American Indian/Alaska Native, <1% No.=38,096 Note: Data from 33 states with confidential name-based HIV infection reporting since 2001.

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50% 30% 18% AIDS cases N*= 40,733 White, not Hispanic Black, not Hispanic Hispanic Asian/Pacific Islander American Indian/ Alaska Native 1% <1% * Includes 283 persons of unknown race or multiple races.

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Mortality and HAART Use Over Time HIV Outpatient Study, CDC, 1994-2003 -Palella et al, JAIDS 2006; 43:27.

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0.0 0.25 0.50 0.75 1.00 0 24 12 36 48 60 84 96 72 108 Months after AIDS diagnosis Proportion of Persons Surviving, by Number of Months after AIDS Diagnosis 1997-2004 and by Year of Diagnosis—U.S. and Dependent Areas 2004 2003 2002 2001 2000 1999 1998 1997 Proportion surviving

How Many Americans Have Been Tested?: 

How Many Americans Have Been Tested? Note: Don’t know responses not shown; Numbers may not add up due to rounding. Source: Kaiser Family Foundation Survey of Americans on HIV/AIDS (conducted March 24 – April 18, 2006). Non-Elderly 55% 21% 34% 42%

HIV Testing by Race/Ethnicity, 2006: 

HIV Testing by Race/Ethnicity, 2006 Note: Don’t know responses not shown; Numbers may not add up due to rounding. Source: Kaiser Family Foundation Survey of Americans on HIV/AIDS (conducted March 24 – April 18, 2006). Non-Elderly White Hispanic Black 48% 70% 56%

Where are People with HIV Being Diagnosed? (2002): 

Where are People with HIV Being Diagnosed? (2002) Source: Branson, B. Slide Set: Revised Recommendations for HIV Testing in Healthcare Settings in the U.S., 2006. Data from the NHIS 2002 and SHAS 2000-2003.

Views on Routine HIV Testing: 

Views on Routine HIV Testing Source: Kaiser Family Foundation Survey of Americans on HIV/AIDS (conducted March 24 – April 18, 2006). HIV testing should be treated just like routine screening for any other disease, and should be included as part of regular check-ups and exams Neither/Both equally (Vol.) HIV testing is different from screening for other diseases, and should require special procedures, such as written permission from the patient in order to perform the test Don’t know

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Reaching Those at Risk and the Undiagnosed

People Living with HIV/AIDS by Awareness of Serostatus and Access to Care: 

People Living with HIV/AIDS by Awareness of Serostatus and Access to Care Sources: Glynn MK and Rhodes P, “Estimated HIV Prevalence in the United States at the end of 2003.” Presentation at the 2005 National HIV Prevention Conference, June 14, 2005; Teshale E. et al., “Estimated Number of HIV-infected Persons Eligible for and Receiving HIV Antiretroviral Therapy, 2003–United States”, Abstract #167, 12th Conference on Retroviruses and Opportunistic Infections, February 2005. Note, among those ages 15-49; Fleming P et al., “HIV Prevalence in the United States, 2000”, Abstract #11, 9th Conference on Retroviruses and Opportunistic Infections, February 2002. Estimates Only

The Undiagnosed are More Likely to Be People of Color: 

The Undiagnosed are More Likely to Be People of Color 2003 Estimate Source: Glynn MK and Rhodes P, “Estimated HIV Prevalence in the United States at the end of 2003.” Presentation at the 2005 National HIV Prevention Conference, June 14, 2005.

The Undiagnosed Are More Likely to Have Been Infected Sexually (Heterosexual & MSM): 

The Undiagnosed Are More Likely to Have Been Infected Sexually (Heterosexual & MSM) 2003 Estimate Source: Glynn MK and Rhodes P, “Estimated HIV Prevalence in the United States at the end of 2003.” Presentation at the 2005 National HIV Prevention Conference, June 14, 2005.

HIV Positive MSM Unaware of HIV Status, Five U.S. Cities, 2004-2005: 

HIV Positive MSM Unaware of HIV Status, Five U.S. Cities, 2004-2005 Notes: Cities are Baltimore, Los Angeles, Miami, New York, San Francisco. Source: CDC, HIV Prevalence, Unrecognized Infection, and HIV Testing Among Men Who Have Sex with Men –– Five U.S. Cities, June 2004–April 2005, MMWR, Vol. 54, No. 24, June 24, 2005.

Failure to Return for HIV Test Results Among Those at High Risk, 2000: 

Failure to Return for HIV Test Results Among Those at High Risk, 2000 Source: Sullivan PS et al., “Failure to Return for HIV Test Results Among Persons at High Risk for HIV Infection: Results from a Multistate Interview Project.” JAIDS, Vol. 35, No. 5, April 2004.

