Routine Opt-Out HIV Testing

1. Routine Opt-Out HIV Testing UCLA / Pacific AIDS Education & Training Center (UCLA PAETC) CDC Routine HIV Testing Project 2011

2. Educational ObjectivesAt 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

3. On my commute this morning, I listened to… • Nothing…I need my quiet time. • Rock and Roll, Baby! • Radio News, Traffic, Weather • Other

4. My most recent HIV testing training was… • In the past 3 months • In the past 6 months • 1 year ago • More than 1 year ago

5. I have worked at XXXXXXX for… • Less than 1 year • 1-5 years • 5-10 years • More than 10 years

6. While working at XXXXXX, I have helped ____ number of patients deal with diabetes… • Zero/None • 1-5 • 5-10 • More than 10

7. What percentage of XXXXX patients aged 13-64 have been tested for HIV?… • Less than 30% • 30-50% • 50-70% • More 70%

8. I believe the number one challenge in implementing opt-out HIV testing here is… • None, it’s easy as pie • New EMR system • It takes too much time • Other

9. AETC Contacts Tom Donohoe donohoe@ucla.edu http://www.aids-etc.org http://www.psattc.org

10. Opt-Out: 2006 CDC Recommendations, Implementation, and Consequences of Late HIV Testing

11. In California in 2011, do you still need consent for HIV testing? • Yes • No

12. What percent of XXXX patients do you think would refuse HIV testing (opt-out)? • < 5% • 5-25% • 25-50% • >50%

13. Do you think some XXXXX patients will avoid clinic visits to avoid HIV testing? • Yes • No

14. Do you know how to connect your newly diagnosed HIV+ patients to local, free HIV care (treatment, medications, etc)? • Yes • No

15. Have you ever been involved with giving an HIV-positive test result to a patient? • Yes • No

16. All XXXXX patients with a positive STD test are tested for HIV: • True • False • Unsure

17. 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

18. 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

20. Awareness of Serostatus Among People with HIV and Estimates of 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 Living with HIV/AIDS: 1,039,000-1,185,000 New Sexual Infections Each Year: ~32,000

22. 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% MSM 61% IDU 16% Heterosexual 76% Females (n ≈ 45,000) Males (n ≈ 112,000) MMWR, Nov 18, 2005

24. “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.

25. HIV tests* HIV+ tests** Private doctor/HMO 44% 17% Hospital, ED, Outpatient 22% 27% Community clinic (public) 9% 21% HIV counseling/testing 5% 9% Correctional facility 0.6% 5% STD clinic 0.1% 6% Drug treatment clinic 0.7% 2% 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. *National Health Interview Survey, 2002 **Suppl. to HIV/AIDS surveillance, 2000-2003

26. Late HIV Testing is CommonSupplement 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

28. 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 Wanted to Routine Required Other at risk know check up

30. The Case for HIV Screening

31. 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 Principles and Practice of Screening for Disease -WHO Public Health Paper, 1968

32. “HIV TESTING IS ROUTINE” • How you offer the HIV test makes a difference in how patients will accept the test.

33. 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

34. 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

36. 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

37. 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

38. 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.

39. 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.

40. 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+

41. HIV TESTING tdonohoe@mednet.ucla.edu

42. 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”