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Improving HIV Testing and Prevention in New York City

Improving HIV Testing and Prevention in New York City. Sekai Chideya, MD, MPH Bureau of HIV/AIDS Prevention and Control NYC Department of Health and Mental Hygiene. Overview. Epidemiology of HIV – U.S. and NYC HIV Testing Recommendations and laws Why ‘opt-out’ testing?

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Improving HIV Testing and Prevention in New York City

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  1. Improving HIV Testing and Prevention in New York City Sekai Chideya, MD, MPH Bureau of HIV/AIDS Prevention and Control NYC Department of Health and Mental Hygiene

  2. Overview • Epidemiology of HIV – U.S. and NYC • HIV Testing • Recommendations and laws • Why ‘opt-out’ testing? • Assessing and reducing risk • Testing Patients • Who and how • The HIV-Positive Patient

  3. The HIV Epidemic Today United States1 • Total # HIV-Infected = 1.1 million • >56,000 new HIV infections per year • >44,000 new diagnoses in U.S. in 2007 • 1 in 5 HIV-positive individuals unaware of infection NYC2 • Total # HIV-Infected = 102,000 (1.3% population) • ~3,800 new diagnoses in 2007 • >2,000 deaths in 2007 (5 people every day) • Hall et al. JAMA. 2008;300:520-529 • New York City HIV/AIDS Annual Surveillance Statistics

  4. Who is Being Diagnosed in NYC? • 80% Blacks and Latinos • Blacks have higher rates of testing* • 73% Men • 80% Men who have Sex with Men (MSM) • 30% 13-29 years old • 27% Women • 17% ≥50 years old …Basically, everyone! * Anderson, et al. Natl Ctr Health Statistics; 2005

  5. You are here!

  6. HIV Testing Recommendations and Laws

  7. CDC Recommendations 2001 Guidelines recommend: • Offer testing in all health-care settings • Notify patients that HIV testing will be performed unless they decline (“opt-out”) • Obtain written consent • Include with general medical consent • Streamline pre-test counseling • Post-test counseling optional if negative test • Test high-risk people at leastannually

  8. New York State Laws • Agrees with most, but not all, CDC recommendations • HIV testing be voluntary • Pre-test counseling streamlined • Patient signature required • Separate, written informed consent still required (not “opt-out”) • Post-test counseling still required if negative test

  9. NYC Department of Health • Follows NY State Law • Supports CDC’s Recommendations • Testing remain voluntary • Informed consent with general consent • Opt-out model • Deemphasize pre-test counseling • Provide in-person or via videos, pamphlets • Brief post-test counseling

  10. DOH HIV prevention campaigns NYC DOH Testing Campaigns

  11. Opt-Out HIV Testing

  12. Opt-Out Testing: Rationale • Effective treatment is available • Late diagnoses are common • Patients don’t think they’re at risk • Many doctors don’t offer testing • Some patients think they’ve been tested • People who know their status change their behavior • Most patients want routinized HIV testing

  13. 1. Effective Treatment is Available • Testing guidelines and laws drafted when no treatment existed • HIV is now a chronic disease • >20 FDA-approved antiretrovirals (ARVs) • 20-year-old HIV+ person starting ARVs today expected to live to age 69* * The Antiretroviral Therapy Cohort Collaboration. Lancet 2008; 372

  14. 2. Late Diagnoses are Common Late Diagnosis = concurrent HIV and AIDS diagnosis or AIDS diagnosis within 3 years • 45% of newly-diagnosed people in the U.S. had an AIDS diagnosis within 3 years* • NYC: ¼ of all new diagnoses also have AIDS • Late diagnoses result in • Prolonged transmission • ↑ morbidity and mortality • ↑ health care costs *CDC, MMWR 2009;58(24):661–665

