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HIV Testing- What’s Your Routine?

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HIV Testing- What’s Your Routine?

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  1. HIV Testing- What’s Your Routine? Susanne Doblecki-Lewis, MD, MSPH, FIDSA University of Miami Miller School of Medicine

  2. No disclosures

  3. Learning Objectives • Understand the rationale for routine HIV testing • Describe current guidance regarding HIV testing in healthcare settings • Identify candidates for enhanced HIV prevention care after completion of HIV testing

  4. Why Routine Screening? • HIV is a serious health issue that can be detected and treated before symptoms develop • Many new infections are transmitted by people who do not know they are infected • Treatment is effective in improving health and cuts the risk of transmission by as much as 96% • People who know their status are more likely to take other protective measures http://www.cdc.gov/hiv/testing/ (accessed Sept 2018)

  5. Marks, et al. AIDS 2006; 20: 1447-1450.

  6. Missed Opportunities Average of 4 healthcare visits per patient without HIV testing prior to positive test MMWR. 2006;55:1269.

  7. Risk-based screening misses many people • 39% of men who had sex with a man within the past year did not disclose their same-sex sexual activity to their health care provider • 51% of rapid test positive patients identified in Emergency Department (ED) screening had no identified risk Bernstein KT, et al. Archives of Internal Medicine. 2008;168(13):1458-1464. Lyss SB, et al. Journal of Acquired Immune Deficiency Syndromes. 2007;44(4): 435-442.

  8. Desired Outcome of Routine HIV Screening

  9. Routinization = Reduced Stigma

  10. Routine HIV Testing is Standard of Care Centers for Disease Control and Prevention 2006 Revised Recommendations: HIV screening is recommended for all patients ages 13-64 in all health care settings after the patient is notified that testing will be done unless the patient declines (opt-out screening). Persons at high-risk for HIV infection should be screened for HIV at least annually. Separate written consent for HIV testing should not be required. General consent for medical care should be considered sufficient to encompass consent for HIV testing. Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health care settings. HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women, and HIV screening is recommended after the patient is notified that testing will be done unless the patient declines (opt-out screening). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

  11. US Preventive Services Task Force https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/human-immunodeficiency-virus-hiv-infection-screening

  12. Affordable Care Act • Affordable Care Act, requires that beginning in 2010 qualified health plans provide at a minimum coverage without cost-sharing for preventive services rated A or B by the U.S. Preventive Services Task Force (USPSTF)

  13. Importance of USPSTF Rating • HIV screening has an “A” rating from the USPSTF. • Therefore -- It is a covered service by Medicare, Medicaid and ACA qualified health plans. • The USPSTF has not recommended specific screening intervals, but has some guidance: • Once for all 15-65 years regardless of risk • Annually for those at “very high risk” including local prevalence >1% • Every 3-5 years for those at “increased risk”

  14. When to test? • Test everyone at least once. • Hospital admissions if no recent test available (in chart / documented) • Test those with ongoing risk, multiple partners, drug use at least annually • Test sexually active MSM, others at higher risk quarterly

  15. Florida’s Testing Laws • In 2015, the Florida statues were amended to allow routine testing for HIV in healthcare settings • Removes need for written informed consent before HIV testing in healthcare settings

  16. What is Required Before HIV Testing? • Must inform patient that test is being ordered • Patient must have opportunity to refuse (“opt-out”) of testing – document if refuses • Must let patient know that positive results will be reported to the Florida Department of Health

  17. How May I Notify Patients of Routine HIV Testing in a Healthcare Setting? • General consent for medical treatment may include HIV testing • Poster in office • Pamphlet / brochure on testing • Verbal notification • Other forms of notification

  18. You are seeing a 30 year old male due to concern regarding HIV exposure. He has multiple male partners, and in particular is concerned about an episode of condomless anal receptive intercourse 10 days ago with someone he suspects was HIV positive. • What would your testing strategy be? • Why?

  19. How to test? • Standard EIA tests • Ab/Ag “4th generation” tests • RNA detection

  20. HIV testing and detection of Acute HIV Symptoms (~60%) p24 Antigen HIV RNA HIV Ab EIAs 0 1 2 3 4 5 6 7 8 9 10 Weeks Since Infection

  21. Nucleic Acid Testing(RNA, DNA, NAAT, Viral Load) • Not for diagnosis unless you are thinking of acute HIV infection • 80% of new infections develop symptoms but most will not associate with possible HIV infection: • Fever • Rash • Headache • Sore throat • Average 1-6 weeks after exposure • Window period = 7-14 days • Remember, the eclipse period (first 4-7 days of infection) – no current test will detect infection

  22. What is the Benefit of Rapid Testing? • Increased receipt of test results • Increase feasibility of testing in acute care settings • Increase number and type of venues where testing can be offered to individuals at increased risk

  23. HIV Ab/Ag Test “4th Generation” • Antigen detection before antibody is detectable • Window period 12-26 days • Increased sensitivity in early infection compared with Ab only test

  24. You are seeing a 30 year old male due to concern regarding HIV exposure. He has multiple male partners, and in particular is concerned about an episode of condomless anal receptive intercourse 10 days ago with someone he suspects was HIV positive. • What would your testing strategy be? • How would you counsel him? • Why?

  25. Follow-up on Testing: What Next? • Reactive tests, with confirmation: • Refer immediately to HIV provider • Inform re: secondary transmission • DOH does partner notification / testing • Baseline testing and selection of regimen

  26. Follow-up on Negative Tests • Evaluate for risk (sexual, injection drugs) • Window periods • What are your plans for staying negative? • Condom use • Pre-exposure prophylaxis (PrEP) • Post-exposure prophylaxis (nPEP) • Recommendations for follow-up testing • STI testing

  27. After infection Time of transmission Prior to exposure Using Antiretroviral Medications for HIV-1 Prevention PEP PrEP ART

  28. References / Additional Resources • AAHIVM Provider Resource Guide • http://www.aahivm.org/ • NASTAD • https://www.nastad.org • https://aidsetc.org/aetc-program/southeast-aetc