HIV Counseling and Testing

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

2. Course Objectives • By the end of this class, participants will be able to: • Cite the changing norms and policies in HIV Counseling and Testing (HIV C&T), global and local perspectives • Cite the components of the HIV test • Cite components of the new NYS HIV C&T regulations • Cite the role of HIV C&T in case finding. • Cite the role of HIV C&T as a tool for HIV prevention. • Cite the role of HIV C&T in the reduction of mother-to-child HIV transmission And time permitting: Cite the policy of HIV partner notification in the context HIV C&T

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

4. 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.

5. True or False • Under the new HIV testing law, you don’t need to consent – just get the test.

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

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

10. HIV related death rates in Central Brooklyn

11. 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

12. HIV in US • During 1993-2004, 39% of persons who tested positive for HIV developed AIDS in <1 year after test result • Persons who tested late were more likely to be black or Hispanic and been exposed through heterosexual contact • 87% received their first positive HIV test at an acute or referral medical care setting • 65% were tested because of an illness

13. HIV in New York City • Number of PLWHA: 96,645. Male = 67,340; Female 29,305 • Estimated number of undiagnosed HIV infections: 11,338 - 45,914* About 1 in 70 New Yorkers is infected with HIV, but the proportion of people in different groups who are infected varies widely: • 1 in 40 African Americans. • 1 in 12 black men age 40-49 years. • 1 in 10 men who have sex with men. • 1 in 8 injection drug users. • 1 in 4 MSM living in the Chelsea NYC DOH 2006

14. HIV in NYC, Cont.

15. HIV Exceptionalism: Impact on HIV testing policy and practice • Define • Targeted testing vs. routine screening • Informed consent vs. ‘opt-out’ • Dedicated counselor vs. diverse professionals • Risk reduction counseling vs. no counseling • Enhance resources for HIV vs. equitable resources to other diseases

16. HIV Exceptionalism: TB and HIV • # of people infected with TB bacilli, microbe that causes TB • # of people infected with HIV, the virus that causes AIDS

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

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

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

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

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

22. TB Screening DOT Quarantine Aggressive contact tracing HIV Targeted testing Adherence counseling Separate consent form Separate confidentiality law Voluntary partner notification TB vs. HIV

23. HIV Exceptionalism: Impact on HIV testing policy and practice • Define • Targeted testing vs. routine screening • Informed consent vs. ‘opt-out’ • Dedicated counselor vs. diverse professionals • Risk reduction counseling vs. no counseling • Enhance resources for HIV vs. equitable resources to other diseases

25. US 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 • 2011 • 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

26. 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 • 2011 • Push to offer HIV C &T in PC, ER, Prenatal • Shorter counseling sessions, minimal risk assessment • Rapid testing encouraged in all settings • HIV prevention for HIV patients emphasized • In NYS: some modifications: written consent remains 7

27. HIV Testing . . . ??? IFA? Oral test? Rapid? UniGold? ELISA? Western Blot? False positive? OraQuick? Blood test? Confirmatory?

28. How is HIV Diagnostic Testing Done? • “Gold Standard:” • ELISA followed by Western Blot confirmatory test or immunofluorescence assay (IFA) • Detects antibody to HIV virus • Usually takes a few days for results • May not be positive during window period • Indeterminate result possible

29. Window Period Antibodies Detectable via ELISA Window Period Virus in Blood Infection

30. The Indeterminate Test • Western Blot: looks for antibodies to specific HIV proteins and demonstrates presence by a change in color. • Indeterminate Result: Some, but not all, bands are present. • Causes: recent infection; advanced HIV; certain strains of HIV; cross reaction to other antibodies; lab error • Next Steps: Retest in >6 weeks. Risk counseling if indicated.

31. The ELISA HIV Test: Perils of Waiting • ELISA: ~25% do not return for test results of standard test • RAPID TESTS: Only ~2% leave before results of rapid HIV test

32. Multispot HIV-1/HIV-2 Uni-Gold Recombigen Stat Pak Reveal G2 OraQuick Advance Complete Rapid HIV Tests

33. Rapid HIV Tests • Results available in < 1 hour • Most easy to perform • High specificity: negative means negative except during window period! • High sensitivity: positive means likely positive BUT… Important! Positive rapid test results must be confirmed for HIV diagnosis!

34. CDC Recommendations: 2006 Objectives • Increase HIV screening • Detect disease earlier • ID & counsel HIV+ patients • Link patients to services • Further reduce perinatal transmission

35. CDC Recommendations: Routine Testing for HIV • Routine, voluntary testing for all patients ages 13-64 • “Opt-out” testing; no separate consent for HIV • Pretest counseling not required • Repeat testing at provider’s discretion

36. 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. • Prior to asking for consent to perform HIV test, providers must makesevenpoints of information about HIV available to patients. • Seven points can be delivered via a wall poster, video loop, brochure or orally • Consent for HIV testing can be incorporated into general consent for medical care. • The 7 points DO NOT have to be included in the consent form. • The consent language must include a place for patients to opt-out.

37. 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

38. Required Offer of HIV Test New law requires that providers offer an “HIV related test” to every individual between the ages of 13 and 64 years of age. (Key provision #1)

39. 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) OR

40. 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

41. Required Offer – How Often? • NYS DOH recommends that providers routinely offer HIV testing to patients, regardless of perceived or reported risks • NYSDOH now legally mandates that providers offer every person 13 to 64 HIV testing (offer patients <13 or >64 testing if indicated ) • Additional offers of HIV testing should be made for persons whose risk behaviors indicate more frequent testing, such as sexually active patients.

42. 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)

43. 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

44. Exceptions to Voluntary HIV Testing • Newborns • 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

45. Before the HIV Test Key provision #2 • Prior to asking for consent to perform the HIV test, providers must make available to patients seven points of information about HIV • The seven points may be in a written document such as a wall poster, brochure or orally. (Facilities can include the 7 points in the consent form) • Consent forms must include a place for individuals to decline HIV testing

46. 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

47. HIV Counseling Skills:Patients may have fears and misinformation that are obstacles to testing. Simple counseling skills can encourage patients to test. • “Client-centered counseling” is based on premise that clients can resolve their own problems and crises through skillful facilitation of counselor. • Developed by psychologists Carl Rogers and Robert Carkuff. • The health care provider who conducts HIV counseling should demonstrate five qualities: • Empathy • Respect • Warmth/Genuineness • Immediacy • Concreteness

48. Seven Points of InformationProvided Before Testing • HIV is the virus that causes AIDS and can be transmitted: • through unprotected sex (vaginal, anal, or oral sex) with someone who has HIV; • by contact with blood of someone with HIV as in sharing needles (piercing, tattooing, injecting drugs); and • by HIV-positive pregnant women to their infants during pregnancy or delivery, or while breast feeding.

49. Seven Points of Information (cont.) • There are treatments for HIV/AIDS that can help an individual stay healthy. • Individuals with HIV/AIDS can adopt safer behaviors to protect other people from acquiring HIV • Testing is voluntary and can be done at a public testing center.

50. Seven Points of Information (cont.) • The law protects the confidentiality of HIV test results and related information • The law prohibits discrimination based on an individual's HIV status and services are available to address discrimination. • An individual's consent for HIV testing is valid for repeated testing until consent is revoked by the person.