  15. Reasons for Testing: Late vs. Early TestersSupplement to HIV/AIDS Surveillance, 2000–2003

  16. 3. Patients Don’t Think They’re at Risk • Kaiser Foundation poll1: 69% people thought they were not at risk • GYN patients2: only 2% considered themselves high-risk but nearly half reported unprotected sex with more than one partner • Why? • “It’s a gay disease” • “I don’t use drugs” • “I’m monogamous” • “I’m too old” • “I feel fine” 1. Kaiser Family Foundation Survey of Americans on HIV/AIDS 2009 2. VH Coleman et al. Matern Child Health J, 2009

  17. 3. Patients Don’t Think They’re at Risk • Kaiser Foundation poll1: 69% people believed they were not at risk • Gynecology patients2: only 2% considered themselves high-risk but nearly half reported unprotected sex with more than one partner • Why? • “It’s a gay disease” – 40% cases heterosexual • “I don’t use drugs” – Sex is #1 transmission risk • “I’m monogamous” – But is their partner? • “I’m too old”– 1in 6 new cases is ≥50 yrs • “I feel fine” – Most people do until they develop AIDS • Kaiser Family Foundation Survey of Americans on HIV/AIDS 2009 • VH Coleman et al. Matern Child Health J, 2009

  18. 3. Patients Don’t Think They’re at RiskReasons for not being tested*among those never tested Source: Kaiser Family Foundation Survey of Americans on HIV/AIDS (conducted Jan. 26–March 8, 2009) *Interviewee may choose more than one reason, so total exceeds 100%

  19. 4. Doctors Aren’t Offering TestingReasons for not being tested*among those never tested Source: Kaiser Family Foundation Survey of Americans on HIV/AIDS (conducted Jan. 26–March 8, 2009) *Interviewee may choose more than one reason, so total exceeds 100%

  20. Why Aren’t Doctors Offering Testing? • Don’t have time • “Burdensome consent process” top reason* • “Patient looks like my mom, brother, etc.” • Counter-transference • Patient is difficult, non-adherent • Patient might be offended • Discomfort discussing it *Burke, et al., AIDS 2007, 21

  21. 5. Some Patients Think They’ve Already Been Tested Many patients assume they were tested as part of routine workup • Healthcare providers often say they’ve checked for “everything” • What does “everything” mean? • 23% of hospitalized patients incorrectly assumed that HIV was included among their blood tests* * McAdam, et al. International J of STD & AIDS 1997; 8

  22. 6. People Who Know They Have HIV Change Their Behavior ~1/4 Unaware of Infection Account for: ~2/3 of New Infections ~3/4 Aware of Infection ~1/3 of New Infections Marks et al., AIDS, 2006

  23. 7. Most Patients Want HIV Testing to be Routine

  24. Removing Separate Consent Increases Testing Mean Rate of HIV Tests, San Francisco Dept. Health Zetola, N. M. et al. JAMA 2007

  25. Your Role as a Doctor Until opt-out HIV testing adopted: • Assess risks – “every patient, every time” • Counsel on risk reduction • Offer testing • Facilitate Prevention with Positives

  26. Patients Don’t Self-Disclose Risks The ideal patient encounter… “Hi Doctor. Just to let you know, I inject drugs, had three STIs last year, and my partner is sleeping with other people.” This NEVER happens!

  27. Assess, Don’t AssumeYou can’t treat a problem if you don’t know it exists Only 35% of primary care physicians routinely ask patients about sexual behaviors* Tips for taking a sexual history: • Develop a routine • Utilize with all patients • Avoid moral or religious judgments • Clarify misinformation, dispel myths, and provide factual information * McCance, et al. Am J Prev Med 1991;7

  28. Are you currently sexually active? Have you ever been? Are your partners men, women, or both? How many partners have you had in the past 6 months? What method of contraception do you use? Do you or your partner(s) use any particular devices or substances (e.g., crystal meth) during sex? Do you have, or have you ever had, any risk factors for HIV? (List them out loud) Have you ever had any STIs? Have you ever been tested for HIV? Would you like to be? What do you do to protect yourself from getting HIV? Assessing Sexual Behavior:Sample Questions* Nusbaum. Am Fam Physician 2002; 66

