Transcript Introduction

Routine Opt-Out HIV Testing
UCLA / Pacific AIDS Education &
Training Center
(UCLA PAETC)
CDC Routine HIV Testing Project
2011
Educational Objectives
At the end of this workshop participants will be able to:
•
Review CDC HIV testing recommendations
Discuss opt-out HIV testing in CA, LA
Underscore the importance of early HIV
testing and treatment
Identify challenges/next steps for..
•
Implementation
•
•
•
On my commute this morning,
I listened to…
0%
1.
17%
2.
67%
3.
17%
4.
Nothing…I need my quiet time.
Rock and Roll, Baby!
Radio News, Traffic, Weather
Other
My most recent HIV testing training was…
33% 1.
17% 2.
17% 3.
33% 4.
In the past 3 months
In the past 6 months
1 year ago
More than 1 year ago
I have worked at XXXXXXX for…
40%
1.
40%
2.
0%
3.
20%
4.
Less than 1 year
1-5 years
5-10 years
More than 10 years
While working at XXXXXX, I have
helped ____ number of patients deal
with diabetes…
17%
1.
17%
2.
0%
3.
67%
4.
Zero/None
1-5
5-10
More than 10
What percentage of XXXXX patients
aged 13-64 have been tested for
HIV?…
17%
1.
17%
2.
0%
3.
67%
4.
Less than 30%
30-50%
50-70%
More 70%
I believe the number one challenge in
implementing opt-out HIV testing
here is…
0%
1.
20%
2.
20%
3.
60%
4.
None, it’s easy as pie
New EMR system
It takes too much time
Other
AETC Contacts
Warmline: (800) 933 – 3413
PEPline:
Perinatal
Hotline:
http://www.aids-etc.org
http://www.psattc.org
(888) HIV – 4911
(888) 448 – 4911
(888) 448 – 8765
Tom Donohoe
[email protected]
Opt-Out:
2006 CDC Recommendations,
Implementation, and Consequences of
Late HIV Testing
In California in 2011, do you still need
consent for HIV testing?
1. Yes
100% 2. No
0%
What percent of XXXX patients do you
think would refuse HIV testing (opt-out)?
25%
50%
25%
0%
1.
2.
3.
4.
< 5%
5-25%
25-50%
>50%
Do you think some XXXXX patients will
avoid clinic visits to avoid HIV testing?
1. Yes
100% 2. No
0%
Do you know how to connect your newly
diagnosed HIV+ patients to local, free
HIV care (treatment, medications, etc)?
100% 1.
0%
Yes
2. No
Have you ever been involved with giving
an HIV-positive test result to a patient?
80%
20%
1. Yes
2. No
All XXXXX patients with a positive STD
test are tested for HIV:
60% 1.
True
40% 2. False
0% 3. Unsure
Clinical Case
• 32 yo female admitted to UCLA blood donation
center to be informed she tested positive.
– She has a 6 year old son
– She is single and has never used drugs
– She has history of depression and threatens suicide
after being told of her HIV diagnosis
Case con’t
•
•
•
•
•
Referred to RW Clinic
Receives free counseling and antidepressants
Receives free mental health services
Receives free blood tests/medications
CD4 133 at first test: Could have been
hospitalized, ER or dead in 6 months without the
test
Awareness of Serostatus Among People
with HIV and Estimates of Transmission
~25%
Unaware
of Infection
Accounting for:
~75%
Aware of
Infection
~54%
of New
Infections
Marks, et al
AIDS 2006;20:1447-50
~46%
of New
Infections
People Living with HIV/AIDS:
1,039,000-1,185,000
New Sexual Infections Each
Year: ~32,000
HIV/AIDS Diagnoses among Adults and Adolescents,
by Transmission Category — 33 States, 2001–2004
MSM/IDU
5%
Other 1%
Other 3%
Heterosexual
17%
IDU
21%
IDU
16%
MSM
61%
Males
(n ≈ 112,000)
MMWR, Nov 18, 2005
Heterosexual
76%
Females
(n ≈ 45,000)
“Down Low”
2/3 Latino MSM in Los Angeles report that
persons of their ethnicity do not approve of
MSMs—so they have to keep their sexuality
hidden.
 Latina women with HIV+ rarely have traditional
risk factors for HIV; IDU, multiple partners, etc.

