Making HIV Testing Routine

1
Making HIV Testing Routine

• Christine Lubinski
• HIV Medicine Association

2
Revised CDC Recommendations for Adults and
Adolescents

• 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 separate signed informed consent not
  recommended
• Prevention counseling in conjunction with HIV
  screening in health care settings is not required
• Intended for all health care settings, including
  inpatient services, EDs, urgent care clinics, STD
  clinics, TB clinics, public health clinics,
  community clinics, substance abuse treatment
  centers, correctional health facilities, primary
  care settings

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Revised CDC Recommendations for Adults and
Adolescents, cont.

• Communicate test results in same manner as other
  diagnostic/screening tests
• Provide clinical HIV care or establish reliable
  referral to qualified providers
• Low prevalence settings
• Initiate screening
• If yield from screening is less than 1 per
  1000, continued screening is not warranted
• Steps should be considered to resolve conflicts
  between the recommendations and state or local
  regulations

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Revised CDC Recommendations for Pregnant Women

• Universal opt-out HIV screening
• Include HIV in routine panel of prenatal
  screening tests
• Consent for prenatal care includes HIV testing
• Notification and option to decline
• Second test in 3rdtrimester for pregnant women
• Known to be at risk for HIV
• In jurisdictions with elevated HIV incidence
• In high HIV prevalence health care facilities
• Opt-out rapid testing with option to decline for
  women with undocumented HIV status in LD
• Initiate ARV prophylaxis on basis of rapid
  test result
• Rapid testing of newborn recommended if mothers
  status unknown at delivery
• Initiate ARV prophylaxis within 12 hours of
  birth on basis of rapid test result

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How Many Americans Have Been Tested?
Non-Elderly
No, never tested
Yes, in last 12 months
Yes, but not in last 12 months
55
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).
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HIV Testing by Race/Ethnicity, 2006
Non-Elderly
No, never tested
Yes, in last 12 months
Yes, but not in last 12 months
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).
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Views on Routine HIV Testing
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
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.)
Dont know
Source Kaiser Family Foundation Survey of
Americans on HIV/AIDS (conducted March 24 April
18, 2006).
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Perceptions on Whether Stigma Follows Testing
If you were to be tested for HIV, do you think it
would make people you know think less of you,
think more of you, or would it make no difference
in how people you know think of you?
Would make no difference
People would think less of me
People would think more of me
Depends/ Dont know
Source Kaiser Family Foundation Survey of
Americans on HIV/AIDS (conducted March 24 April
18, 2006).
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Timing of AIDS Diagnosis, 2004
Data from 35 Areas
Source CDC, HIV/AIDS Surveillance Report, Vol.
16, 2005.
10
In Not in Care Receipt of HAART by Those
Eligible for HAART, 2003
Of those aged 15-49 estimated to be eligible for
HAART
Source Teshale EH 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
11
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.
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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.
13
A Majority of Newly Diagnosed are People of
Color
Race/Ethnicity at Time of HIV Diagnosis,
1994-2000 (Data from 25 States)
Note Among those for whom insurance coverage
data were available May not total 100 due to
rounding. Source CDC/KFF, unpublished analysis
of data from the CDCs National HIV/AIDS
Reporting System (HARS).
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The Undiagnosed Also More Likely to be People of
Color
2003 Estimate
60
60
Diagnosed
Diagnosed
50
50
Undiagnosed
Undiagnosed
40
40
30
30
Percent
Percent
20
20
10
10
0
0
Black
Black
White
Hispanic
White
Hispanic
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.
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.
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Late HIV Testing is CommonSupplement to HIV/AIDS
Surveillance, 2000-2003

• Among 4,127 persons with AIDS, 45 were first
  diagnosed HIV-positive within 12 months of AIDS
  diagnosis (late testers)
• Late testers, compared to those tested early (gt5
  yrs before AIDS diagnosis) were more likely to
  be
• Younger (18-29 yrs)
• Heterosexual
• Less educated
• African American or Hispanic

MMWR June 27, 2003
16 states
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Awareness of Serostatus Among People with HIV
and Estimates of Transmission
25 Unaware of Infection
Accounting for
54 of New Infections
Marks, et al AIDS 2006201447-50
75 Aware of Infection
46 of New Infections
People Living with HIV/AIDS 1,039,000-1,185,000
New Sexual Infections Each Year 32,000
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Knowledge of HIV Infection and Behavior
After people become aware they are HIV-positive,
the prevalence of high-risk sexual behavior is
reduced substantially.
Reduction in Unprotected Anal orVaginal
Intercourse with HIV-neg partners HIV-pos Aware
vs. HIV-pos Unaware
68
Meta-analysis of high-risk sexual behavior in
persons aware and unaware they are infected with
HIV in the U.S. Marks G, et al. JAIDS.
200539446
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US Preventive Services Task ForceScreening for
HIV (updated 11/06)

• Strongly recommends that clinicians screen for
  HIV all adolescents/adults at increased risk for
  HIV infection (persons reporting 1 or more risk
  factors, live in high prevalence areas, treated
  in high-risk settings. High risk settings include
  STD clinics, correctional facilities, homeless
  shelters, TB clinics, clinics that serve MSM.
• Recommends that clinicians screen all pregnant
  women for HIV.
• Makes no recommendation for or against routinely
  screening for HIV adolescents/adults not at
  increased risk.

