Making HIV testing routine

1. Making HIV testing routine Pennsylvania’s Act 148 and the new CDC recommendations

2. Presenter • David Herrera-Korman, JD • Pennsylvania/MidAtlantic AIDS Education and Training Center • University of Pittsburgh • Graduate School of Public Health

3. Contents • Part I: Background • Part II: Guidelines • Part III: Current Law • Part IV: Implications • Part V: Putting the Puzzle Together • Part VI: Challenges

4. Part I: Background Current statistics on HIV/AIDS in the United States

5. Who has recently been tested for HIV? • In the Kaiser Family Foundation Survey of Americans on HIV/AIDS: • 21% were tested within the past 12 months • 34% were tested, but not within the past 12 months • 42% were NEVER tested. • Universal agreement: HIV testing should be routinely offered to increase number of people tested. Source: Kaiser Foundation Survey, 2006

6. Prejudice/Discrimination against people with HIV/AIDS • What do people perceive to be the current level of prejudice/discrimination? • 45% believe there is “a lot” of prejudice against those living with HIV/AIDS. • 36% believe there is “some” • 11% believe there is “only a little” • 5% “Don’t know” • 3% “None” • Universal agreement: Stigma poses a serious challenge to testing acceptance. Source: Kaiser Foundation Survey, 2006

7. Stigma and HIV/AIDS • How would being tested for HIV affect other’s perception of you? • 62% “No difference” • 21% “Think less of me” • 9% “Think more of me” • 7% “Depends/don’t know” Source: Kaiser Foundation Survey, 2006

8. Awareness of status and access to care • Estimate based on current population living with HIV/AIDS: • 50% are in care • 25% are undiagnosed • 25% are diagnosed but not in care Source: Kates and Levi, 2006

9. Part II: Guidelines Why revise current guidelines?

10. Why revise the guidelines? • Approx. 1-1.2 million persons are living with HIV in the US. • ¼ of these are unaware of their infection • Unable to benefit from clinical care • These persons who are unaware may transmit disease unknowingly. Source: CDC recommendations (2006)

11. Why revise the guidelines? • Revised guidelines are an attempt to routinize testing with the ultimate goal of reducing the number of persons who are unaware. • The majority of persons who are aware will reduce risk behaviors that can transmit disease. • Risk behavior- 68% lower for persons who were aware than for persons who were unaware Source: CDC recommendations (2006)

12. How to increase HIV+ diagnosis • Make testing routine • Only 10% of ER providers encouraged STD patients to undergo HIV testing. • Only 35% referred patients to confidential testing sites. • Actual number tested is probably much lower. Source: CDC Recommendations (2006)

13. What does routine testing do? • Destigmatizes HIV testing process • Assessment of risk behaviors • Many people do not perceive themselves to be at risk or do not disclose risks • More patients accept HIV testing when it is offered to everyone • Opt-out policy • Reduces HIV transmission • Ignorance is not bliss! • Prolongs life Source: CDC recommendations (2006)

14. When is routine testing effective? • Opt-out screening • HIV screening is higher using opt-out rather than opt-in programs. • Opt-in requires pre-test counseling and written consent. • Pregnant women experience less anxiety with opt-out HIV screening Source: CDC Recommendations (2006)

15. When is routine testing effective? • Linking of infected patient with preventive and care measures • HIV screening without linkage to care confers little to no benefit to patient. • Ensure immediate access to clinical care. Source: CDC recommendations (2006)

16. Views on routine testing • Should HIV testing be treated like routine screening for other diseases? • 62% “Yes” • 27% “No- HIV requires special procedures” • 5% “Don’t know” • 4% “Neither/Both” • Routine testing in PA would treat HIV testing more similarly to routine screening for other diseases, but would still require consent. Source: Kaiser Foundation Survey, 2006

17. The role of the physician • Women are more likely to be tested when they perceive a strong recommendation from their health-care provider. • Adolescents prefer to receive HIV prevention information from a health-care provider rather than a parent, teacher, or friend. • 58% of adolescents tested for HIV cite primary care provider as primary reason for being tested. Source: CDC Recommendations (2006)

18. Role of the physician continued • Where are people with HIV/AIDS being diagnosed in the US? • 44% in Private MDs/HMOs • 22% Hospitals/EDs • 9% Community Clinics • 5% HIV C&T • 1% Corrections • 1% Drug Treatment Clinics • 0% STD Clinic Source: Kates and Levi, 2006

19. Cost effectiveness of routine screening • As cost-effective as other routine screening programs • i.e. breast cancer, colon cancer • In populations with HIV prevalence >0.1% • Screening reaches cost-effectiveness at the stage of early diagnosis Source: CDC Recommendations (2006)

20. Part II: Guidelines Continued CDC Recommendations

21. Goal of the CDC Recommendations • Maximize the number of persons who are aware of HIV status, particularly those who are HIV infected, and increase the number of HIV infected persons who receive care and prevention services.

22. CDC Recommendations- what doesn’t change • The new recommendations DO NOT modify existing guidelines for persons who receive testing in non-clinical settings • THESE RECOMMENDATIONS ARE FOR HEALTH-CARE SETTINGS ONLY

23. Recommendations on screening • Routine testing for all patients ages 13-64 • All patients treated for TB should be screened for HIV • All patients seeking treatment for STDs should be screened routinely for HIV, regardless of risk behavior. Source: CDC recommendations (2006)

24. Recommendations on repeat screening • All “higher” at-risk persons should be tested at least annually. • IV-drug users and their sex partners • Men who have sex with men (MSM) who have had more than one sex partner since most recent HIV test • Encourage testing for patients before initiating new sexual relationship. Source: CDC recommendations (2006)

25. Recommendations on consent and pretest information • Testing is voluntary • Patient should have full knowledge and understanding that test will be performed. • Opt-out screening • Consent incorporated into general informed consent (no separate test form) • Informational materials should be made readily available (language appropriate)

26. How recommendations differ from previous versions • Opt-out screening • Annual screening for those at “higher” risk • Results provided in same manner as other diagnostic tests. • Prevention counseling not required. • HIV testing is considered distinct from counseling as a preventive measure. • Post-test counseling for positive tests only.

