Revised USPHS Recommendations for HIV Testing in Health Care Settings

1

Sustaining HIV Prevention HIV Testing in Health
Care Settings
Kevin A. Fenton, MD, PhD, FFPHDirector, National
Center for HIV/AIDS, Viral Hepatitis, STD, and TB
PreventionCenters for Disease Control and
Prevention
The International AIDS SocietyUSA
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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
3
Overview

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

4
Estimated Number of AIDS Cases, Deaths, and
Persons Living with AIDS--United States, 2001-2005
90
)
s
d
80
n
a
s
u
70
o
h
t

n
60
i
(

s
h
50
t
a
e
d

40
d
n
a

30
s
e
s
a
20
c

f
o

.
10
o
N
0
1985
Year of diagnosis or death
Note. Data have been adjusted for reporting
delays.
5
Race/Ethnicity of Persons with HIV/AIDS Diagnosed
during 2005, 33 States
No.38,096
White, 31
African American, 49
Hispanic, 18
American Indian/Alaska Native, lt1
Asian/Pacific Islander, 1
Note Data from 33 states with confidential
name-based HIV infection reporting since 2001.
6
AIDS cases
N 40,733
1
lt1
18
30
50
White, not Hispanic
Asian/Pacific Islander
Black, not Hispanic
American Indian/
Alaska Native
Hispanic
Includes 283 persons of unknown race or
multiple races.
7
Mortality and HAART Use Over Time HIV Outpatient
Study, CDC, 1994-2003
-Palella et al, JAIDS 2006 4327.
8
Proportion of Persons Surviving, by Number of
Months after AIDS Diagnosis 1997-2004 and by Year
of DiagnosisU.S. and Dependent Areas
1.00
2004
2003
2002
2001
2000
0.75
1999
1998
1997
Proportion surviving
0.50
0.25
0.0
0
36
48
60
84
96
72
108
24
12
Months after AIDS diagnosis
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How Many Americans Have Been Tested?
Non-Elderly
55
21
34
42
Note Dont 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).
10
HIV Testing by Race/Ethnicity, 2006
Non-Elderly
48
White
70
Black
56
Hispanic
Note Dont 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).
11
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.
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Views on Routine HIV Testing
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
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
Neither/Both equally (Vol.)
Dont know
Source Kaiser Family Foundation Survey of
Americans on HIV/AIDS(conducted March 24 April
18, 2006).
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• Reaching Those at Risk and the Undiagnosed

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People Living with HIV/AIDS by Awareness of
Serostatus and Access to Care
Estimates Only
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, 2003United 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.
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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.
16
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.
17
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 2004April 2005, MMWR, Vol. 54,
No. 24, June 24, 2005.
18
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.
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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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Revised Recommendations for HIV Testing of
Adults, Adolescents, and Pregnant Women in
Health-Care Settings

• MMWR 200655(No. RR-14)1-17
• Published September 22, 2006
• http//www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.
  htm

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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

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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

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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 lt 1 per 1000,
  continued screening no longer warranted

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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 LD
• Initiate ARV prophylaxis on basis of rapid test
  result
• Newborn testing if mothers status unknown

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Moving Forward
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Uni-Gold Recombigen
Clearview Complete HIV 1/2
Multispot HIV-1/HIV-2
Reveal G3
Clearview HIV ½ Stat Pak
OraQuick Advance
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HIV Testing Expansion InitiativeNYC 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

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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

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

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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

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Implementation Guidance

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

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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

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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

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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

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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

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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

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Thank you.