Implementation of the Revised Recommendations for HIV Testing in Health Care Settings

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Implementation of the Revised Recommendations for
HIV Testing in Health Care Settings
Raul A. Romaguera, DMD, MPH Associate Director
for Prevention in Care Division of HIV/AIDS
Prevention Centers for Disease Control and
Prevention February 27, 2007
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Outline

• Overview of the Revised Recommendations for HIV
  testing in healthcare settings
• Engaging partners
• Implementation plan
• Emergency departments
• Community health centers
• Jails and correctional facilities
• HIV Screening in other clinical settings
• State and local considerations
• Future Activities

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Revised Recommendations for HIV Testing of
Adults, Adolescents, and Pregnant Women in
Health-Care SettingsMMWR 200655(No.
RR-14)1-17Published September 22, 2006

• http//www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.
  htm

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Source of HIV Tests and Positive Tests

• 38 - 44 of adults age 18-64 have been tested
• 16-22 million persons age 18-64 tested annually
  in U.S.

National Health Interview Survey, 2002
Suppl. to HIV/AIDS surveillance, 2000-2003
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Revised RecommendationsAdults 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 separate signed informed consent not
  recommended
• Prevention counseling in conjunctions with HIV
  screening in health care settings is not required

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Revised RecommendationsAdults and Adolescents -
II

• 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
• Communicate test results in same manner as other
  diagnostic/screening tests
• Provide clinical HIV care or establish reliable
  referral to qualified providers

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Revised RecommendationsAdults and Adolescents -
III

• 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
• Updated HIV Testing Laws at the National HIV/AIDS
  Clinicians Consultation Center
  http//www.ucsf.edu/hivcntr/PDFs/WEB2006State20La
  ws.pdf

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Revised RecommendationsPregnant Women - I

• 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 3rd trimester for pregnant women
• Known to be at risk for HIV
• In jurisdictions with elevated HIV incidence
• In high HIV prevalence health care facilities

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Revised RecommendationsPregnant Women - II

• 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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Engaging Partners
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Consultation with National Medical Organizations,
Atlanta, Oct 16, 2006

• Consulted with key medical organizations and
  insurers to
• Identify tools currently available to assist
  clinicians
• Propose modifications to increase utility of
  tools
• Identify gaps and recommend development of
  additional tools
• Identify process for promotion/dissemination of
  tools through existing communication networks
• Identify regulatory/legislative barriers and
  strategies to address them
• Identify strategies to seek reimbursement for HIV
  screening
• Provide input on implementation guidance

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Recommendations from Consultation

• Develop resources to support implementation
• Implementation guidance addressing operational
  and system issues
• Educational materials for patients
• Tools tailored to different type of providers
• Need to tailor strategies to individual settings
• Private public
• Hospitals community clinics
• Specialty programs (STD, substance abuse)
• Need to identify and disseminate best practices
  and models
• Provide access to state-specific resources
• State laws and regulations
• Resources to facilitate referrals to care
  treatment and prevention services

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Challenges

• Policy existing state and local laws and
  regulations
• Reimbursement
• Health plans and Medicaid coverage for screening
• Limited resources to cover cost of testing
  uninsured patients
• Limited resources to assist with follow up care
  and HIV prevention services

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Strengthening Partnerships

• Strengthen partnerships with National
  organizations to assist CDC in the development of
  tools, resources and strategies for the private
  and public sectors.
• Establish private-public working groups to
  expedite development of tools and resources.

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Partners

• National Medical Association
• American Medical Association
• American Academy of Pediatrics
• Society of General Internal Medicine
• American College of Obstetricians and
  Gynecologists
• HIV Medicine Association
• American Academy of HIV Medicine
• Health Research and Educational Trust of the
  American Hospital Association
• National Association of Community Health Centers
• National Association of Social Workers

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Implementation Activities
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CDC Implementation Plans

• Domains
• Implementation guidance
• Monitoring and evaluation
• Reimbursement
• Policies, laws and regulations
• Follow-up care
• Collaboration with health departments
• Professional education
• Community partners
• Corrections
• Social marketing
• Laboratories

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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 FP clinics

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Reimbursement Issues

• Worked with AMA to obtain current procedural
  terminology (CPT) codes for HIV screening tests
• Contacted CMS to discuss procedures to seek
  reimbursement for HIV screening under Medicaid
• Working with Americas Health Insurance Plans and
  its members to discuss issues related to
  reimbursement of HIV screening

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Emergency Departments
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Health Research Educational Trust (HRET)

• HRET is supporting CDC on a number of projects
  related to the implementation of HIV testing in
  hospital settings
• Independent, research affiliate of the American
  Hospital Association
• Conducts research education on critical issues
  for hospitals/health systems and the communities
  they serve.

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Health Research Educational Trust - II

• HRET Activities
• Conducted a baseline assessment of the number of
  hospitals conducting HIV testing in the ED before
  recommendations were published in September
• Developing an web-based tool to assist hospitals
  in initiating or expanding HIV testing in the ED
  and UCC
• Conducting an in-depth evaluation of ED and UCC
  HIV testing programs, including cost assessment
• Planning to conduct ongoing monitoring of US
  hospitals to assess uptake

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HRET Online Guide
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Multi-Site Evaluation of HIV Testing Programs in
Emergency Departments

• 6 case studies of different approaches to routine
  HIV testing in EDs
• Outcomes evaluation of different models
• Cost analysis of various approaches and models
• Collaborators
• Rich Rothman, Johns Hopkins University (co-PI)
• Harold Pollack, University of Chicago (CEA
  Adviser)

