Future of HIV in VA

1. Future of HIV in VA Office of Public Health Department of Veterans Affairs Maggie Czarnogorski, MD Deputy Director, HIV, Hepatitis, and Public Health Pathogens Program Maggie.czarnogorski@va.gov April 2012

2. Office of National AIDS Policy

3. National HIV/AIDS Strategy Goals • Reducing New HIV infections • Improving Access to Care and Health Outcomes • Reducing Health Disparities • Working across federal agencies

4. Engagement in Care Cascade:VA vs. Community 30,000 25,000 20,000 15,000 10,000 5,000 0 Gardner EM, et al. Clin Infect Dis. 2011;52:793-800

5. VA HIV Testing Policy Changes August 17, 2009 • VA National HIV Testing Policy revised • After Section 124 repealed, VA was able to revise policy to promote widespread routine HIV testing • Routinely offer HIV testing to all Veterans • Eliminate written informed consent and prescribed pre- and post-test counseling • Verbal consent still required and must be documented in medical record • Written educational materials about HIV testing must be provided to patients VHA Informed Consent Handbook 1004.01: August 17th, 2009 VHA Directive 2009-036, August 17, 2009

6. VA HIV Testing Rates: Data Collection Methods • Data Extract Routine installed at all facilities to generate HIV test reports by Calendar Year (CY) • Data collected on all outpatients in that CY • Number with HIV test ever done • Number with HIV test done in that CY • Number with positive result in that CY • In 2011, added Gender, Race/Ethnicity, Age information

7. Veterans Ever Tested for HIV by Year2009-2011 13.5% Ever Tested n= 795,126 20% Ever Tested n= 1,221,328 9.2% Ever Tested n=524,267 2009 2010 2011 Outpatient Visits n= 5,713,265 Outpatient Visits n= 5,888,599 Outpatient Visits n= 6,114,034

8. Percent of Veterans EVER Tested for HIV, by VISN: 2009, 2010, 2011 Percent Outpatients EVER Tested for HIV VISN

9. Percentage of HIV Positive Tests in CY 2011, by VISN 0.7% Mean: 0.38% Median: 0.35% Range: 0.14-0.64% *CDC Threshold for routine HIV testing 0.6% 0.5% 0.4% % HIV Tests Performed in 2010 that were Positive 0.3% 0.2% * 0.1% VISN

10. Percentage EVER Tested by Race/Ethnicity – CY2011

11. Percentage EVER Tested by Age and Gender – CY2011

12. Gender and Age of Veterans with HIV Positive Test Results in CY 2011 (n= 2,149) 93.25%

13. HIV Seropositivity in CY 2011 by Age and Gender 0.7% 0.6% 0.5% 0.4% 0.3% 0.2% 0.1% 0.0%

14. HIV Seropositivity in CY 2011 by Race/Ethnicity 0.0% 1.0% 0.2% 0.8% 0.6% 0.4%

15. VA National HIV Testing Data for 2009, 2010 and 2011 Abbreviations: CY= calendar year; HIV = human immunodeficiency virus

16. VA Initiatives to Improve HIV Testing Rates 2009-2011 • Legislative and Policy Changes • Verbal consent for testing • Routine offer of HIV testing to Veterans • Routine HIV test clinical reminder • Funding for facility-level quality improvement projects • Clinical HIV testing • Laboratory • Women’s Health • Homeless Veteran Stand Downs • Social marketing campaign

17. Conclusions • VA is the largest US provider of HIV care • The quality of HIV care VA provides is excellent • The percentage of Veterans ever tested for HIV more than doubled in two years • Many Veterans in VA care have still not been tested for HIV • In 2011, all VISNs had an HIV seropositivity rate above the CDC threshold (>0.1%) for routine HIV testing • Routine HIV testing is warranted in VA • VA will continue to provide timely linkage of care

18. The Future • Continued Excellence of Care • Improve Access and Expand Workforce • Telehealth/SCAN-ECHO • Patient Centered Teams • Targeted approaches with Special Populations to decrease disparities • New Veterans • Women • Homeless, Incarcerated • Regional

19. Office of Public Healthwww.hiv.va.gov