Welcome! AETC HIV Testing Collaborative

1. Welcome! AETC HIV Testing Collaborative For the audio portion of this meeting: Dial 1-888-205-5513, Enter participant code: 987837# Please turn off your computer speakers

2. Agenda • Welcome • Updates from CDC and HRSA • Benny Farro, Diana Travieso-Palow • Presentations • Finding Unaware Youth: Thinking Outside (and inside) the box • Lisa Hightow-Weidman, MD, MPH Associate Professor of Medicine University of North Carolina, Chapel Hill • Scaling up HIV Testing for Youth • Donna Futterman, MD Director, Adolescent AIDS Program Professor of Clinical Pediatrics Children's Hospital at Montefiore Einstein College of Medicine • Next Call

3. Finding Unaware Youth Thinking Outside (and Inside) the Box Lisa Hightow-Weidman, MD, MPH Associate Professor of Medicine University of North Carolina at Chapel Hill

4. HIV testing among youth? • In 2009, 59.5% of youths with HIV were unaware of their infection (highest for any age group) • The percentage of youths tested for HIV overall was 12.9% among high school students(22.2% among those who had ever had sex) and 34.5% among those aged 18–24 years • Lower among males than females, and lower among whites and Hispanics than blacks CDC Vital Signs MMWR November 27, 2012

5. 68,600 youth living with HIV at the end of 2008;, nearly 60% did not know they were infected. Rates are disproportionately high among black and Hispanic adolescents and young MSM. In 2011, an estimated 10,347 youth were newly diagnosed with HIV infection.

6. CDC: Young Adults and Adolescents Are More Likely to Be Unaware of Their HIV Infection Estimated Percentage of Persons Living With HIV Infection Whose HIV Infection Was Undiagnosed—United States, 2008 80 60 Persons Living With HIV Infection Whose HIV Infection Was Undiagnosed, % 40 20 0 Gender Age Range, Years CDC. MMWR. 2011;60:689-693.

7. Increase motivation to test (change risk perception) • Increase access to counseling and testing services • Minimize the potential negative consequences of testing by providing support (including immediate linkage to care) • Change community attitudes around HIV, particularly the benefit of knowing one’s HIV status Finding the Unaware

8. Home Testing • Cost • Access • Age restrictions • Linkage to care

9. Embed testing in an online intervention

10. Home Collection Allows for linkage to care and treatment Availability of Doctor to discuss test results Videos embedded demonstrating collection procedures

11. Using incentives for motivation • Reinforcing desired behavior through rewards • Money • Points • Virtual or real “prizes” • Collaborative gaming environments foster long-term, repeat interaction with core content, facilitate learning, and promote competition

12. Selling the “testing experience”

13. Selling the “testing experience”

14. Reaching Youth Online: Sexually Explicit Websites • 70% of men aged 18-24 visit sexually explicit websites in a typical montha • Link to home testing or free testing • Ads as triggers to test: • Unprotected anal sex • Symptoms of acute HIV infection aOnlineMBA.com

15. Reaching Youth: what the private sector would do) • Radio • Pandora or other radio sites • Television • Rupaul’s drag race • Sporting games • Online • Both Social and Hook up sites • Products • Energy drinks • Clothing lines • Celebrities • Musicians/Hip-hop artists • Athletes

16. Recognition of Acute HIV • Provider/Community education • Pediatricians • School nurses • Parents • Is there an app for that?

