1. Performing Routine HIV Screening in Your Health Center Karen McCraw Chief Program Officer Family First Health

2. Why routine HIV screening? Don’t we have enough to do??

3. National HIV/AIDS Strategy • Goals: • Reducing New HIV Infections • Increasing Access to Care and Improving Health Outcomes for People Living with HIV • Reducing HIV-Related Health Disparities and Health Inequities • Achieving a More Coordinated National Response to the HIV Epidemic

4. UDS—New in 2014 • The number of patients with a first time diagnosis of HIV • Rationale: HIV positivity is a HHS data reporting priority that is not currently in the UDS. • Quality of Care Measures • Adding a measure for new HIV cases with timely follow up

5. ACA and HIV Screening • HIV screening must be included as a covered Preventive Service by private insurance plans under the Affordable Care Act* • Screening for ages 15-65; other ages at increased risk • What does “at increased risk” mean? • No deductible or copayment can be applied to HIV screening

6. USPSTF • In April 2013, the U.S. Preventive Services Task Force (USPSTF) updated its previous recommendations for HIV screening as follows: • The USPSTF recommends that clinicians screen adolescents and adults aged 15 to 65 years for HIV infection.  Younger adolescents and older adults who are at increased risk should also be screened.  (Grade A recommendation)

7. The Cascade

8. The Clinical Case for Screening • Early diagnosis of HIV infection leads to better outcomes • 33% of the newly diagnosed are “late testers” with an AIDS diagnosis within one year • People in treatment are less likely to transmit HIV to others • There are ~50,000 new HIV infections a year; half of those new infections originate from the 18-20% of people with HIV who are unaware of their status

9. So we know we need to do it. But how???????

10. The patients will freak out! NO TIME! You can't give a positive result on a Friday! Too much to do in an appointment already What if someone tests positive? It will make us run late!!!

11. Plan around your existing processes

12. Getting a program together • Management and staff buy-in • The law • Choosing the right HIV test • Developing a framework • Training • Reactive tests • Linkage to care • Financial issues • Record keeping/data management • Ongoing monitoring

13. Management and staff buy-in • What is the selling point for routine screening for your audience? • Public health? • Medical? • Ethical? • Funder expectations? • Insurance regulations? • PI issue?

14. The Law • PA no longer requires pre- and post-test counseling • Documentation of informed consent required • Positive results must be reported via NEDSS as with all other reportable diseases • Cannot use the word “positive” in the absence of a confirmatory result • Opt-out testing allowed

15. Choosing the right HIV test • One of the most important variables • Considerations: • Processing time!! • Storage • Ease of use • Reliability • CLIA status • Shelf life • Cost

16. Developing a framework • Who will obtain consent? • Who will answer patient questions? • Informational handouts • Who will perform tests? • Who will deliver results? • How will a reactive result be handled? • How to keep track of multiple tests concurrently? • EHR documentation • How to handle minors? Parent in room?

17. Training • HIV 101 for support staff • Training on performing test • How to answer patient questions • How to offer a routine HIV test • How to deliver a reactive test result • Reassurance • Confirmatory • Assessing immediate patient needs

18. Reactive tests • Develop a protocol in the event of a reactive test • Forget the conventional wisdom about not testing on a Friday—”routine” means whenever you are seeing patients • Consider performing a second rapid test to rule out a defective test • Always get confirmatory lab work done before patient leaves • Resources for patient

19. Linkage to care • People who are engaged in care soon after diagnosis have a higher rate of remaining engaged in care • Do you do in-house HIV care? • Are you interested in developing the capacity to provide HIV care? • Referral agreements with Ryan White-funded entities • Clarify who is responsible for tracking a patient once the referral is made • Document linkage to care

20. Financial issues • Negotiate lower test cost • Some tests available through 340B pricing • Public grant funding • Uninsured patients and those covered by PPS rate may be majority of patients • Pharmaceutical company grant funding • Increased reimbursement from private payers under ACA

21. Recordkeeping/data management • Incorporation into EHR • EHR reporting capacity • What do you want to track? • What would potential funders want to see? • Offered tests/accepted tests/linkage to care at minimum • Do you need a separate database?

22. Ongoing monitoring • Just like everything else, routine HIV screening can fall off the radar • Family First Health has included routine HIV screening in monthly PI chart audits • Share outcomes to reinvigorate staff • Family First Health includes testing in set of core competencies for clinical support staff

23. Lessons Learned--FFH • Routine HIV screening did not disrupt the clinic flow • Routine HIV screening is helping reduce stigma around HIV testing • Routine screening is philosophically provider driven but operationally support staff driven • Clinical staff buy-in increased dramatically after the first positive test • The first people newly diagnosed as HIV positive through this program were existing health center patients

24. Lessons Learned-FFH • We were terrible at assessing “risk” • Patients like the rapid test and the absence of risk assessment • Staff members were initially upset when tests were reactive—had to recalibrate their perspective • There is still a role for testing outside the primary care setting

25. Family First Health’s Cascade • Approximately 82% of HIV positive individuals in York County have been linked to care • 77% of HIV positive clients have been retained in HIV care • 100% of clients retained in care are receiving Antiretroviral Treatment • Out of the clients who are retained in care and receiving treatment, 93% have an undetectable viral load • Across all Caring Together clients, 83% have an undetectable viral load

26. Contact Information • Karen McCraw Family First Health (717) 845-7244 kmccraw@familyfirsthealth.org