HIV Counseling, Testing, Partner Notification

1. HIV Counseling, Testing, Partner Notification Policy and Regulations for New York State Presented by David Odegaard, MPH Director of Training and Education, STAR Program, SUNY DMC

2. True or False • Less than 5% of the US population who are infected with HIV do not know they have HIV.

3. True or False • If you go to your primary health care provider for an annual exam that includes blood tests, you automatically get tested for HIV.

4. True or False • Under New York State HIV testing law, you don’t need to consent – just get the test.

5. True or False • If you test positive, your partners are automatically informed by the New York State that they have been exposed to HIV.

6. US HIV Testing Norms: Then and Now 1986 • No effective treatment: HIV care centered on case work • Discrimination against those infected: MSM, IDU, immigrants & sex workers • HIV C&T offered to ‘high risk’ patients (shifting from group to behavior) • Dedicated counseling model: • 4-5 day training • Certified counselors for enhanced Medicaid reimbursement 2014 • Many effective treatments: HIV managed as chronic disease • HIV discrimination reduced & at-risk populations have changed • HIV C&T offered to all patients • Diversified counseling model: physicians, nurses, nurses aides, social workers, etc 7

7. US HIV Testing Norms: Then and Now 1986 • HIV testing only offered at specialty centers • Long counseling sessions, lengthy risk assessments • Two week results turnaround • Partner notification not emphasized • In NYS: C&T regulations limit testing: • mandated counseling • written consent 2014 • NYS 2010 Law: Mandate to offer HIV test PC setting, 13-64 • Shorter counseling sessions, minimal risk assessment • Rapid testing encouraged in all settings • HIV prevention for HIV patients emphasized • MAY 2014: NO MORE WRITTEN CONSENT 7

8. HIV Exceptionalism: Impact on HIV testing policy and practice • Should HIV be treated differently than other infectious diseases?

9. HIV Exceptionalism: TB and HIV • # of people infected with TB bacilli: 2 billion • # of people infected with HIV 33.3 million

10. HIV Exceptionalism: TB and HIV • # of new TB cases (2007): • # of new HIV cases (2009):

11. HIV Exceptionalism: TB and HIV • # of new TB cases (2007): 9.77 million • # of new HIV cases (2009): 2.6 million

12. HIV Exceptionalism: TB and HIV • # of deaths attributable to TB (2007) • # of deaths attributable to AIDS (2009)

13. HIV Exceptionalism: TB and HIV • # of deaths attributable to TB (2007): 1.77 million • # of deaths attributable to AIDS (2009): 1.8 million

14. TB Screening DOT (quarantine) No separate consent or confidentiality law Aggressive, mandatory contact tracing HIV Targeted testing Adherence counseling Separate consent form Separate confidentiality law Voluntary partner notification TB vs. HIV

15. Driving HIV Policy • Then: • Protection of civil liberties of people with HIV • Now: • Treatment as prevention

16. According to the CDC, what percentage of people infected with HIV in the U.S. do not know they are infected? • About 25%

17. HIV Incidence in the U.S. • Transmission is higher among people unaware of infection • Risk behavior is reduced with awareness of HIV+ status: • 68% reduction in unprotected sex

18. Trends in Annual Rates of Death due to the 9 Leading Causes among Persons 25−44 Years Old, United States, 1987−2010 Note: For comparison with data for 1999 and later years, data for 1987−1998 were modified to account for ICD-10 rules instead of ICD-9 rules.

19. Measuring the HIV Continuum of Care: The Treatment Cascade 79% 62% 41% 36% 28% Using data from 3 different surveillance systems, able to measure engagement in care Source: MMWR Vital Signs, Dec. 2, 2011, Vol 60 (47).

20. Key Provisions in NEWNew York State Law Signed into law September 1 2010. • Providers legally mandated tooffer HIV testing to all persons ages 13 – 64. • Specific consent for HIV test is still required. Prior to asking for consent to perform HIV test, providers must makesevenpoints of information about HIV available to patients. • Consent for HIV testing can be incorporated into general consent for medical care.

21. Key Provisions in Law (cont.) • Consent for the rapid HIV test can be oral • Test providers are legally required to arrange an appointment for follow-up HIV care to all persons who test positive for HIV • HIV information may be released to medical providers & health insurers without a written disclosure statement from patient

22. Required Offer – Where? • In these health care settings: • Inpatient department of hospitals • Emergency departments • Primary care services in outpatient departments of hospitals • Primary care services in diagnostic and treatment centers (includes school-based clinics & family planning sites)

23. Which Providers are required to offer HIV screening? • Physicians, physician assistants, nurse practitioners, or midwives providing primary care* regardless of setting • *Primary Care means the medical fields of: • family medicine • general pediatrics • primary care • internal medicine • primary care obstetrics/gynecology

24. Required Offer – Exceptions • When the individual is being treated for a life threatening emergency • When the individual has previously been offered or tested for HIV (unless otherwise indicated due to risk factors) • When the individual lacks capacity to consent (and no other person is available to provide consent)

25. Offer vs. Testing • The new law mandates the offer of HIV testing only, not testing itself • In NYS, HIV testing remains voluntary and requires the consent of the person to be tested (or someone authorized to consent for that person) • There are some general exceptions to voluntary testing, but these have not changed

26. Exceptions to Voluntary HIV Testing • Newborn screening • Blood, body parts, and organ donations • In order to participate in some federal programs, e.g., Job Corps and the Armed Forces • Under certain conditions, inmates in federal prisons (but not in state or local correctional facilities) are tested for HIV without their consent • Sexual assault defendant testing • For certain types of insurance

27. Why Counsel Prior to HIV Testing? • Opportunity to conduct risk assessment with patient. • Assess patient’s readiness to test (Is it ever an ‘emergency’ to test?) • Prepare patient and clinician for possible positive results. • Opportunity for risk reduction counseling/ behavioral change intervention* • Provide education on treatment • Helps encourage patient to return for results

28. Post-test Counseling • HIV post-test messages must be tailored to status • Post-test messages for negative results do not have to be delivered in person • Providers can hand an information sheet or brochure to patients.