27. Part III: Current Law Pennsylvania’s Act 148 of 1990

28. Act 148 of 1990 • Requirements for HIV testing • Consent • Pretest Counseling • Confirmatory test • Notice of test result • Post-test Counseling

29. Consent • Testing is voluntary* (Opt-in) • Must be WRITTEN • Must be obtained BEFORE testing • Must include an explanation of the test • Purpose of test • Potential uses • Limitations • Meaning of results • CDC Recommendations: Oral consent/opt-out

30. Pretest Counseling • Must include information on • Prevention of HIV • i.e. condoms/safe sex, “works”, personal items • Exposure to HIV • i.e. alcohol, needles, sex • Transmission of HIV • i.e. sex, perinatal transmission, injection drug use • CDC Recommendations: no pretest counseling

31. Confirmatory Test • No test result can be concluded as positive without a confirmatory test • No positive test result can be revealed without confirmatory test • Dialogue: “We need to do further testing.” • Should not say, “You tested positive.”

32. Notice of test results • Physician who ordered the test shall inform the subject in person of the test results • Physician’s designee or successor may also deliver the test results • Typically nurse or HIV counselor

33. Post-test Counseling • Must be provided IMMEDIATELY after the results are delivered (for both positive and negative results). • Must have the opportunity for individual, person-to-person counseling. • CDC Recommendations: Counseling for only Positive Results

34. Post-test Counseling continued • Counseling for both Negative and Positive results must include: • Explanation of the what the results mean • Measures for prevention of transmission • Importance and benefit of locating and informing/educating individuals that engaged in risk behavior with the subject about risky behavior • Inform subject of resources

35. Post-test Counseling continued • Additional counseling for Positive Results must include: • Information about healthcare services available • Including mental health services • Importance and benefit of locating and counseling any individual who may have been exposed by the subject • Inform subject of resources

36. Minors • Parental consent is not needed to test minors for HIV • Minor can give consent without parental notification • Results are delivered to minor, not to parents • Parents are only notified at minor’s request • CDC Recommendation: Routine testing of everyone ages 13-64

37. Part IV: Implications What do these changes mean for health care providers?

38. Implications • “To access all individuals who are at risk for infection, routine testing should be offered at various clinical sites, including primary care offices, health clinics, hospitals, urgent care centers, emergency departments, and clinics for the treatment of sexually transmitted diseases…” Beckwith et al (2005) • What does this mean for: • Treating clinicians? • Health care facilities? • Emergency departments?

39. Treating Clinicians • Clinicians will need to be prepared to: • Work with HIV positive patients • Provide pre and post-test counseling • Deliver test results • Have support systems in place for those patients who test positive • Have materials readily available for patient counseling

40. Health Care Facilities • Health care facilities will need to be prepared to: • Follow-up with patients to provide post-test counseling, especially to those who do not receive rapid testing • Spend more time talking with and counseling patients • Have materials readily available for patient counseling

41. Emergency Departments • Emergency departments will need to be prepared to: • Utilize rapid testing techniques • Follow-up with patients to provide counseling, especially to those who do not receive rapid testing • Deliver counseling quickly yet thoroughly • Have materials readily available for patient counseling

42. Emergency Departments • 110 million ED visits in US per year • In a two-year study, the ED accounted for 19.8% of all tests, but identified 24.7% of all HIV + cases. - Lyons et al. (2005) • In another study, twice as many new cases of HIV were detected among patients discharged vs those admitted. –Kelen et al. (1999) • ED’s are an important piece of the testing puzzle!

43. Part V: Putting the puzzle together… Reconciling CDC recommendations with PA’s Act 148

44. Reconciling recommendations with state laws • What can be done? • Implementation of new strategies that fall within the boundaries of the law. • Speed up counseling. Ex: ACTS • Speed up testing. Rapid Testing

45. ACTS • From www. adolescentaids.org • Four step process designed to make provider-delivered HIV testing feasible in clinical care settings.

46. Fast facts on ACTS • Provides instruction and tools for making operational and clinical practice changes. • Meets CDC testing requirements. • Condenses 45-minute process to 5-10 minutes. • Allows for better allocation of counseling resources. Source: ACTS NRC Training Guide

47. ACTS continued • Step 1: Source: ACTS Pocket Guide CDC Recommendations: Testing for all patients aged 13-64

48. Assessing the patient: dialogue • “I discuss routine HIV testing with all of my patients. I’d like to tell you about the benefits of getting an HIV test…” • “I’d also like to make sure you understand how the virus is transmitted. What do you know about HIV transmission?” • “I recommend getting an HIV test today. The visit will be short and we can discuss safer sex methods following the test.” • “Do you have any questions or concerns?”

49. ACTS continued • Step 2: Source: ACTS Pocket Guide CDC Recommendations: Oral consent is OK, no pre-test counseling *PA LAW requires written consent AND pre-test counseling.

50. Beliefs of many HIV/AIDS advocates • Pre-test counseling is valuable, especially for people who test negative but are at high-risk. • Written informed consent: • Ensures that individuals fully understand their decisions • Ensure individuals are protected from medical abuses. • Is not cumbersome, time-prohibitive, or an impediment to testing acceptance. Source: Munar, AIDS Foundation of Chicago, 2006