Transcript Slide 1

Jean Davis, PhD, PA, AAHIVS
Dean, Postgraduate Studies and Continuing Education: QVIUS
University, Associate Professor: Charles R. Drew University, College
Of Medicine, Assistant Professor: UCLA, Geffen School of Medicine
Upon conclusion of this module participants will be able to:
 Describe the epidemiology of HIV/AIDS among diverse
populations.
 Discuss the rationale for the CDC Recommendations.
 Understand the Need to Promote HIV Testing among
diverse populations.
 Identify implementation strategies relative to promoting
HIV testing among diverse populations.
 Describe the Potential Benefits of Early Testing.
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Diverse populations include, but are not limited to:
ethnicity, religion and spiritual beliefs, cultural
orientation, color, physical appearance, gender,
sexual orientation, ability, education, age, ancestry,
place of origin, marital status, family status, socioeconomic circumstance, profession, language,
health status, geographic location, group history,
upbringing and life experiences.
Alberta Health Services, 2009
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For the purpose of this presentation, diverse populations are the
following groups of individuals disproportionately impacted by
HIV/AIDS:
 Ethnic and Racial Minorities
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American Indian and Native Alaskans
Asians and Pacific islanders
Blacks/African American
Hispanics/Latino
 Men who have Sex with Men
 Women who are from underserved communities
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EPIDEMIOLOGY OF HIV DISEASE
General Population
(n=304,059,724)
AIDS Cases
(n=37,151)
Hispanic/
Latino
19%
White
66%
Hispanic/
Latino
15%
Black
49%
White
29%
Black
12%
Native Hawaiian/
Other Pacific Islander
<1%
Asian 4%
American Indian/
Native Alaska
<1%
Asian 1%
American Indian/
Native Alaska
<1%
Native Hawaiian/
Other Pacific Islander
<1%
CDC. HIV Surveillance Report, 2008.
Available at: http://www.cdc.gov/hiv/surveillance/resources/reports/2008report/index.htm.
Cases, %
http://www.cdc.gov/hiv/graphics/images/L178/L178-8.htm.
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CDC Study found:
 in 2008 one in five (19%) MSM in 21 major US cities were
infected with HIV, and nearly half (44%) were unaware of their
infection.
 28% of black MSM were HIV-infected, compared to 18% of
Hispanic/Latino MSM and 16% of white MSM.
 Other racial/ethnic groups of MSM also have high numbers of
HIV infections, including American Indian/Alaska Native MSM
(20%) and Native Hawaiian/Pacific Islander MSM (18%).
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Among all black MSM, there were more new HIV infections
(52%) among young black MSM (aged 13–29 years) than any
other racial or ethnic age group of MSM in 2006.
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Among all Hispanic/Latino MSM in 2006, the largest
number of new infections (43%) occurred in the
youngest age group (13–29 years), though a substantial
number of new HIV infections (35%) were among those
aged 30–39 years.
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From 2005–2008, estimated diagnoses of HIV infection
increased approximately 17% among MSM. This
increase was likely due to a combination of factors:
 increases in new infections,
 increased testing, and
 diagnosis earlier in the course of infection
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HIV and AIDS were originally thought to affect mostly gay men
However, women have always been affected
If new HIV infections continue at their current rate worldwide, women with
HIV may soon outnumber men with HIV.
In some respects HIV and AIDS affect women in almost the same way
they affect men
 Women of color (especially African American women) are the hardest hit
Younger women are more likely than older women to get HIV
AIDS is a common killer, second only to cancer and heart disease for women
The most common ways of transmission:
 having unprotected sex with a man who has HIV
 sharing injection drug works (needles, syringes, etc.) used by someone
with HIV
Centers for Disease Control and Prevention. HIV/AlDS and Women. Updated Feb 2010
HIV TESTING, CDC
RECOMMENDATIONS IN 2006
AND IMPLEMENTATIONS
• All patients aged 13-64 in all health care settings should be tested
• Patients should be notified that testing will be performed, and can
decline (“opt-out”)
• Those at high risk should be tested at least annually
• Written consent should not be required; general consent for medical
care is sufficient
• Prevention counseling should not be required with HIV screening
programs.
CDC Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings.
