HIV Testing in Medical Settings

1. HIV Testing in Medical Settings Mark Thrun, MD Denver Public Health Mark.thrun@dhha.org

2. Prevention is Spectrum Spans the spectrum of care of persons at risk for HIV Ongoing personal behavior modification Personal assessment/ acknowledgement of risk Prevention discussions/ counseling Positive HIV Test Screening for STD/HIV

3. Prevention is Spectrum Spans the spectrum of care of persons living withHIV Compliance with care Linkage into HIV care Prevention discussions/screening in care Positive HIV Test Return to HIV care

4. Updated CDC recommendations for HIV screening in clinical care settings • All patients between 13 – 64 years of age – an initial screening test • All patients being evaluated for possible TB • All patients being evaluated for possible STD • Annual screening for persons at increased risk • Men who have sex with men • Persons with > 1 sexual partner • Drug users

5. Awareness of Serostatus Among People with HIV and Estimates of Transmission ~25% Unaware of Infection Accounting for: ~54% of New Infections Marks, et al AIDS 2006;20:1447-50 ~75% Aware of Infection ~46% of New Infections People Living with HIV/AIDS: 1,039,000-1,185,000 New Sexual Infections Each Year: ~32,000

6. Knowledge is Power Multispot HIV-1/HIV-2 Uni-Gold Recombigen OraQuick Advance Reveal G2

7. Persons aware of HIV infection less likely to have risk of transmission Marks, JAIDS 2005

8. HIV tests* HIV+ tests** Private doctor/HMO 44% 17% Hospital, ED, Outpatient 22% 27% Community clinic (public) 9% 21% HIV counseling/testing 5% 9% Correctional facility 0.6% 5% STD clinic 0.1% 6% Drug treatment clinic 0.7% 2% Source of HIV Tests and Positive Tests • 38% - 44% of adults age 18-64 have been tested • 16-22 million persons age 18-64 tested annually in U.S. *National Health Interview Survey, 2002 **Suppl. to HIV/AIDS surveillance, 2000-2003

9. Many persons living with HIV seek care outside HIV clinic • HIV clinic 2006 : 220 people at risk for transmitting HIV • 1000 patients x 22% high risk • STD clinic 2006: 167 people at risk for transmitting HIV • Clients asked HIV status or offered HIV test • ED estimate 2006: 315 people at risk for transmitting HIV • 3.5% in DH ED HIV+; 0.7% previously unrecognized infection x approx 45K unique visits/yr (Goggin, J Emerg Med, 2000)

10. Emergency Department

11. ED Testing and Counseling Haukoos, Acad Emerg Med, 2007

12. Targeted testing * 1 died, 1 incarcerated, 1 homeless

13. Routine HIV TestingOpt-out Consent

14. STD Clinic

15. Changes in the clinic re: HIV testing • HIV testing acceptance and HIV test positivity was evaluated for 4 time periods: • Period 1: The year before introduction of rapid testing • December 2002 – November 2003 • Period 2: The 6 months following introduction or rapid testing, before logistical adjustment in the clinic and discontinuation of the standard test • December 2003 – May 2004 • Period 3: The 10 months following logistical adjustment, but before introduction of the electronic medical record and opt-out testing • June 2004 – March 2005 • Period 4: The 6 months following opt-out testing • April 2005 – September 2005

16. HIV Testing Acceptance % Period 1: Before introduction of rapid testing Period 2: Following Period 1, before logistical adjustments Period 3: Following Period 2, before opt-out consent Period 4: After Introduction of opt-out

17. HIV Positivity % Period 1: Before introduction of rapid testing Period 2: Following Period 1, before logistical adjustments Period 3: Following Period 2, before opt-out consent Period 4: After Introduction of opt-out

18. Rapid testing only. Rapid Testing Trends9/01/03 – 9/31/04 Change in clinic logistics Number of Tests Performed

19. Impacts of Rapid Testing Denver Metro Health Clinic Percentage of patients who received their positive test results: Before: After: 66% 100%

20. Caveat: False positive tests

21. Predictive Value, Positive Test HIV Prevalence OraQuick Reveal Single EIA Uni - Gold 10% 99% 92% 98% 97% 5% 98% 85% 96% 95% 2% 95% 69% 91% 87% 1% 91% 53% 83% 77% 0.5% 83% 36% 71% 63% 0.3% 75% 25% 60% 50% 0.1% 50% 10% 33% 25% Test Specificity 99.9% 99.1% 99.8% 99.7% Positive predictive values

22. Caveat: Routine HIV testing may mean more staff time Lessons in positive predictive value Example 1: Test 1,000 persons Test Specificity 99.6% HIV Prevalence 10% True Positives: 100 False Positives: 4 Positive predictive value: 100/104 = 96% Example 2: Test 1,000 persons Test Specificity 99.6% HIV Prevalence 0.4% True Positives: 4 False Positives: 4 Positive predictive value: 4/8 = 50%

23. Caveat: What happens when people test positive

24. Disposition and Linkage into Care Haukoos, Acad Emerg Med, 2007

25. Coordination of referrals Haukoos, Acad Emerg Med, 2007

26. Linkage to care/Additional prevention counseling

27. Linkage to Care: Denver 2005 - 6/2007 Patients referred to LTC staff: 366 Patients seen by LTC staff: 311 Confirmed linked to care: 220 (71%)

28. Training Needs Related to Expansion of Testing • New technologies require staff to be brought up to speed • Emphasis of training may need to shift • Less didactic class time • More technical assistance • Training must be ongoing and collaborative • Training needs may fall outside “target” topic area: e.g. testing and linkage to care

29. Kees Rietmeijer Jason Haukoos Emily Hopkins Bill Burman Tom Deem Marshall Gourley Reina Lopez Ryan Westergaard Acknowledgements