Rationale for Revising Recommendations: 

Rationale for Revising Recommendations Part of comprehensive HIV prevention strategy Previous recommendations did not have intended effect New evidence Awareness of HIV infection leads to substantial reductions in high-risk sexual behavior Screening is cost effective Experience with HIV testing Effective treatment available Late testing is common

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MMWR 2006;55(No. RR-14):1-17 Published September 22, 2006 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings

Adults and Adolescents - I: 

Adults and Adolescents - I Routine, voluntary HIV screening for all persons 13-64 in health care settings, not based on risk Repeat HIV screening of persons with known risk at least annually Opt-out HIV screening with the opportunity to ask questions and the option to decline; include HIV consent with general consent for care

Adults and Adolescents - II: 

Adults and Adolescents - II Prevention counseling in conjunction with HIV testing in health care settings not required Patients who test HIV positive are to be linked to clinical care, counseling, support and prevention services. HIV negative patients known to be at high risk should be advised of need for periodic re-testing and offered or referred for prevention counseling Recommendations intended for all health care settings Recommendations not intended for non-clinical settings, such as CBOs

Adults and Adolescents - III: 

Adults and Adolescents - III Recommendations on referral to care remain unchanged (i.e., all HIV positive persons should be referred or linked to care) Low prevalence settings: Initiate screening If HIV prevalence shown to be < 1 per 1000, continued screening no longer warranted

Pregnant Women: 

Pregnant Women Universal opt-out HIV screening Include HIV in panel of prenatal screening tests Consent for prenatal care includes HIV testing Second test in 3rd trimester for pregnant women: Known to be at risk for HIV In key jurisdictions In high HIV prevalence health care facilities Opt-out rapid testing for women with undocumented HIV status in L&D Initiate ARV prophylaxis on basis of rapid test result Newborn testing if mother’s status unknown

Moving Forward: 

Moving Forward

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Uni-Gold Recombigen Multispot HIV-1/HIV-2 Reveal G3 OraQuick Advance Clearview Complete HIV 1/2 Clearview HIV ½ Stat Pak

HIV Testing Expansion InitiativeNYC Health and Hospitals Corp: 

HIV Testing Expansion Initiative NYC Health and Hospitals Corp Largest municipal hospital system in US Serves 1.3 million New Yorkers 218,300 discharges 5,800,000 visits Increase the number of patients who know their HIV status -- test 100,000 patients Increase the proportion of patients who enter care early -- reduce the number of concurrent AIDS diagnoses

NYC Health and Hospitals Corp.:Year One Summary Results: 

NYC Health and Hospitals Corp.: Year One Summary Results Testing increased by 57% (from 58,785* in FY05 to 92,123 in FY06) Number of new diagnoses nearly doubled to 1,514 76% of newly positive** patients received and kept their first appointment for primary HIV care (589/774) *Includes some individuals who were tested at more than one facility. **Newly positive = patients who reported no prior positive test and for whom no prior positive test was documented at the facility

Trends in HIV Testing: San Francisco Public Health: 

20.6 HIV positive tests per month 30.6 HIV positive tests per month Trends in HIV Testing: San Francisco Public Health Zetola et al, JAMA March, 2007

CDC Implementation Planning: 

CDC Implementation Planning Domains: Health departments Professional partners Professional education Community partners Implementation guidance Monitoring and evaluation Reimbursement Laws and regulations Linkage to care Corrections Social marketing Laboratories

Strengthening Partnerships: 

Strengthening Partnerships Strengthen partnerships with national organizations to support implementation of recommendations through training and technical assistance: National Medical Association American Medical Association American Academy of Pediatrics Society of General Internal Medicine HIV Medicine Association American Academy of HIV Medicine Health Research and Educational Trust of the American Hospital Association National Association of Community Health Centers

Implementation Guidance: 

Implementation Guidance Develop implementation guidance for various types of settings in collaboration with key stakeholders: Hospitals (EDs, inpatient, L&D) STD clinics Substance abuse treatment centers Community health centers Correctional health facilities Primary care settings Urgent care clinics Prenatal care clinics

Fostering Implementation: 

Fostering Implementation CDC: Six regional workshops for high-priority EDs National Medical Association: Work with primary care providers in 5 cities Gilead Sciences: Funding support for acute-care testing in 8 cities Baltimore Chicago Detroit Miami New York City Philadelphia San Francisco West Palm Beach

Reimbursement : 

Reimbursement Work with health insurers to seek reimbursement for HIV screening Work with the Centers for Medicare and Medicaid Services and state Medicaid directors Consider HIV testing in Early Periodic Screening, Diagnosis, and Treatment Program Request CPT codes to cover increased costs associated with use of single point of care tests (i.e. increased labor costs, use of external controls) Uninsured

State and Local Considerations: 

State and Local Considerations Some require specific signed consent 26 states & District of Columbia require written consent Some require specific counseling 24 states require specific pre-test counseling 7 states have specific training & certification requirements for individuals providing pre-test counseling 5 states require test results to be given face-to-face by trained individuals Screening can be implemented now within current laws, rules, and regulations

FY 2007 HIV Testing Initiative: 

FY 2007 HIV Testing Initiative $45 million realignment of Agency funds to support implementation of HIV testing in 26 jurisdictions with highest incidence of reported AIDS cases. Majority of funds to health departments for testing in clinical settings

Summary: 

Summary Testing is an important HIV prevention strategy CDC has issued revised recommendations for HIV testing of adults, adolescents and pregnant women in health care settings Implementation of the revised testing recommendations will require new partnerships and strategies Screening in health care settings is feasible A number of activities to implement the recommendations are underway

Thank you.: 

Thank you.