MMWR Rep. 2006; 55(RR14);1-17.
Purpose
• Increase HIV screening of patients, including pregnant women, in
health-care settings
• Foster earlier detection of HIV infection
• Identify and counsel persons with unrecognized HIV infection and link
them to clinical and prevention services
• Further reduce perinatal transmission of HIV in the United States
CDC Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings.
MMWR Recomm Rep. 2006; 55(RR14);1-17.
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Increases diagnosis of HIV
Preserves staff resources by streamlining
the process
Reduces stigma of testing
Potentially leads to earlier HIV diagnosis
Improves access to HIV clinical care and
prevention services
CDC. HIV testing and implementation guidance for correctional settings. January 2009.
http://www.cdc.gov/hiv/topics/testing/resources/guidelines/correctional%2Dsettings. Accessed July 23, 2009.
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The national clinician consultation center created a
compendium that will assist clinicians at understanding
their respective state laws as it relates to HIV and to
implement sound HIV testing policies.
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The compendium can be download by state at
http://www.nccc.ucsf.edu/docs/QRG.pdf
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Questions about HIV testing can be answered by the
National HIV Telephone Consultation Service at 800933-3413
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RATIONALE FOR CDC
RECOMMENDATION
38% - 44% of adults age 18-64 have been tested
16-22 million persons age 18-64 are tested annually in U.S.
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%
*National Health Interview Survey, 2002
**Suppl. to HIV/AIDS surveillance, 2000-2003
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HIV estimated prevalence1
1,056,400 - 1,156,400
Undiagnosed1
232,700
Estimated new
annual infections (2008)2
56,300
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From 2004 to 2007, the estimated number of newly diagnosed
HIV/AIDS cases increased 15%3
1CDC.
HIV prevalence estimate—United States, 2006. MMWR. 2008;57(39):1073-1076.
HI, et al. Estimation of HIV incidence in the United States of America. JAMA. 2008;300:520-529.
3CDC. HIV/AIDS surveillance report—cases of HIV infection and AIDS in the United States and dependent areas, 2007;19.
http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/default.htm. Accessed July 23, 2009.
2Hall
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% Receiving AIDS Diagnosis
Age
Within 1 Yr of HIV Diagnosis
Within 3 Yrs of HIV Diagnosis
13-19
16.1%
22.7%
20-29
24.7%
31.6%
50-59
51.3%
57.5%
57%
63.2%
≥60
CDC. MMWR Weekly Rep. 2009; June 26, 2009 / 58(24);661-665.
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% Receiving AIDS Diagnosis
Race/Ethnicity
Within 1 Yr of HIV Diagnosis
Within 3 Yrs of HIV Diagnosis
White
37.1%
42.6%
Multiple/
Unknown
34.9%
42.9%
Black/African American
38.7%
46.1%
Amer. Indian/
Alaska Native
39.0%
47.2%
Hispanic/
Latino
42.0%
48.4%
Asian
44.6%
50.4%
CDC. MMWR Weekly Rep. 2009; June 26, 2009 / 58(24);661-665.
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Up to 70% of AIDS cases were diagnosed within 1 year of
HIV diagnosis
 53.2% diagnosed with AIDS within 1 month of HIV
diagnosis
Blacks and Hispanics were more likely to present with
concurrent HIV and AIDS diagnoses
 Blacks: OR 1.4 (95% CI 1.2-1.6)
 Hispanics: OR 1.7 (95% CI 1.3-2.1)
 More than 80% of these participants were receiving
routine medical care
Castel AD et al. 15th CROI; 2008; Boston. Abstract 543.
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Increase morbidity, hospitalization for
opportunistic infection
Increase cost of treatment
Development of Viral resistance
HIV re-infection from ongoing risk behavior
Disproportionately high number with AIDS
High baseline viral load
Impaired immune status
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Average Years of Life Lost
40
2005
White (n=12,300)
Hispanic (n=4160)
Black (n=40,347)
30
20
Estimated Life Expectancy
(years)
10
0
10
Males
Females
White
25.5
21.5
Hispanic
22.6
21.2
Black
19.9
24.2
15
20
25
30
35
40
45
50
55
Age at Diagnosis (years)
Data from 25 US states with confidential name-based HIV surveillance since 1996.