29. Post-Test Messages forNegative Test Result • Negative post-test messages • Describe meaning of the test result • Discuss possibility of HIV exposure during the last three months • Emphasize risks associated with participating in sexual and needle-sharing activities • May want to refer high-risk clients to intensive prevention programs

30. Post-Test Counseling forPreliminary Positive Test Result • Positive post-test counseling messages must explain that • ELISA (EIA) screening is NOT diagnostic and must be followed up by: • Confirmatory Western Blot test • Explain the timeframe and location for providing the person with a confirmatory HIV test and the result • Ask the individual if he or she understands the meaning of the ELISA antibody test result

31. Appointments for Confirmed Positive Test Results Key provision #7 • The person ordering the HIV testis legally required to provide or arrange follow-up HIV medical care for all persons who test positive • For legal compliance, the individual’s medical record/client file must reflect name of provider/facility with whom follow-up appointment was made.

32. HIV Disclosure and Confidentiality

33. Disclosure PracticesHave Not Changed • “HIPAA Compliant Authorization for Release of Medical Information and Confidential HIV Related Information,” still to be used to authorize release of HIV-related information

34. Confidentiality case: Setting: 2005, small community-based clinic • A two clinicians discussed a patient’s HIV negative test results in an exam room with an open door. • An HIV positive patient heard them identify the name and reasons for testing of the patient under discussion. • Patient felt he knew who they were discussing. • Patient complained to the administration that he felt confidentiality at this clinic was not respected. • Patient did not return to the clinic and was lost to follow-up.

36. 1988: New York State enacts Public Health Law, Article 27-F • In the historical context of discrimination, New York State passes Public Health Law specific to HIV. • Protects confidentiality of those tested for HIV, exposed to HIV, infected with HIV. • Requires people who take a voluntary test for HIV sign a consent form: the person understands what the test means and agrees to take it.

37. 1988: New York State enacts Public Health Law, Article 27-F (continued) • Requires that information about a person’s HIV status can only be disclosed if the person signs an HIV release form (with noted exceptions). • Applies to individuals and facilities that provide health and social services to people with HIV or testing for HIV.

38. HIV/AIDS STIGMA “HIV/AIDS stigma is manifested through discrimination and social ostracism directed against individuals with HIV and AIDS, against groups of people perceived to be or likely to be infected, and against those individuals, groups, and communities with whom these individuals interact.” Source: Herek, G.M., & Capitanio, J.P. 1998. Symbolic prejudice or fear of infection? A functional analysis of AIDS-related stigma among heterosexual adults. Basic Applied Social Psychology, 20(3), 230-241.

39. Challenges to HIV Confidentiality in New York State • 1997: Mandatory unblinding of newborn heelsticks for HIV antibodies (effectively discloses HIV status of all pregnant women) • 1997: Nushawn Williams case: 20 yo male infects 16 females with HIV, 9 of whom are from Chautauqua County, NY • 2000: Partner notification and mandatory HIV names reporting law enacted

40. Is HIV confidentiality necessary? • Era of HIV exceptionalism over? • HIPPA covers all medical record confidentiality, including HIV • In minority ethnic and rural populations, HIV stigma is thought to be higher than urban MSM communities • Stigma remains: confidentiality law remains.

41. ACTG 076ReducingPerinatal HIV Transmission • Large randomized double-blind placebo-controlled study • Tested a 3 part regimen of AZT • Orally to 180 women starting at 14-34 weeks gestation throughout pregnancy • IV during labor and delivery • Orally to infants for 6 weeks • 184 women were given placebo

42. ACTG 076 Results • Transmission in placebo group= 25.5 % • Transmission in AZT group= 7.6 % • Two thirds reduction in transmission • Findings highly significant

43. In utero 25-40% Intrapartum 60-70% Breastfeeding: Additional 12-14% risk, highest in the first weeks of life When does Mother to Child Transmission Occur?

45. Expedited Testing (ET) Program • Prenatal HIV testing status of all mothers is assessed on admission to site for delivery • If mother’s HIV status is unknown, improperly documented, or undocumented, you must offer expedited testing (informed consent is required to test the mother)

46. Expedited Testing • If the mother declines test, baby is tested immediately after birth (no consent required) • HIV testing of infant is also done as part of Newborn Screening panel.

47. New York State Expedited Testing Regulations Effective November 1, 2003 • Screening test result must be returned ASAP, and must be received no later than 12 hrs after: • Mother consents to testing • Birth of baby • All preliminary positive results must be reported to DOH regardless of confirmatory result

48. Primary HIV Infection: Pathogenesis CD4 Cell Count (cells/mm³) Symptoms Plasma RNA Viral Load 1,000 CD4 Cell Count 500 4-8 Weeks Up to 12 Years 2-3 Years

49. Acute HIV Infection (AHI) • High infectious stage: high viremia. Amplification of transmission with co-existing STIs • Risk of further transmission if diagnosis is missed • Enhanced case finding: Partner Notification and sexual network interventions can lead to more AHI cases or undiagnosed established infections

50. Planned Public Health Response for detection and f/u of AHI in Pregnancy • Intensify efforts to engage high-risk pregnant women in prenatal care • Educate prenatal providers about acute HIV infection during pregnancy • Advise immediate HIV RNA (viral load) and antibody testing for pregnant woman with symptoms of acute HIV infection • Recommend routine second HIV antibody test in third trimester