17. Using social/sexual network analysis for case finding? • Undiagnosed cases may cluster within networks • Clustering may extend beyond immediate partners and reach several degrees of separation. • Individuals unaware of their HIV infection may be connected together in network chains • Target HIV testing (followed by biomedical interventions, e.g., ARV treatment and PrEP) at members of undiagnosed clusters for maximal public health impact

18. Harnessing the Power of Social Media

19. Social media landscape is “dynamic”

20. Can social media lead to social good? • What determines? • Like • Share • Unlike • Move on/ignore

21. Social Media Driven PSAs

22. Increased participation from relevant celebrities

23. Increased Access to Sexual Health Services • MSM specific clinics or wellness centers • Train providers (pediatricians, family practitioners) to provide comprehensive care to MSM clients • Focus on improving patient-provider relationships

24. School-Based Programs • In Fall of 2012, 14.8 million students were in grades 9-12 • School Health Policies and Programs Study 2006 indicates that among U.S. high schools: • Only 24% provided services for LGBT students • Only 5% provided condoms • More comprehensive health services • Provision of rapid HIV testing by school nurses or via direct referrals

25. Virtual “Safe Spaces”

26. Virtual Testing Clinics • Use avatars to role play and try out different scenarios • Provider-patient communication • Navigating the health care setting • Taking the test • Dealing with results

27. Novel technology-based interventions to engage and motivate youth should be considered • Consider these ideas as a package of potential interventions to help facilitate HIV testing for youth • The fit of each intervention may depend on race, age, gender, sexual identity • Behavior changes with these interventions may be subtle at first • While messages may not motivate youth to test the 1st or 2nd time. They may “prime” them and make testing seem less threatening • Repeated delivery of these may be necessary

28. Concluding Thoughts • Implementation of the National HIV/AIDS Strategy should include increased investments in prevention and expansion of service delivery programs that target the most vulnerable youth while continuing efforts to address HIV in all young people • Expanded access to youth-friendly, comprehensive and culturally-grounded HIV-related education and healthcare must be available • As we move forward to test more youth, we must also prioritize the Treatment As Prevention research agenda as it pertains to youth

29. Scaling up HIV Testing for Youth AETC | May 2014 Donna Futterman, MD Professor of Clinical Pediatrics, Einstein College of Medicine Director, Adolescent AIDS Program, Children’s Hospital at Montefiore

30. AIDS is NOT Over for US Youth 39%New HIV infections among youth 13-29 Only age group with rise in new infections 20KUS youth infections annually - 1 every hour 70%US youth infections among MSM >2/3 HIV+ youth sexually infected (25% young women) >3/4HIV+ youth are racial/ethnic minorities >60%HIV+ youth untested Growing numbers Perinatally-infected aging into adolescence (n=7000) AdolescentAIDS.org

31. The Power of Routine Testing Prolongs Life • HIV treatment can improve quality of life and increase survival by many years/normal life span Reduces HIV Transmission • Lower viral loads from ARV reduce transmission (96%) • HIV+ people who know their status reduce high-risk sex by about 50-65% Preserves Resources • Successful ARV reduces overall care costs for HIV+ AdolescentAIDS.org

32. Reducing New HIV Infections NHAS • Testing & linkage to care is current BEST strategy • Most HIV+ youth asymptomatic: testing must be: Routine • Scale up and promote to youth in Medical, ED, SBC, CBO, detention settings • Low numbers but high benefit • Its the law in NYS Targeted • Gay youth and women of color • Importance of ongoing/repeat testing AdolescentAIDS.org

33. New HIV+ Patients 2012ATN Query n=506 Los Angeles Boston Denver New York Philadelphia Baltimore DC Tampa Miami New Orleans Chicago Memphis Detroit Houston AdolescentAIDS.org

34. Patient Characteristics 2012ATN Query n=506 AdolescentAIDS.org

35. New HIV+ Referrals 2012ATN Query n=506 (396 Male, 101 Female, 9 TG) Black >70% in all regions except West (47%) and NE (60%) Latino <16% in all regions except West (26%) and NE (20%) White <11% in all regions except NE (18% and Boston: 52%) Females <15% in all regions except South (28%) and MidAtl. (46%) Race AdolescentAIDS.org

36. Referral Sources 2012ATN Query n=506 Medical >30% in all regions except West (19%) DoH <22% (3-22%) in all regions except South (36%) CBO/NGO >16% except South (10%) & MidAtl. (12%); Note West = 56% Self/Partner/Family >10% except in MidAtl. (0%) & West (7%); Note NE = 23% AdolescentAIDS.org