Harrison KM, et al. JAIDS. 2010;53:124-130.
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HIV TESTING TECHNIQUES
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Conventional blood test
Conventional oral fluid test: OraSure is the only FDA-approved
HIV oral fluid test.
Rapid tests:
 OraQuick Advance Rapid HIV-1/2 Antibody Test (whole blood finger prick or
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venipuncture; plasma; oral fluid)
Reveal Rapid HIV-1 Antibody Test (serum; plasma)
Uni-Gold Recombigen HIV Test (whole blood finger prick or venipuncture; serum;
plasma)
Multispot HIV-1/HIV-2 Rapid Test (serum; plasma)
Two Clearview tests—Clearview HIV 1/2 Stat Pak, Clearview Complete HIV 1/2
(whole blood; serum; plasma).
Home Tests: HomeAccess HIV-1 Test System is the only home HIV
test approved by the FDA
Urine Test: Calypte is the only FDA-approved
HIV urine test.
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BARRIERS TO PARTICIPATING IN HIV
TESTING ACTIVITIES
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Lack of diversity in health care leadership and
workforce
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Systems of care poorly designed for diverse
populations
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Poor Cross-cultural communication between
providers and patients
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Patient fears and distrust
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Cultural stigma
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State and local laws and regulations
Concerns about stigma and stereotyping
Belief that pre-test counseling is needed
Time constraints
How and when to give results
Reimbursement concerns
Rapid test not available at their site
Bashook PG, et al. 31st SGIM. Pittsburgh, 2008. Abstract 144.
During Clinical Trainings in Washington, DC and LA, clinicians
expressed the following concerns related to providing care to
patients who are HIV positive:
 “Fear of contracting the disease”
 “Concern among pregnant professionals and potential risk for
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unborn fetus”
“Concern for children who may come to the office”
“Concern for law suit – quality of care”
“Concern that I may lose my patient base”
“Patient too complex – not compliant”
“ I’m not adequately compensated for treating HIV patients”
“ I plainly do not want to treat HIV patients”
Downer, G., NMA 2008 Presentation
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Patients unaware of Community viral load
Patients do not think they are at risk for HIV
Patients’ fear of status
Based on Focus Groups: Los Angeles, CA and Washington, DC
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Was recently tested for HIV
Not enough time to take test
Not prepared to receive results today
No risky sexual encounter
Thinks he/she is HIV-negative
Worried about confidentiality/name reporting
Bowles, K.E. et al;
37%
17%
12%
11%
11%
6%
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Lack of knowledge about HIV/AIDS and new treatments
Fear of knowing they have the disease
HIV-related stigma and discrimination
Financial challenges that extend beyond testing
Cultural attitudes
Mistrust of health care providers
Drug use
Mental illness
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Attitudinal assessment of
outpatients in HIV clinic (N =
611)
Differential responses
between minorities and non
minorities regarding origins of
HIV/AIDS and trust in
government
Trust in providers associated
with
Agreement with statement:
The government created AIDS to kill
minorities
 Fewer emergency department
(ED) visits, more outpatient clinic
visits
 Increased use of antiretrovirals
 Improved physical and mental health
(patients’ self-report)
Whetten K, et al. Am J Public Health. 2006;96:716-721.
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Little to no risk of HIV infection when in a
monogamous relationship
Fear of discrimination (traditional gender roles
and cultural norms such as “machismo”
contribute to the perception of Hispanic/ Latino
gay men as “failed men”).
Socioeconomic factors such as poverty,
migration patterns, social structures, or
language barriers.
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Lack of access to IHS related to migration
Fear of discrimination
Distrust of the healthcare system
Violence and victimization
Thurman, P. et al. (2007). Advancing HIV/AIDS Prevention Among American Indians Through Capacity Building
and the Community Readiness Model, Journal of Public Health Management & Practice, S49- S54.
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Cultural barriers
Lack of linguistic and cultural competencies
Women often put their family and spouses' health
above their own, often waiting to seek services or
care until they are already ill.
Finding providers who are sensitive to gender and
cultural issues is difficult.
