Perspectives on Outreach from the NYC Department of Health and Mental Hygiene

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Perspectives on Outreach from theNYC Department
of Health andMental Hygiene

• Benjamin Tsoi, MD, MPH
• Bureau of HIV/AIDS Prevention and Control
• NYC Department of Health and Mental Hygiene

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Steps Leading to HIV Testing

• Identify persons at risk for HIV
• Find infected persons who are unaware of their
  HIV status
• Make offer of HIV test
• Provide HIV test

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Steps Leading to HIV Testing

• Identify persons at risk for HIV
• Use of epidemiology surveillance data

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New HIV Diagnoses in NYC, 2007Race/Ethnicity

• 80 of new HIV diagnoses are in blacks and
  Hispanics
• Blacks have a higher percentages of new HIV
  diagnosis, PWHA, and death

As reported to the New York City Department of
Health and Mental Hygiene by September 30, 2007
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States Regulation of Reportable Conditions,
including HIV

• Facilitators
• Allows for tracking of HIV epidemic over time
• Allows for identification of at risk
  subpopulations

• Limitations
• Reporting incomplete
• Information limited to those who test positive,
  not those who test negative
• Confidentiality provision may prevent use of HIV
  registry data for programmatic use

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Steps Leading to HIV Testing

• Identify persons at risk for HIV
• Find infected persons who are unaware of their
  HIV status

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The Bronx KnowsGet Smart, Get Safe, Get Tested
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Outreach to UndiagnosedHIV-infected Persons
HIV Screening
Targeted Testing
Performing HIV test on a subpopulation of persons
at higher risk, usually based on specific
characteristic(s)
In a defined population, broadly performing HIV
test for all persons
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HIV Screening

• Facilitators and Barriers

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CDCs Revised Recommendations
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CDCs Recommendation for Testing in Health-Care
Settings

• Facilitators
• Makes it easier to go to medical facilities to
  promote screening

• Limitations
• Lacks enforcement capability
• Lacks associated funding to support expansion
  nationally
• Variable level of knowledge of recommendations by
  providers

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Many Physicians-in-training Not Aware of
Recommendations

• Fifteen NYC internal medicine residency programs
  surveyed in early 2007
• 450 (38.3) of 1175 residents responded
• Most (63.9) ordered about 10 HIV tests in past 6
  months
• 32.6 aware of 2006 recommendations
• 35.8 used routine testing approach

Jain et al. AIDS Patient Care STDs. 2009
March167-76
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Medicare Preventive Services include HIV
Screening Tests
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Medicare Beneficiaries for HIV Screening

• Men who have had sex with men after 1975
• Men and women having unprotected sex with
  multiple partners
• Past or present injection drug users
• Men and women who exchange sex for money or
  drugs, or have sex partners who do
• Individuals whose past or present sex partners
  were HIV-infected, bisexual or injection drug
  users
• Persons being treated for sexually transmitted
  diseases
• Persons with a history of blood transfusion
  between 1978 and 1985
• Persons who request an HIV test despite reporting
  no individual risk factors
• Voluntary HIV screening of pregnant Medicare
  beneficiaries when the diagnosis of pregnancy is
  known, during the third trimester, and at labor

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Medicare Coverage of HIV Screening

• Facilitators
• Allows for coverage of some HIV screening
• Other insurance plans may follow lead of Medicare

• Limitations
• Medicare coverage limited to older adults and
  those with disabilities
• Screening is not recommended or required
• Testing based on risk, contrary to CDC
  Recommendations

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Patient Dont Always Disclose

• NYC National HIV Behavioral Surveillance project
  (20042005)
• All men who reported at least one male sex
  partner in past year self-reported HIV
  seronegative
• 39 with same-sex attraction did not disclose to
  healthcare provider
• Black and Hispanic men who have sex with men
  (MSM) less likely to disclose than white MSM

Bernstein et al. Arch Intern Med.
2008168(13)1458-1464
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Sexual Identity Dont MatchSexual Behavior

• Random digit-dialed telephone survey of NYC
  residents (2003)
• 12 reported sex with other men
• Of those, 61 straight identified
• Racial minority, be foreign-born, have lower
  education and income levels, and be married
• 36 gay identified
• 3 bisexual identified

Pathela et al. Ann Intern Med. 2006145416-425
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Missed OpportunitiesMany HIV-Infected Persons
Access Health Care But Are Not Tested

• Example South Carolina
• Of 4,300 newly reported HIV cases
• 3,100 (73) made gt20,000 health care visits prior
  to their first HIV diagnosis
• 77 did not have diagnosis code to prompt for HIV
  test

• CDC ED chart review findings of 195 HIV patients
• Chest pain 16(8.2)
• Bronchitis 13 (6.6)
• Abd Pain 11 (5.6)
• Convulsions 10 (5.1)
• Headache 7 (3.6)
• Lumbago 7 (3.6)
• Dizziness 5 (2.6)

MMWR December 1, 2006
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Kaiser PermanenteMissed Opportunities

• 440 patients with new HIV diagnosis
• Mean 8.6 health-care contacts before positive
  HIV test
• CD4 count at diagnosis
• 62 lt 350
• 43 lt 200
• 18 lt50
• Only 26 had risk factors documented in chart

- Klein D, et al JAIDS 2003
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Reported Reasons for Not Being TestedAmong 51
who say they have never been tested
Many people will not be tested if relying on
patient to initiate testing encounter
Source Kaiser Family Foundation Survey of
Americans on HIV/AIDS (conducted Jan. 26March 8,
2009) Interviewee may choose more than one
reason, so total exceeds 100
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Targeted TestingDifficulties in Finding
Undiagnosed Cases

• While we may know neighborhoods with the highest
  rates of HIV, people may not necessarily want to
  be tested near home
• Non-gay-identifying MSM may not be found in
  traditional gay venues
• Difficulty in locating at-risk females
• Their partners may have sex with men, but may not
  disclose information to female partner

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Steps Leading to HIV Testing

• Identify persons at risk for HIV
• Find infected persons who are unaware of their
  HIV status
• Make offer of HIV test

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Separate Consent for HIV Testing

• Six states still require separate consent for HIV
  testing
• Burdensome consent process is one of eight core
  physician barriers to routine HIV testing1

1 Burke et al. AIDS. 20071617-1624.
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HIV Testing in San FranciscoBefore/After
Elimination of Consent Requirement
Zetola, JAMA, March 14, 2007
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Reimbursement for HIV Testing

• Insurance plans differ on amount of coverage for
  HIV testing
• In New York, different reimbursement codes for
  fee-for-service Medicaid vs. managed care
  Medicaid
• Rate of reimbursement often individually
  negotiated with plans

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Steps Leading to HIV Testing

• Identify persons at risk for HIV
• Find infected persons who are unaware of their
  HIV status
• Make offer of HIV test
• Provide HIV test

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Other Barriers to HIV Testing

• Stigma
• Stigma associated with testing
• Stigma associated with being infected
• Other nations have access to more
  state-of-the-art testing technologies than we do
  in US

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Thank you

• Questions?

The findings and conclusions in this presentation
are those of the author and do not necessarily
represent the views of the NYC Department of
Health and Mental Hygiene