community health centers Routine HIV testing in community health centers Karen Barton, MD, Akron Community Health Resources Kris Drummond, DDS, Akron Community Health Resources National Association of Community Health Centers, Inc.

Brief Description of HIV Testing Initiative Objective: To develop a model for the integration of HIV testing into routine primary care at Non-Ryan White funded health centers along with a model for post test counseling and referral to specialty care Target States: Mississippi (3 health centers; 9 clinical sites) North Carolina (2 health centers; 7 clinical sites) South Carolina (1 health center; 3 clinical sites) Ohio (4 health centers; 6 clinical sites)

National Association of Community Health Centers (NACHC) Who We Are NACHC is a non-profit organization that represents the interests of America’s community health centers Our Mission To promote the provision of high quality, comprehensive health care that is accessible, coordinated, culturally and linguistically competent, and community directed for all underserved populations. 3

In 2007, 1076 grantees served over 18 million pts in nearly 63 million visits

Health Centers Nationally Patient Profile 1 in 4 minorities below poverty 1 in 7 rural Americans 1 in 8 Medicaid beneficiaries 1 in 7 uninsured persons, including 1 in 5 low income uninsured 1 in 3 people in poverty 936,000 Farmworkers, 1,044,000 Homeless Persons Line four about the uninsured…?

Akron Community Health Resources Location Akron, Ohio Size 3 Sites 2 Medical Sites (11 providers) 1 Dental (1 Dentist) Demographics In 2008, 75% of patients (5,770) were 13-64 years of age

Patient Care Model with Integrated Rapid HIV Testing Front Desk Check-in ROUTINE SCREENING FLOW SHEET attached to encounter form Waiting Room During intake process (which may occur in a “vitals area” in some centers), dental team offers RAPID HIV SCREENING Negative results given by any team member Reactive results given by provider Exam Room (or dental operatory) Laboratory Blood draw, if needed Check Out Check out

Routine HIV Screening Algorithm Rapid HIV Test Negative Reactive Inform patient Give “Negative” handout, if desired Review risks, if appropriate Discuss “window period” No further testing Inform pt preliminary results are reactive Give “Reactive” results handout Draw confirmatory Western Blot Schedule follow-up appt in 5 days Advance call to DIS with f/u appt date & time Patient likely negative unless recent risk Review risks & prevention Schedule 3 mo repeat Western Blot ?change colors Western Blot Negative Positive Indeterminate Counsel patient Notify DIS Ensure referral to HIV care Complete “Reactive Tracking Sheet” Repeat Western Blot at 5 day follow-up visit

Post Test Counseling & Referral Rapid HIV Test Reactive CHC informs pt preliminary results reactive CHC provides written “Reactive” results handout CHC draws confirmatory Western Blot CHC schedules follow-up appt in 5 days CHC* Notifies DIS of Reactive result DIS may come to CHC to counsel pt regarding results, window period, risk reduction; if not CHC does counseling Western Blot Negative Positive Indeterminate DIS performs post-test counseling DIS completes CDC data form DIS refers to HIV specialty care and case management DIS addresses partner notification DIS comes to CHC to counsel pt and Western Blot redrawn *CHC=Community Health Center

HIV Testing Experiences Southeast Jan/Feb 07-March 08 Ohio Sept 08 – July 09 Offered HIV testing (% of total patients) 17,237 3,733 Received HIV testing (% of those offered) 11,255 (66%) 1,908 (51%) Reactive Rapid Test (% of tests performed) 42 (0.37%) 5 (0.26%) Confirmed as newly HIV-infected 17 (0.15%) Linked to care (% of newly confirmed HIV-infected linked to care) 161 (94%) 5 (100%) 1One patient moved out of state but was believed to be in care.

Akron HIV Testing Medical Dental 1630 520 698 (43%) 376 (72%) 1 n/a Offered HIV testing (% of total patients) 1630 520 Received HIV testing (% of those offered) 698 (43%) 376 (72%) Reactive Rapid Test (% of tests performed) 1 Confirmed as newly HIV-infected n/a Linked to care (% of newly confirmed HIV-infected linked to care)

OraSure Technologies, INC Step 1 – Collect sample. Swab between the teeth and upper and lower gum once. Step 2 – Insert the device into the buffer. Step 3 - Read between 20 and 40 minutes. Preliminary Positive Line in the C and T Zones Non-Reactive Line in the C zone

Patients Tested1 African Americans and Latinos were significantly more likely to test than were Whites. Women were more likely to test than were men in the southeast; women and men were equally likely to accept testing in Ohio. Uninsured patients were more likely to test than those with any kind of insurance. Patients insured under Medicare or Medicaid were less likely to test in the southeast; this difference was not noted in Ohio. Patient age was not associated with testing in the southeast. In Ohio, older patients were slightly less likely to accept testing than younger patients. 1Findings are across the southeast and Ohio unless otherwise noted.

New Access1 This project provided new access to HIV screening. For 56% of patients, this was their first HIV test. Patients who had not been tested before were significantly more likely to accept testing (p=.009). Of those testing before in the southeast, only 19% had been tested 3 or more times; the majority were not repeat testers. 1Findings are across the southeast and Ohio unless otherwise noted.

A Conundrum? “I am surprised by the data. I thought we would have more confirmed cases. I am surprised based on some judgments I made but now I wonder if we need to make more effort to reach those who are really positive. We know it is there.” – Medical Director “We have found low prevalence and have had false positives. We need to prove why it’s worth it.”

What Worked Well? Development of a model for routine screening Design of a uniform data collection tool for routine HIV screening in primary care. Having patient level data Engagement of leadership and staff…understanding “why” Training and preparation of staff…understanding “what” External coaching and support - NACHC Testing well received by patients Easy test with immediate results Partnerships established for follow-up HIV counseling/care Involving state and national partners Tests FREE to health centers…FREE to patients

What Did Not Work? Difficulty of building in another task for staff to do in an already busy day – buy in. Competing priorities for entities engaged in HIV screening: health departments, AIDS Education and Training Centers (AETC). Lack of state health department support and understanding for the initiative Lack of a uniform data collection process at the onset of the project – e.g., there was no data collection tool applicable to routine HIV screening in a primary care setting Lack of a clear plan at the onset for handling reactives and addressing false positives Lack of funding for, or access to, tests on an ongoing basis after the pilot effort!

Creation of a new paradigm! From Our Perspective, the Opportunity for HIV Testing in Primary Care is……. Creation of a new paradigm! If routine HIV screening in primary care is the goal, then primary care providers need to be part of the programmatic model and test distribution process

For More Information NACHC ( www.NACHC.com) Kathy McNamara 301.347.0400 Email: kmcnamara@NACHC.com Cheryl Modica 631.757.6375 Email: camodica@optonline.net 19

For More Information Kris Drummond, DDS, MPH, CPH 330/785-2044 kdrummond@achrhealth.org 20

Support: This project was made possible through funding from the Centers for Disease Control and Prevention (CDC) and Gilead. Rapid HIV Tests for the southeast project were donated by Health Providers Direct. 21