Branson HIV and Privacy 2

CDC Recommendations for HIV Screeningin Health Care Settings:Moving Forward: 

Bernard M. Branson, M.D. Associate Director for Laboratory Diagnostics National Center for HIV, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention CDC Recommendations for HIV Screening in Health Care Settings: Moving Forward The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention

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Number HIV infected 1,039,000 – 1,185,000 Number unaware of their HIV infection 252,000 - 312,000 (24%-27%) Estimated new infections 40,000 annually Defining the Problem: Persons with HIV, United States Glynn M, Rhodes P. 2005 HIV Prevention Conference

Rationale for Revising Recommendations: 

Rationale for Revising Recommendations Treatment Testing Transmission Developments related to:

HIV Testing in the United States - 2002: 

HIV Testing in the United States - 2002 38% - 44% of US adults have been tested for HIV 16-22 million persons age 18-64 tested annually More than 75% of persons report they were tested for HIV in doctor’s offices, hospitals, or clinics Yet, 40% of persons reported with HIV receive an AIDS diagnosis within 1 year of their first HIV test – on average, 10 years after they first became infected (and infectious). - National Health Interview Survey, 2002 - CDC HIV Surveillance Report, 2005

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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

Aptima HIV-1 Qualitative RNA Assay: Intended Use: 

Aptima HIV-1 Qualitative RNA Assay: Intended Use FDA approved September 2006 Aid to HIV-1 diagnosis Diagnosis of acute HIV-1 infection in antibody-negative persons Confirmation of HIV-1 infection in antibody-positive persons when it is reactive

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care SettingsMMWR 2006;55(No. RR-14):1-17: 

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

Revised RecommendationsAdults and Adolescents - I: 

Revised Recommendations Adults and Adolescents - I Routine, voluntary HIV screening for all persons 13-64 in health care settings, not based on risk All patients with TB or seeking treatment for STDs should be screened for HIV Repeat HIV screening of persons with known risk at least annually

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Previous Recommendations

Revised RecommendationsAdults and Adolescents - II: 

Revised Recommendations Adults and Adolescents - II Opt-out HIV screening with the opportunity to ask questions and the option to decline testing Separate signed informed consent not recommended Prevention counseling in conjunction with HIV screening in health care settings is not required

Change in Written Informed Consent Requirement: 

Change in Written Informed Consent Requirement n=79 Comments

Change in Prevention Counseling Recommendation: 

Change in Prevention Counseling Recommendation n=80 Comments

Headlines: San Francisco Public Health: 

Headlines: San Francisco Public Health City health agencies move to streamline HIV testing: San Francisco drops counseling requirement (SF Chronicle 18 May 2006) Officials move to block HIV testing changes (SF Chronicle 25 May 2006)

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

Initial Focus: HIV Screening in Hospitals and Emergency Departments: 

Initial Focus: HIV Screening in Hospitals and Emergency Departments Cook County ED, Chicago 2.3% Grady ED, Atlanta 2.7% Johns Hopkins ED, Baltimore 3.2% King-Drew Med Center ED, Los Angeles 1.3% Inpatients, Boston Medical Center 3.8% New HIV+ Site CDC studies and demonstration projects:

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Implementation: Examples

Rapid HIV Testing in the ED: 

Rapid HIV Testing in the ED OraQuick testing since Jan 03 62% accept HIV testing 98% receive test results 3,305 patients screened 83 (2.5%) new HIV positive 80% entered HIV care (median 18 days) HIV tests ordered by ED providers increased from 5 to 29 per month Stroger (Cook County) Hospital Chicago - Lyss et al, JAIDS 2007

Characteristics, Rapid Test Positive Patients Identified in ED Screening: 

Characteristics, Rapid Test Positive Patients Identified in ED Screening - Lyss et al, JAIDS 2007

Screening vs Provider Referral: Chicago: 

Screening vs Provider Referral: Chicago Eligible 4849 436 Accepted 2824 (58%) 414 (95%) HIV-infected 35 (1.2%) 48 (11.6%) Admitted 19 (54%) 34 (71%) CD4 <200 14 (45%) 37 (82%) % of total 35 (42%) 48 (58%) Routine Screening Provider Referral

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ED Rapid Testing, New Jersey Shaded: counties offer rapid testing Essex Sussex Burlington Atlantic Cumberland Salem Gloucester Camden Cape May Somerset Morris Bergen Passaic Warren Middlesex Hunterdon Union Hudson Monmouth Mercer Ocean NJ health department provides counselors, test kits 23 EDs now offer rapid HIV testing 10,628 tested through November 9, 2006 274 (2.6%) HIV positive

Highland Hospital ED Testing Overview: 

Highland Hospital ED Testing Overview Feasibility study Rapid HIV screening in ED and urgent care Routinely offer HIV testing to all eligible patients at triage Existing staff perform oral fluid test Streamlined testing and counseling protocol

Informed Consent: 

Informed Consent

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Disclosed by nurse at bedside Negative handout provided Negative Test Results

Preliminary Positive Results: 

Preliminary Positive Results Physicians Disclose Counsel HIV Counselors serve as back-up Link to care Preliminary Positive Packet

Acceptance and Testing Rates - 19 months: 

Acceptance and Testing Rates - 19 months

Patient Satisfaction: 

Patient Satisfaction 57/65 positives completed survey 57/57 (100%) satisfied 55/57 (96%) felt disclosure private 178 negatives approached, survey completed in 105 104/105 (99%) satisfied 96/105 (91%) felt disclosure private Conclusion Perception of privacy maintained despite testing and disclosure of negative results in variety of clinical areas

What do the patients think?: 

What do the patients think? Would you recommend to a friend to get an HIV test if they went to the ER? - Preliminary data, 500 pts GWU Hospital ED

“The ER is a good place to perform HIV testing”: 

“The ER is a good place to perform HIV testing” What do the patients think? - Preliminary data, 500 pts - GWU Hospital ED

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

Summary: 

Summary There is an urgent need to increase the proportion of persons who are aware of their HIV-infection status Expanded, routine, voluntary, opt-out screening in health care settings is needed Several jurisdictions have already begun