Routine HIV Testing in Texas Felipe Rocha MSSW, Director, TB/HIV/STD/Viral Hepatitis Unit, Texas Department of State Health Services
The U.S. HIV Epidemic - 30 Years Later • Over 575,000 Americans have lost their lives to AIDS • More than 56,000 people in the US become infected with HIV each year • There are more than 1.2 million Americans living with HIV • 1 in 5 are unaware of their infection • Almost half of all Americans know someone living with HIV
HIV… A Health Problem/Concern? • 1995 – 44% Urgent Health Problem • 2009 – 6% Urgent Health Problem • 2006 – 21% concern about what others would think if tested • 2010 – 16% concern about what other would think if tested • 69% don’t think friends would care either way. 9% think friends would think more of them if tested. http://www.kff.org/kaiserpolls/upload/8186.pdf
Background on Texas Texas population growth, increased by 20.6% from 2000-2010, compared with 9.7% growth nationwide-wide About 25 million people live in Texas, nearly half (49%) of whom live within the Dallas-Ft Worth and Houston metro areas
Background on Texas Texas is different from U.S. in that it is now a minority/majority state In ten years ,Texas will have more persons of Hispanic descent than any other racial or ethnic group due to immigration and new births. In 2010, the total population was 45.1% White, 38.8% Hispanic, and 11.5% Black . Other racial groups made up the remaining 4.6%
Background on HIV in Texas As of 2010, 86% of people living with HIV/AIDS (PLWH) were diagnosed within one of the five EMA/TGAs, with nearly one third of all PLWH in Texas diagnosed within the Houston EMA.
65,077 (2010) 4,242 (2010)
Newly-diagnosed HIV Case Rates by Race/Ethnicity: Texas, 1999-2010 B -60.8/100,000 H -13.5/100.000 W -9.1/100,000
Percent 0 10 20 30 40 50 Total 34 Male 35 Female 31 White 31 Select Characteristic Black 30 Hispanic 43 MSM 35 IDU 31 MSM/IDU 32 Hetero 35 1 in 3 Texans with HIV Receives a Late Diagnosis Percent of New HIV Diagnoses with an AIDS Diagnosis within One Year, Texas 2003-2009
Effect of Awareness on 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 with HIV/AIDS: 1,039,000-1,185,000 New Sexual Infections Each Year: ~32,000
Reasons for Testing: Late versus Early Testers Supplement to HIV/AIDS Surveillance, 2000-2003
National HIV/AIDS Strategy “The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”
National Strategy • Identify Undiagnosed Infections • Increase Access to Care and Improve Health Outcomes for People Living with HIV • Reduce HIV Related Health Disparities.
Source of HIV Tests & Positive Tests * National Health Interview Survey, 2006 ** Supplement to HIV/AIDS Surveillance, 2000-2003
Previous CDC RecommendationsAdults and Adolescents • Routinely recommend HIV screening in settings with high HIV prevalence (>1%) • Targeted testing based on risk assessment • Routinely recommend HIV Testing seeking treatment for STDs • Annual testing for sexually active MSM
HIV Testing Practices in EDs • Survey of 154 ED providers • Average: 13 STD patients per week • Only 10% always recommend HIV test • Reasons for not testing for HIV: • 51% concerned about follow up • 45% not a “certified” counselor • 19% too time-consuming • 27% HIV testing not available -Fincher-Mergi et al, 2002: AIDS Pat Care STDs
Recommendations Are Not Having Their Intended Effect in Acute Care Settings • EDs account for 10% of all ambulatory care visits National Hospital Ambulatory Medical Care Survey, National Center for Health Statistics
The Status Quo • Has brought us a long way, but we are currently stalled • Late diagnosis is frequent, especially of socio-economically disadvantaged persons • Numerous missed opportunities for earlier diagnosis, treatment, and prevention
Rationale for Revising Recommendations • Many HIV-infected persons access health care but are not tested for HIV until symptomatic • Effective treatment available • Awareness of HIV infection leads to substantial reductions in high-risk sexual behavior • Inconclusive evidence about prevention benefits from typical counseling for persons who test negative • Great deal of experience with HIV testing, including rapid tests
Criteria that Justify Routine Screening 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 Treatment must be accessible Principles and Practice of Screening for Disease -WHO Public Health Paper, 1968
Missed Opportunities for HIV Diagnosis 2001 to 2005 a total of 4,315 cases of HIV infection were reported in S Carolina; 1,784 (42%) developed AIDS within 1 year of HIV test; CDC report examined HIV/AIDS case reporting & health care visits in S Carolina before the 2006 guidelines: MMWR December 1, 2006
Missed Opportunities for HIV Diagnosis • 1,302 (73%) made 7,988 previous health-care visits (median 4 per patient) but were not tested for HIV; • 6,303 (79%) of previous visits were to emergency departments; • Diagnosis codes for 6,277 (79%) of prior visitswould not have prompted an HIV test.
