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

1. 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

2. 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

3. Steps Leading to HIV Testing • Identify persons at risk for HIV • Use of epidemiology & surveillance data

6. 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

8. 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 State’s Regulation of Reportable Conditions, including HIV

9. Steps Leading to HIV Testing • Identify persons at risk for HIV • Find infected persons who are unaware of their HIV status

10. The Bronx KnowsGet Smart, Get Safe, Get Tested

11. 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

12. HIV Screening Facilitators and Barriers

13. CDC’s Revised Recommendations

14. 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 CDC’s Recommendation for Testing in Health-Care Settings

15. 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 March:167-76

16. Medicare Preventive Services include HIV Screening Tests

17. 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

18. 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 Medicare Coverage of HIV Screening

19. Patient Don’t Always Disclose • NYC National HIV Behavioral Surveillance project (2004–2005) • 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. 2008;168(13):1458-1464

20. Sexual Identity Don’t 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. 2006;145:416-425

21. Example: South Carolina Of 4,300 newly reported HIV cases 3,100 (73%) made >20,000 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%) Missed Opportunities:Many HIV-Infected Persons Access Health Care But Are Not Tested MMWR December 1, 2006

22. Kaiser PermanenteMissed Opportunities • 440 patients with new HIV diagnosis • Mean: 8.6 health-care contacts before positive HIV test • CD4 count at diagnosis: • 62% < 350 • 43% < 200 • 18% <50 • Only 26% had risk factors documented in chart - Klein D, et al JAIDS 2003

23. Reported Reasons for Not Being Tested*Among 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. 26–March 8, 2009) *Interviewee may choose more than one reason, so total exceeds 100%

24. 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

25. 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

26. 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. 2007:1617-1624.

27. HIV Testing in San FranciscoBefore/After Elimination of Consent Requirement Zetola, JAMA, March 14, 2007

28. 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

29. 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

30. 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

31. 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