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HIV Testing Workshops

• 6 Regional strategic planning workshops for ED
  staff
• 10 hospitals per workshop
• Commitment to develop an action plan addressing
  implementation steps and challenges identified
  during workshop

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Community Health Centers
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Collaboration with National Association of
Community Health Centers (NACHC)

• NACHC, in collaboration with CDC and HRSA
• Analyzed HIV testing, prevention, and linkage to
  care policies
• Developed operational guide to help community
  centers
• NACHC is working with 6 community health centers
  (17 treatment sites) through on-site TA to
  incorporate HIV testing into routine care and
  arrange follow up care for HIV-infected patients

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CHCs Screening for HIV

• Aaron E. Henry Community Health Services Center,
  Inc., Clarksdale, MS
• Mantachie Rural Health Care, Mantachie, MS
• Northeast Mississippi Health Care, Mt. Pleasant,
  MS
• Blue Ridge Community Health Services,Hendersonvil
  le, NC
• Greene County Health Care, Inc., Snow Hill, NC
• Rural Health Services, Clearwater, SC
• 5 sites are using Unigold (under the 340-B
  program)
• 1 site is using Orasure

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Lessons Learned Within the Health Center

• Leadership buy in and support is key
• HIV screening has not increased patient cycle
  time
• Staff have been very engaged and enthusiastic,
  there has been no push back or stigma experiences
• Access to kits continues to be a challenge
• Reimbursement and/or funding for testing needs to
  be solved for it to be sustainable
• All staff need to be trained at the same time, it
  needs to start at all levels in the organization

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Other Lessons

• Experiences are different for Ryan White funded
  health centers and those that are not.
• Non-Ryan White health centers have no
  relationship with the HIV network, building these
  relationships can be time consuming. Follow up
  care needs to be arranged before clinic starts
  testing.  
• There is no communication infrastructure for
  non-Ryan White programs.
• Individuals who have worked in the field for a
  long time are experiencing a learning curve and
  challenged by what to let go of how to retool
  their work.

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Jails and Correctional Facilities
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HIV Testing in Corrections

• Prisons -- All provide HIV testing
• Policies and State and Federal Statutes vary
• Legislation has been proposed to change policies
  in some jurisdictions
• Jails -- Less HIV testing
• Survey, 18.5 since admission
• Unknown how many inmates with HIV in custody
• CDC Revised recommendations on HIV testing (9/06)

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CDC Activities

• Advancing HIV Prevention Demonstration Project
  on rapid HIV testing in Jails
• 4 States 27 jails
• Over 33,000 inmates
• Notification of test result
• Link to services inside jail community
  services
• Florida and New York - continue to provide HIV
  testing

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CDC Activities - II

• Developing guidance document to make routine
  testing part of medical evaluation
• Collaboration with
• Health Departments
• Medical providers in corrections
• Department of Justice

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Other Settings
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HIV Screening in Other Settings

• Developing guidance in collaboration with SAMHSA
  and Division of STD Prevention.
• AAP is completing an online training program to
  help providers introduce HIV testing for
  adolescents in their practice.
• NMA is developing practice standards and training
  for physicians serving the African American
  Community.
• NMA is working in 5 mid-size cities to increase
  testing by primary care providers serving African
  Americans.

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HIV Screening in Other Settings - II

• SGIM will develop strategies to introduce HIV
  screening in residency programs and promote
  testing among their members.
• AMA and AAHIVM reaching out to other
  organizations to develop provider tools for
  primary care providers.

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State and Local Considerations
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State and Local Considerations

• Some require specific signed consent
• Some require specific counseling
• Screening can be implemented now within current
  laws, rules, and regulations

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Example Texas Informed Consent Law

• Sec. 81.105. Informed Consent.
• (a) Except as otherwise provided by law, a
  person may not perform a test designed to
  identify HIV antibody without first obtaining the
  informed consent of the person to be tested.
• Sec. 81.106. General Consent.
• (a) A person who has signed a general consent
  form for the performance of medical tests is not
  required to also sign a specific consent form
  relating to medical tests to determine HIV
  infection that will be performed on the person
  during the time in which the general consent form
  is in effect.

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(No Transcript)
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Future Activities
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New Rapid Testing Initiative (NRTI)

• In 2006 the President proposed 90 million for a
  rapid HIV testing program
• Congressional Justification for FY 2008 includes
  63 million
• Goal to increase the proportion of HIV-infected
  persons that learn their status and to link them
  to medical care and prevention services.

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NRTI Secondary Goals

• Increase adoption of the Revised Recommendations
• Promote collaboration between HD, clinical
  entities and CBOs
• Allow HIV uninfected persons to learn their
  status and access prevention services
• Increase testing opportunities in geographic
  areas with greatest impact among African Americans

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NRTI Program Components

• Support testing in 10 jurisdictions with greates
  rates of new infections
• HIV screening will be offered in
• Medical care settings
• Substance abuse treatment programs
• Correctional settings
• Funding to State Health Departments or City
  Health Departments

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Services Covered

• Rapid HIV tests
• Optional pre-test counseling
• Post-test counseling for HIV
• Training and support for sites providing tests
• Linkage to medical care services
• Referral to local health departments for
  counseling, partner notification, testing of
  spouses and sex and drug using partners
• For drug users linkage to substance abuse
  treatment and other effective interventions

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Expected Impact
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Summary

• Testing is an important HIV prevention strategy
• Testing is a key step in linking to care
• Implementation of the revised testing
  recommendations will require new resources and
  new partnerships
• Screening in health care settings is feasible
• A number of activities to implement the
  recommendations are underway