Common Reasons for Delaying Testing • When read a list of potential barriers: • 69% didn’t believe they were at risk • 52% thought their behaviors were safe • 70% had at least one healthcare visit before being diagnosed with HIV/AIDS American Sexually Transmitted Diseases Association, August 2011, Vol 38, Issue 8, pp 715-721.
Revised RecommendationsAdults and Adolescents Routine, voluntary HIV screening for all persons 13-64 in health care settings, not based on risk. (Opt-out HIV screening with the opportunity to ask questions and the option to decline testing) Repeat HIV testing of persons with known risk at least annually Continue routine testing unless HIV prevalence of patient population is <0.1
Diagnostic testing:performing an HIV test based on clinical signs or symptoms Targeted testing:performing an HIV test on subpopulations of persons at higher risk based on behavioral, clinical or demographic characteristics Screening:performing an HIV test for all persons in a defined population Opt-out screening:performing an HIV test after notifying the patient that the test will be done; consent is inferred unless the patient declines Terminology
Will this work in Texas? Opt-out HIV testing pregnant women 1997 Opt-out HIV testing in STD clinics 1999 Diffusion of Innovation Test Texas HIV Coalition www.testtexashiv.org
Pregnant Women Health and Safety Code 81.090 Test HIV, HBV, Syphilis at 1st prenatal care visit Test HIV during third trimester At Labor and Delivery if NO 3rd trimester test, test for HIV, result returned within 6 hours. If at birth of infant no 3rd trimester test OR L&D test of mother, test infant, result returned within 6 hours. Test HBV and Syphilis at L&D.
Texas STD Clinics: Reasons Seroprevalence studies: ~50% of HIV-positive clients were not tested in some STD clinics Only 50% of clients accepted opt-in HIV testing Routine opt-out testing is effective and has been the norm for other STD screening historically Early detection of HIV can help communities, STD clinicians and especially clients (Early Intervention)
Texas STD Clinics: Focus Groups Pre-test counseling identified as a deterrent to HIV testing Many clients thought they were tested routinely and assumed they were HIV negative after their STD clinic visit Focus group participants strongly recommended making routine HIV testing part of STD screening
Routine Opt-Out HIV TestingTexas STD Clinics, 1996-97 Opt-In Opt-Out N (%) N (%) % change STD Visits 31,558 34,533 +9 Eligible Clients 19,184 (61) 23,686 (69) +23 Pre-test counsel 15,038 (78) 11,466 (48) -24 Tested 14,927 (78) 23,020 (97) +54 Post-test counsel 6,014 (40) 4,406 (19) -27 HIV-positive 168 (1.1) 268 (1.2) +59 Texas Department of State Health Services, 2005
Texas Expanded Testing Projects Purpose: Implement routine HIV screening in medical settings to identify PLWH unaware of their infection Diagnose PLWH earlier in the disease process Link and retain PLWH in care
Texas Law * SupportsCDC Revised RecommendationsAdults and Adolescents • Include HIV consent with general consent for care. A separate signed informed consent is not required • Prevention counseling in conjunction with HIV screening in health care settings is not required • Arrange access to care, prevention, and support services for patients with positive HIV test results *Health & Safety Codes 81.105, 81.106 & 81.109
The AMERICAN MEDICAL ASSOCIATION ETHICS POLICY states that a physician’s duty to promote patient welfare and to improve the public’s health are fostered by routinely testing their adult patients for HIV. www.ama-assn.org/go/cdjareports
The Texas Model • Routine • Opt-out • Integrated • Sustained
Routine Testing Sites • 10 Emergency Centers • 8 Jails • 60 + Community Health/Primary Health • STD Clinics • Teen Clinics • Family Planning
Rapid and Conventional Testing • Point-of-care (rapid) testing can be performed on site • Results available in ~20 minutes • Use either blood or oral fluid • Very sensitive • Need to perform confirmatory testing on positive specimens
Compare and Explore • Rapid • Labor intensive • Cost • Return of results • Confirmatory specimen • Conventional • Batching • Quality assurance • Automated confirmatory
Challenges • Exceptionalism • Establishing standing orders • Staff training and maintenance of practice • Billing/Coding • Reimbursement • Link to Care • Public Health Follow up
TEST TEXAS HIV COALITION Phase I If We Build It, They Will Come?
Test Texas HIV Coalition Steering Committee HIV Test Training Development Workgroup May 7, 2008 Sept 16, 2008 How it all began…
TEST TEXAS HIV COALITION Speakers Inaugural Meeting Website Test Texas HIV Coalition Steering Committee Innovators Early Adopters
Test Texas HIV Coalition July 1, 2009 Steering Committee Test Texas HIV Coalition Training Sub-committee Website Sub-committee Your Sub-committee Could Be Here
TEST TEXAS HIV COALITION Website, Speakers December Summit Educational Materials HIV Testing Becomes Routine Medical Practice in Texas Speakers Inaugural Meeting Website Innovators Early Adopters Early Majority, etc.