  29. Risk Reduction CounselingYou know they’re at risk…now what? • Behavior change is a gradual process, not “all or nothing” • Ex., few smokers quit “cold turkey” – have to decrease # cigarettes, use NRT, etc. • Emphasize that your primary concern is their health and that they are in control • Clearly outline what is putting them at risk, then ask if they are willing to make some changes to be safer • Don’t pressure them if not ready/willing

  30. Risk Reduction Counseling (2) For willing patients: • Be nonjudgmental but avoid downplaying risks • Brainstorm with patient about acceptable alternatives • “What if you always carried a condom?” • “On the first of the month, buy syringes from Duane Reade instead of sharing used ones” • Refer, refer, refer: case management, psychiatry, etc. Don’t go it alone • Draft an informal contract on a Rx pad **Even if patients don’t want to discuss their sexual history, offer them HIV testing

  31. Offering HIV Testing

  32. Offering HIV Testing: Who • Everyone establishing care • Everyone getting a physical • High-risk patients (based on assessment) • Unprotected sex • Anyone wanting a STI or pregnancy test • Drug or alcohol dependent • “Frequent flyers” with recurrent illnesses • Mental health issues, if competent • Symptoms consistent with AIDS

  33. Offering HIV Testing: How • Introduce topic • Provide brief pre-test counseling (face-to-face, video, or written) • Answer any questions • Get consent • Provide post-test counseling

  34. Introduce the topic Reassure patients that you offer it to everyone. • “I’d like to include an HIV test on your lab panel because I think it’s important that everyone know his/her HIV status.” • “I recommend HIV testing to every (new) patient getting a physical, no matter his/her age….” • “HIV is preventable and treatable, just like high blood pressure or diabetes. So it’s important to check for it, just like those other diseases.”

  35. Obtaining Consent • Answer questions - expertise not needed 2. Obtain consent Minimal Requirements • Present HIV Consent Form Part A to patient • Patient signs Part B • Perform test • Provide “Information on Negative HIV Test Result” to those who test negative www.health.state.ny.us/diseases/aids/regulations/2005_guidance/negativetestresults.htm

  36. The HIV-Positive Patient So, what do you do if patient is positive? • 1st, confirm it with Western Blot • Reassure that not a death sentence • Complete Provider Report Form (PRF) • Facilitate: • Partner Notification (PN) • Counseling on how to stay healthy and safe • Linkage to care • Case management • Pharmacotherapy, if indicated

  37. The HIV-Positive Patient So, what do you do if patient is positive? • 1st, confirm it with Western Blot • Reassure that not a death sentence • Complete Provider Report Form (PRF) • Facilitate: • Partner Notification (PN) • Counseling on how to stay healthy and safe • Linkage to care • Case management • Pharmacotherapy, if indicated “PWP”

  38. Prevention With Positives (PWP) • PWP: Any activity that reduces the likelihood of HIV transmission to others • PWP aims to prevent the ~1/3 of all new infections due to transmission from known HIV-positive people • NYC: # new cases from 3,800/yr  2,500/yr

  39. Examples of PWP • Making people aware of their HIV status • Facilitating partner notification • Keeping viral loads low • Practicing safer sex • Prevention of mother-to-child transmission • Syringe exchange for HIV+ drug users • Housing support • Many other activities…

  40. Making PWP Successful • Ask, ask, ask: regularly reassess behavior • Come up with a few responses to convince people to talk freely • Frame PWP in a life-affirming way that emphasizes their safety • “Using a condom will give you peace of mind and will also protect you from STIs that could make your HIV worse.” • “Not sharing needles makes it less likely you’ll get Hepatitis C” • Collaborate with social service providers

  41. PWP at the Facility-Level • Prioritize cultural competency regarding ethnicity, language, religion, etc. • Have low-literacy materials in Spanish, Russian, Creóle, French, etc. in your waiting rooms and offices • Put PWP-related questions on intake and examination forms • Make PWP a quality improvement (QI) criteria

  42. You CAN make a difference.Remember…“Every Client, Every Visit”Thank you!

  43. Partner Notification Options • Provider/DOHMH-assisted • Contract notification with patient • Anonymous notification

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