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.
Private doctor/HMO
Hospital, ED, Outpatient
Community clinic (public)
HIV counseling/testing
Correctional facility
STD clinic
Drug treatment clinic
HIV tests*
44%
22%
9%
5%
HIV+ tests**
17%
27%
21%
9%
0.6%
0.1%
0.7%
5%
6%
2%
*National Health Interview Survey, 2002
**Suppl. to HIV/AIDS surveillance, 2000-2003
Late HIV Testing is Common
Supplement to HIV/AIDS Surveillance, 2000-2003


Among 4,127 persons with AIDS*, 45% were first
diagnosed HIV-positive within 12 months of AIDS diagnosis
(“late testers”)
Late testers, compared to those tested early (>5 yrs before
AIDS diagnosis) were more likely to be:
 Younger (18-29 yrs)
 Heterosexual
 Less educated
 African American or Hispanic
MMWR June 27, 2003
*16 states
Reasons for testing: late versus early testers
Supplement to HIV/AIDS Surveillance, 2000-2003
100%
Late (Tested < 1 yr before AIDS dx)
80%
Early (Tested >5 yrs before AIDS dx)
60%
40%
20%
0%
Illness
Self/partner
at risk
Wanted to
know
Routine
check up
Required
Other
The Case for
HIV Screening
Criteria that Justify Routine Screening
1.
2.
3.
4.
Serious health disorder that can be detected
before symptoms develop
Treatment is more beneficial when begun before
symptoms develop
Reliable, inexpensive, acceptable screening test
Costs of screening are reasonable in relation to
anticipated benefits
Principles and Practice of Screening for Disease
-WHO Public Health Paper, 1968
“HIV TESTING IS ROUTINE”

How you offer the HIV test makes a difference in
how patients will accept the test.
Opt-Out Screening
Prenatal HIV testing for pregnant women:
 RCT of 4 counseling models with opt-in consent: (formal
written consent with pre and post counseling)
 35% accepted testing
 Some women felt accepting an HIV test indicated high
risk behavior

Testing offered as routine, opportunity to decline
 88% accepted testing
 Significantly less anxious about testing
Simpson W, et al, BMJ June,1999
Clinical Case

25 yo man told by his PMD that he is HIV+






Comes to UCLA for second opinion on treatment
Brings parents, brother and sister to clinic.
Girlfriend flown in from Manilia.
Everyone in tears
HIV Elisa +, Western blot negative, HIV PCR negative
PMD can be sued for not waiting for the Western blot resutls
California Law

AB 682 (Berg/Garcia/Huffman) in California
Legislature to implement opt-out testing. Now
law in January 2008
Verbal consent only needed
 If patient refuses HIV test, write in chart
 Posted signs enough for pre-counseling

Make it Easy

Incorporate HIV test into general women’s lab
form/ health panel: pap smear, mammogram,
GC/Chlamydia screen/cholesterol
Incorporate HIV test into routine tests for
cholesterol, glucose, CBC, PSA
 Pair HIV tests with all other STD tests—no
RPR, GC or Chlamydia test should be
ordered WITHOUT an HIV test

HIV Treatment--and Training--is Available

Ryan White funds available for indigent and/or
undocumented patients for free HIV care:
Website: Google “HIV LA”
 UCLA PAETC can conduct onsite training for
providers working with HIV-infected migrants
who may return to Mexico/Central America.

Positive Test Results
Positive test results should NOT be delivered in
an inappropriate manner (e.g., over the
telephone, via a clerk, etc.)
 Positive test results should always be given face
to face by an experienced clinician (RNP, MD,
PA) or trained counselor who can refer patients
appropriately for care.
 Linkage to HIV care is essential.

Summary
Opt out testing is law in California
 Will increase new HIV diagnoses when patients
are asymptomatic and prevent new
transmissions
 Entire staff (medical assistants, nurses, PA’s
and MD’s) should all be conscious of HIV testing
 Referral system should be updated/practiced by
staff and available for ALL patients who test
HIV+

HIV TESTING
[email protected]
Signs for Medical Assistants/Nurses

“Test for HIV with every gonorrhea, chlamydia,
or syphilis test”

“Test for HIV with every cholesterol test”
“Test for HIV with every Pap smear”
 “PPD+? Test for HIV”