37. Universal Testing: The Challenges First step on the HIV Care Continuum but success relies on non-HIV care system • In 2011, only 7.4% of eligible patients tested among the 17M treated at HRSA CHCs Persistence of provider resistance to testing • Risk-based testing works; HCT doesn’t belong in routine care • Prevention counseling integral to testing • Only counselors/SWs know how to counsel pts • Providers lack time and experience for testing • Fear of giving HIV+ results • Current staff already overextended AdolescentAIDS.org

38. Why Testing Is Our Job • Testing not routine so we have missed/late diagnoses - NYC: 40% diagnosed HIV+ develop AIDS in 1 year • For some, this may be ONLY visit to a doctor/CBO • Patients expect doctor to recommend what’s good for their health; assume they’re tested • Health care providers can help to de-stigmatize HIV • HIV prevention education is important, but does not need to be linked to the test • Ongoing testing needed for those most at risk AdolescentAIDS.org

39. Why The Bronx? Epidemiologic • Bronx pop. 1.3 million, larger than Boston, SF, DC • HIV death rate higher in Bronx than Citywide • 40% first diagnosed with AIDS Public Health • CDC: Routine HCT if HIV prev. >1% | Bx = 1.3% (.2-2.7%) • Leadership opportunity: Bronx has strong network of collaborative health and community providers • Majority of HIV+ pts. identified in clinical settings • Montefiore learning lab: provides care for 1/3 of Bronx AdolescentAIDS.org

40. AAP/MMC: A Decade of Work Moving HIV Testing Forward • Successful trial of ACTS at 10 MMG clinics (2003-8) • Municipal Routine HCT Movement born in DC (2006) • CDC/PEPFAR funding for Province-wide scale up in South Africa (2007-now) • Initiation of “The Bronx Knows” with DOH (2008-now) • NIH Test and Treat Trial: Bronx and DC (2010-now) • Montefiore scale up after NY State law (2011-now) • Outpatient, Inpatient, Emergency AdolescentAIDS.org

41. Managed Practice Change Utilizing existing resources • Buy-in • Implementation Planning • Training & Mentoring • Monitoring & Evaluation Streamlined C&T Integrating HCT into routine care Advise Consent Test Support + AdolescentAIDS.org

42. ACTSHIVTest.org

43. ACTS Success in 10 Bronx CHCs ACTS begun ACTS begun AdolescentAIDS.org

44. ACTS South Africa • 2007: AAP/MMC awarded 5yr grant to scale up routine testing in Western Cape’s 400+ DoH clinics • 19% HIV prevalence in Western Cape • ACTS trained & mentored 4500 nurses/doctors + LCs • ACTS significantly increased monthly HIV testing in all 6 districts: from 31,000 to 47,000 tests/month (>50% gain) • ACTS now being scaled up in four additional provinces: NC, EC, KZN, Gauteng

46. 1 Million Tests7,400 Diagnosed HIV+

47. LESSONS LEARNED • Strong leadership commitment with clearly defined expectations and accountability are key • Involve staff who will be expected to offer HIV testing in the Implementation Planning phase • Modify policies and protocols to reflect new work flow • Utilize technology (EMR) to facilitate routine offer • Ensure that all staff are trained in the new systems • Streamlined counselling significantly increases HIV testing by providers and counsellors and uptake by patients • Ongoing efforts needed to sustain increases in routine testing

48. “The benefit of operational research is only as good as the willingness to take up the results and improve the services.”Donald Enarson Editor in Chief, Public Health Action

49. Contact Us Donna Futterman, MD DFutterman@AdolescentAIDS.org Stephen Stafford SStafford@AdolescentAIDS.org AdolescentAIDS.org SPECIAL THANKS: Bronx Providers & CBOs NYC Department of Health NYC Health & Hospitals Corp. Adolescent AIDS Program Stephen Stafford, Michelle Lyle Monica Sweeney, Blayne Cutler, Ben Choi, Andrea Mantsios

50. Questions?