HIV and Hep C testing Ardis Moe, M.D. UCLA CARE/NEVHC Van Nuys HIV Clinic amoe@mednet.ucla

1. HIV and Hep C testing Ardis Moe, M.D. UCLA CARE/NEVHC Van Nuys HIV Clinic amoe@mednet.ucla.edu Friday 20 June, 2014

2. I do not have any financial arrangements or affiliations with commercial sponsors which have direct interest in the subject matter

3. Goals • What types of HIV and hep C tests are available • USPSTF Recommendations • How to tell someone they are HIV+ • How to get HCV meds paid for.

5. Types of HIV tests

6. Clinical case • 18 year old high school senior donates blood • Phone call from blood bank: patient has HIV. Elisa positive, NAAT positive. No WB done

7. Is he HIV+? • How do you counsel him? • What is NAAT? • What is Elisa?

8. Audience Response Questions • 1)I have given an HIV test result to someone newly HIV+ • 2)I have never given an HIV test result • 3)I do not give HIV test results as a scope of my practice

9. Legally, a patient is not HIV+ unless there are two licensed rapid HIV tests --two different kits--- (mostly used in developing countries) • OR a repeatedly reactive Elisa test AND a confirmatory test: Western blot or IFA. • OR +Elisa test and HIV viral load >1,000 copies

10. NAAT is a simplified HIV viral load test • Used by blood banks to screen for HIV seroconversion • Elisa is also a screening test; false positives occur with pregnancy; blood transfusions, flu shots, hepatitis, SLE, etc. there are 3rd and 4th generation tests

12. Rapid blood tests for HIV • Rapid oral tests for HIV

16. 3rd and 4th generation HIV tests • 3rd generation—antibody test—will miss some patients in seroconversion “window” period” • 4th generation—combination antibody/p24 antigen—will pick up more people in the window period (57-84%) Uptodate 2014

17. What does a western blot look like?

19. Need for HIV testing

20. Half of HIV+ patients are infected before age 25 • 1/3 infected before age 20 • 60% of MSM AA men will be infected with HIV by age 40 (40% of white MSM)

23. Treatment of HIV+ partners decreases HIV transmission by 96% • Detection of HIV virus alone would reduce new HIV infections by up to 50% • uptodate 2014

24. The combination of early testing and treatment is the most effective tool we have to prevent further infections

27. 67 yo married businessman, while sitting in waiting room for a routine cholesterol blood draw, decides to fill in the circle on the paper lab form for an HIV test

28. His HIV test comes back positive. • He first indicates his risk factor was sex with prostitutes • He then recalls a blood transfusion. This is not in his medical records • He is then noted to flirt with the male clinic staff.

29. He is turning 82 this year. Wife is still HIV negative.

31. Test everyone 13- dead • Test persons who ask for viagra for all STI’s, including HIV. • Persons with obvious risk factors should be tested every 6-12 months (IDU, meth, MSM, etc)

32. Pregnant women should be tested twice if possible; in first or second trimester, and again in 3rd trimester • Treatment of HIV during pregnancy decreases HIV transmission to <1% of newborns

33. If you are doing any other test of STI (GC/CT screen for PAP test) order an HIV test as well. • Early HIV mimics lupus: rash, joint aches • AIDS mimics lymphoma or other cancers: weight loss, night sweats, lymph nodes

34. Any person under age 60 with shingles needs an HIV test • Anyone with hep C or ITP • Any person under age 65 being worked up for dementia needs an HIV test. • If you are ordering an RPR or any other STD test (GC etc), order an HIV test.

35. What if results come back INDETERMINATE? • Order an HIV RNA PCR (HIV viral load) • If they are in seroconversion, the viral load will be >1,000 copies. If undetectable, reassure the patient they have a false-positive

36. If they have an indeterminate HIV test and a positive viral load <1,000 copies, call your ID consultant

37. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement Summary of Recommendations and Evidence The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen adolescents and adults ages 15 to 65 years for HIV infection. Younger adolescents and older adults who are at increased risk should also be screened. See the Clinical Considerations for more information about screening intervals. This is a grade A recommendation. The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor whose HIV status is unknown. This is a grade A recommendation.

38. Audience Response Question: You have a 22 yo pregnant female who had an HIV test that came back INDETERMINATE. What do you do? 1)Repeat the HIV Elisa and Western blot in 3 months • 2)Repeat the HIV Elisa and Western blot immediately • 3)Do an HIV viral load

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

40. 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

41. 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

42. 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

43. HIV Treatment--and Training--is Available • Ryan White funds available for indigent and/or undocumented patients for free HIV care; many HIV clinics have case managers who can sign up patients for the ACA on site • PAETC resources available to counsel patients being deported or moving back to other countries to access HIV treatment.

44. How to give HIV test results

45. When you order an HIV test, schedule a followup visit one week later. • Positive tests should always be given face to face by an MD, RN, or RNP. • If the HIV test is negative, you can always cancel the appointment and tell negative results over the phone

46. When your patient is HIV positive… • Have HIV results and other paperwork ready for when the patient shows up • Have an HIV/ID clinic appointment available for the patient: HMO referral sent, etc. • Red, white and blue panic reactions.

49. Say” I have important news: your blood test is positive for the virus that causes AIDS” • Say “important news” not bad news. Many patients later tell me that getting HIV was the best thing that ever happened.

50. Red panic • Patient is angry, but it is a fear-type anger • They threaten to infect others, may suddenly get violent; they may want to sue you • Sit with your back to the door so you can escape.