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STRATEGIES TO INCREASE HIV
TESTING AMONG DIVERSE
POPULATIONS
Culture and ethnicity are products of both personal history and
wider situational, political, social, political, geographic and
economic factors
Factors related to culture and ethnicity shape:
• The way people interact with a health care system
Their participation in programs of prevention and health promotion
Their access to health information and services
Their health-related choices and decisions
Their understanding of and priorities re: health and illness, help
seeking
• behavior and adherence to treatment
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Encourage racial/ethnic minorities to learn
more and educate others about HIV and its
impact
Encourage HIV counseling and testing options
Collaborate with local CBOs to promote HIV
prevention services (including testing)
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Utilize social marketing campaigns (facebook, twitter,
PSAs on local radio stations) to promote testing
 Provide incentives (extended hours of care, bus tickets)
 Provide routine rapid HIV testing in the following
settings
– Emergency room and urgent care clinics
– Sexually transmitted disease clinics
– Primary care practice (private and public)
– OB/GYN clinics and practices
– College campus clinics
– Prison clinics
– Mobile health care vans (“street” testing)
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Increased awareness of the importance of the
CDC Recommendations among low-volume
providers and within health care facilities
 Develop HIV Testing policies and procedures
 Implement the CDC Recommendation
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Increased acceptance of testing by patients
should be linked to the provider being:
 Non-judgmental
 Removing the need for “risk factor”
interrogation component of HIV testing
 Making the test truly “Routine” -- like Pap
Smears, Mammograms, Flu shots, etc.
 Decreasing the stigma of the test and the
diagnosis
Adapted from CDC. MMWR Morb Mortal Wkly Rep. March 9 2007;56:189-193.
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EVIDENCE PRACTICE
Number of Tests Performed
80,000
Non-Clinical Setting
Clinical Setting
70,000
60,000
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Encouraged “opt-out” HIV
testing in medical settings
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Increased jail testing, school
testing, needle exchange,
and couples services
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Resulted in 1-year increase in
testing from 43,271 to 72,864
tests
12.7%
68.4% increase in
number of tests done
50,000
40,000
18.2%
30,000
87.3%
20,000
81.8%
10,000
0
FY 2007
FY 2008
N=43,721
N=72,864
Hader S. 16th CROI. February 8-11, 2009. Montreal. Abstract #57.
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Program results for CD4
counts at diagnosis:
Median CD4 Count
at Time of Testing
350
332
300
higher CD4 counts at initial
testing
 Increase during 18 months of
surveillance:
▪ Increases in median CD4
counts to 332 cells/mm3 at
diagnosis after only 18 months
of treatment expansion
initiation
Hader S. 16th CROI. February 8-11, 2009. Montreal. Abstract #57.
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Median CD4 Count
 Patients were diagnosed with
250
200
220
215
183
187
198
150
100
50
0
2001 2002 2003 2004 2005 2006 2007
Year of HIV Diagnosis
Testing campaign
Jail testing
Med. settings
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Public health HIV testing program, Seattle, WA
 Trends toward increased HIV testing between 1995 and 2008
 Proportion of MSM who reported never been tested
decreased from 25% in 1995 to 5% in 2007
and 2008
 The median interval between last HIV– test and first
HIV-positive test (inter-test interval) among MSM decreased
from 692 to 248 days between 1995 and 2008
 66% of all persons tested had CD4 counts of
>350 cells/mm3, indicating that more patients are being
captured earlier in the course of their HIV infection
Golden M, Stekler J, Wood R. 16th CROI; 2009; Montreal. Abstract 1043.
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Rapid HIV testing program at an emergency
department in New York City
 ED diagnoses accounted for 16.5% of all new HIV
diagnoses at the medical center between 2006 and
2007
 71% of newly diagnosed patients were linked to
care with an HIV care provider
 ED-based testing programs may help identify
persons with HIV who have no other access to
medical care
Christopoulos K, Schackman B, Lee G, Green R, Morrison E. 16th CROI; 2009; Montreal. Abstract 1040.
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CASE STUDIES
Theresa, a 22-year-old African American female, presents to her primary
care physician for enlarged lymph nodes. She reports swelling in her neck
for the past two weeks and believes she is experiencing some continuing
effects from a “really bad” case of the flu she had two weeks ago. She
reports that she is extremely tired, has frequent headaches, and has also
had a rash.
