Kevin Cranston, MDiv Director, Bureau of Infectious Disease Massachusetts Department of Public Heath

1. Practical Considerations of Expanded HIV Testing and Screening: A State-Level ViewInstitute of MedicineWorkshop to Identify Facilitators and Barriers to HIV TestingApril 15-16, 2010Washington, DC Kevin Cranston, MDiv Director, Bureau of Infectious Disease Massachusetts Department of Public Heath

2. Background/Disclosure • Massachusetts remains an opt-in HIV test state, with pending legislation that would remove written consent • Massachusetts contributes the highest state funding for HIV services per person with HIV/AIDS of any state (>$35M/year) • Recent loss of $1.75M pales by comparison to other states • Due to Massachusetts’s 2006 health reform law, 97.4% of legal residents currently have health insurance • 31% of recent incident cases of HIV infection in Massachusetts are concurrently diagnosed with AIDS • Lateness to care a global problem affecting all populations • Particularly evident among men, non-US born individual, “presumed heterosexual”/NIR

3. Background/Disclosure • Over 60% of new HIV positives reported in Massachusetts in 2008 were identified through targeted testing in funded CTR programs • Targeted testing is chronically underutilized by African Americans and other black individuals • In 2009 Massachusetts Department of Public Health recommended routine screening of adults in primary and urgent care settings

4. Barriers to Expanded HIV Testing • Low-hanging fruit phenomenon • We are experiencing the limits of HIV risk-based testing • Growing proportion of men and women with “presumed heterosexual” exposure mode, including those with second-hand or undisclosed risk • Challenge of building personal risk awareness and disclosure skills • Challenge of building clinical capacity to elicit accurate risk histories • Instability of state funding for HIV testing systems • Limited ability to ramp up routine screening in clinical settings • Currently successful targeted testing programs unable to grow • CBO infrastructure dependent on government grants; other sources shrinking or eliminated • Fear of losing benefits of targeted HIV testing system • Limits readiness to shift resources from targeted testing to routine screening • Limited authority of health departments re: clinical care systems • Can recommend and study, but generally cannot dictate practice

5. Barriers to Expanded HIV Testing • Clinicians’ overt resistance to adding more public health issues to the clinical encounter • Substance abuse, domestic violence, diet, tobacco use, bicycle safety, seat belt use, etc. plus chronic disease screening burdens are already high and variably observed • Clinicians’ variable skill and comfort exploring patients’ risk history • Pre-service and in-service training on sexuality and substance use generally limited • Perceived barrier of informed consent process • Absence of written consent does not equate to widespread routine screening

6. Potential Facilitators of Expanded HIV Testing • Ample reimbursement rates for expanded and imbedded clinical encounters • There is basic coverage for HIV tests by most MA insurers; rapid tests still not adequately covered, nor is time of test operator • Cover testing process by non-clinicians working in medical settings • Create add-on reimbursement of HIV testing over and above bundled clinic visit rates • Create add-on reimbursement for expanded health education/risk management discussions where indicated

7. Potential Facilitators of Expanded HIV Testing • More substantial decision making guidance for state health departments about their relative investments in targeted vs. routine testing • Need to better examine cost and cost-effectiveness of various models, including hybrid (“targeted routine”) models • Seek models of the optimal mix for various jurisdictions based on epidemiology, funding levels, and public health/health care systems • Be selective about which CBOs and clinical sites to fund; don’t let historic funding or infrastructure support needs be the primary drivers of investment

8. Potential Facilitators of Expanded HIV Testing • Expand contractual freedom for funded testing providers • Potential for greater integration of community-based providers working alongside clinicians in medical settings • Reduce data reporting requirements for clinical settings; enable more routine, automated transfer of data from electronic medical records • Strategically relax strict population reach or seroprevalence targets for selected CTR programs; facilitate creative responses to reaching hidden positives

9. Potential Facilitators of Expanded HIV Testing • National credentialing and accreditation bodies should clearly establish routine HIV screening as a standard of care • Support litigation for failure to screen when medically or demographically indicated

10. Thank you kevin.cranston@state.ma.us