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Medicaid

• Major health program for low-income Americans,
  providing healthcare to 55 million people.
• Largest source of federal spending for HIV care
  in the U.S.
• Provides health coverage to about half of all
  people with AIDS and a significant number of
  those newly diagnosed with HIV.
• An analysis of HIV diagnoses in 25 states found
  that 22 were already Medicaid eligible at the
  time of diagnosis

HIV/AIDS Policy Fact Sheet, Medicaid and
HIV/AIDS, Henry J. Kaiser Family Foundation,
October 2006 Kates J et al. Poster TuPeG 5690,
XIV International AIDS Conference, Barcelona
Spain, July 2002
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Medicaid and HIV Screening

• Federal Medicaid law allows HIV screening to be
  covered by states either under fee-for-service or
  Medicaid managed care and will provide federal
  matching funds.
• This service is optional therefore is dependent
  upon the policy decisions of an individual state.
• Routine HIV testing has not been widely adopted
  by state Medicaid programs with the exception of
  New Jersey.

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Medicaid Options for HIV Screening

• Federally Qualified Health Centers -- All states
  must provide FQHC services in their Medicaid
  program. FQHCS are required to provide
  screenings for communicable diseases. HRSA
  could, but has not, required HIV screening as
  part of this requirement.
• Family Planning- California has broad family
  planning services created through an 1115 waiver
  that includes HIV testing and counseling for men
  and women of childbearing age up to 200 percent
  of the federal poverty level. In general, federal
  regulations limit what services can be covered
  through family planning programs.

Wilensky, Burke, Palen, Levi, Reimbursement
Options for Population-Based HIV Screening Under
Medicaid and Medicare in Inpatient, Outpatient,
and Emergency Department Settings A Legal
Analysis, George Washington Univ. Medical Center,
School of Public Health and Health Services,
Center for Health Services Research and Policy,
Unpublished document, April, 2004.
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Florida Medicaid Program

• The provider service network shall ensure that
  its providers, in accordance with Florida law,
  offer all pregnant women counseling and testing
  at the initial prenatal care visit and again at
  28-32 weeks.
• The PSN shall ensure that the providers provide
  all women of childbearing age HIV counseling and
  offer them HIV testing.

Florida Agency for Healthcare Administration, FFS
PSN Model Contract, Attachment II, July 2006, p.
55 of 231.
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Health Department Sources of Funding for HIV
Screening in Clinical Settings

• 35 state/city health departments report funding
  HIV screening in clinical settings
• Key sources of funding are CDC prevention
  funding, State/local funding sources, Medicaid
• A majority reported screening in STD clinics,
  family planning clinics and correctional
  facilities.
• 60 reported supporting screening in community
  health clinics.

Report on Findings from an Assessment of health
Department Efforts to Implement HIV Screening in
Health Care Settings, NASTAD, June 2007.
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Health Dept. Reported Barriers to HIV Screening
in Healthcare Settings

• Lack of funding
• Informed consent statutes/regulations
• Insufficient financial incentive
• Lack of provider buy-in
• Educating healthcare providers about statutory
  requirements
• Counseling statutes/regulations
• Health insurance will not reimburse screening

Report on Findings from an Assessment of health
Department Efforts to Implement HIV Screening in
Health Care Settings, NASTAD, June 2007.
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Financing Essential for Implementation of CDC
Guidelines

• Discretionary funding through CDC, Ryan White or
  state and local health departments is inadequate
  to implement population-based HIV screening.
• Medicaid with its significant reach into low
  income populations, especially low income women
  adolescents, and ethnic/racial minorities must be
  part of financing mix.
• Federal leadership could and should facilitate
  state Medicaid programs to cover HIV routine
  screening.

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Roadblocks to Medicaid and Private Insurance
Financing of Routine Testing

• CMS and Administration commitment to restrain
  federal Medicaid spending. State budgetary
  constraints and competing priorities for Medicaid
  dollars
• Statutes or public health regulations that
  require pre- and post-test counseling and/or
  written informed consent
• US Preventive Health Task Force guidelines inform
  insurance coverage policies.
• No HRSA mandate for community health center
  testing
• Low prevalence of HIV infection in many states
• Lack of enthusiasm from many community AIDS
  advocates for routine HIV testing

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Summary

• Many HIV infected patients in the U.S. do not
  know they are infected.
• Awareness of serostatus reduces risky behavior
  and further transmission
• The majority of newly diagnosed patients are
  diagnosed late
• Mortality and health care costs are much higher
  when patients are diagnosed late
• Fiscal and policy barriers prevent routine
  testing in many areas and settings

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Summary

• Community health centers provide care to many
  persons at high risk for HIV infection but
  currently do very little HIV testing.
• Providers, including HIV medical providers and
  community health centers must become advocates
  for policy changes and financing to support
  routine testing.