The physical exam reveals that Theresa’s inguinal lymph nodes are also
swollen. Dr. Beal tells Theresa that her symptoms could be related to a
number of things and asks about her last HIV test. She denies a history of
ever having an HIV test, adding, “My throat hurts, not my blood, plus I
have not lost any weight and I’m obviously not a gay man.” She says she
has been with the same male sexual partner for the past four years. She
and her partner rarely use condoms because she uses Depo Provera®
injections for pregnancy prevention. She does recall that her partner
complained of similar symptoms three months ago but he “got better”
after one week. She also says that her boyfriend looks healthy and is not
gay.
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How can the primary care provider explain the early
signs/symptoms of HIV to Theresa as well as discuss the risk
factors?
Should the provider encourage Theresa to have an HIV test?
Why or Why not? What tactics could be used to initiate the
discussion?
If Theresa is not infected, what precautions will be most
important to discuss?
If Theresa is found to have HIV, what is the primary care
provider’s role in preparing her for living with the infection?
Based on the case study discussion, what strategies to
address health literacy might you include in an action plan
for Theresa’s care?
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Archina, a 55-year-old East Indian woman, is brought to her
OB/GYN appointment by her husband. Her native language is Hindi,
but she speaks and understands English. She complains of vaginal
irritation for the past three months and pain with sex for one
month. She reports that her husband is tired of her crying during
sex. She stated that she doesn’t like to see doctors too often,
because she doesn’t want to be a burden. She tries to take care of
most problems herself, plus her husband doesn’t want her to
“charge up” the health insurance. Archina moved to the United
States from India with her family in 1996. She currently lives with
her husband and is unemployed. She reports occasional sex with
her husband, but states that he is gone most of the time for
business. During a pelvic exam, her provider notices signs of a
severe yeast infection.
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Dr. Rue reviews the chart for lab test history and
notices that there isn’t an HIV test on file. She
encourages Archina to have an HIV test as part of
her routine care. Archina is hesitant and states that
she should ask her husband.
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Based on the information we have, who makes health
care decisions for Archina? How could this make a
difference with getting tested?
How could the provider empower Archina to address her
own health problems? Discuss potential barriers to
empowerment.
How could the provider have handled this situation
differently?
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Jose is a 34 years-old Latino monolingual Spanishspeaker. He was referred from the STD clinic
w/diagnosis of Syphilis and weight loss >15% in the
last 3 months. He presents with oral candidiasis,
diarrhea and constant fatigue. He has no clue why
he has been sent to your clinic. He is married with
children (his family lives in Mexico). He has been
living in the U.S. since 2010. In Mexico he worked in
construction. In the U.S. is a day-labor worker.
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Why do you think Jose has no idea why he has been
referred?
Based on the information we have, what may be Jose’s
risk factors?
How could this make a difference with getting tested?
Discuss potential barriers to HIV testing and care.
What type of tailored intervention, prevention for
positives should we develop for Jose?
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HIV Test should be offered to patients based on CDC
Recommendation and/or State Law
Early testing promotes early treatment.
Knowledge of HIV status and the initiation of early HIV
medical treatment for infected patients can gain years of life
and improve its quality.
HIV medications and treatment not only improve the lives of
those infected (morbidity and mortality) but also serves to
reduce their infectiousness; thus, reducing their risk of
transmitting the disease to others.
Studies have shown that people who are aware of their HIV
status will adopt behaviors that reduce HIV transmission to
others.
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Goulda Downer, Ph.D., RD, LN, CNS - Principle
Investigator/Project Director (AETC-NMC)
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Kerry Hawk Lessard, MAA
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Michael R. Noss, DO
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Josepha Campinha-Bacote, PhD, MAR, PMHCNSBC, CTN-A, FAAN
1840 7th Street NW, 2nd Floor
Washington, DC 20001
202-865-8146 (Office)
202-667-1382 (Fax)
Goulda Downer, Ph.D., RD, LN, CNS
Principle Investigator/Project Director (AETC-NMC)
www.AETCNMC.org
HRSA Grant Number: U2THA19645