Practical Considerations of Expanded HIV Testing and Screening: A State-Level View Institute of Medicine Workshop to Identify Facilitators and Barriers to HIV Testing April 15-16, 2010 Washington, DC Kevin Cranston, MDiv Director, Bureau of Infectious Disease Massachusetts Department of Public Heath

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

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

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

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

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

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

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

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

Thank you