Perspectives on Outreach from the NYC Department of Health and Mental Hygiene Benjamin Tsoi, MD, MPH Bureau of HIV/AIDS Prevention and Control NYC Department of Health and Mental Hygiene

Steps Leading to HIV Testing Identify persons at risk for HIV Find infected persons who are unaware of their HIV status Make offer of HIV test Provide HIV test

Steps Leading to HIV Testing Identify persons at risk for HIV –Use of epidemiology & surveillance data

New HIV Diagnoses in NYC, 2007 Race/Ethnicity 80% of new HIV diagnoses are in blacks and Hispanics –Blacks have a higher percentages of new HIV diagnosis, PWHA, and death As reported to the New York City Department of Health and Mental Hygiene by September 30, 2007

State’s Regulation of Reportable Conditions, including HIV Facilitators –Allows for tracking of HIV epidemic over time –Allows for identification of at risk subpopulations Limitations –Reporting incomplete –Information limited to those who test positive, not those who test negative –Confidentiality provision may prevent use of HIV registry data for programmatic use

Steps Leading to HIV Testing Identify persons at risk for HIV Find infected persons who are unaware of their HIV status

The Bronx Knows Get Smart, Get Safe, Get Tested

Outreach to Undiagnosed HIV-infected Persons HIV ScreeningTargeted Testing In a defined population, broadly performing HIV test for all persons Performing HIV test on a subpopulation of persons at higher risk, usually based on specific characteristic(s)

HIV Screening Facilitators and Barriers

CDC’s Revised Recommendations

CDC’s Recommendation for Testing in Health-Care Settings Facilitators –Makes it easier to go to medical facilities to promote screening Limitations –Lacks enforcement capability –Lacks associated funding to support expansion nationally –Variable level of knowledge of recommendations by providers

Many Physicians-in-training Not Aware of Recommendations Fifteen NYC internal medicine residency programs surveyed in early (38.3%) of 1175 residents responded –Most (63.9%) ordered about 10 HIV tests in past 6 months –32.6% aware of 2006 recommendations –35.8% used routine testing approach Jain et al. AIDS Patient Care STDs March:167-76

Medicare Preventive Services include HIV Screening Tests

Medicare Beneficiaries for HIV Screening Men who have had sex with men after 1975 Men and women having unprotected sex with multiple partners Past or present injection drug users Men and women who exchange sex for money or drugs, or have sex partners who do Individuals whose past or present sex partners were HIV-infected, bisexual or injection drug users Persons being treated for sexually transmitted diseases Persons with a history of blood transfusion between 1978 and 1985 Persons who request an HIV test despite reporting no individual risk factors Voluntary HIV screening of pregnant Medicare beneficiaries when the diagnosis of pregnancy is known, during the third trimester, and at labor

Medicare Coverage of HIV Screening Facilitators –Allows for coverage of some HIV screening –Other insurance plans may follow lead of Medicare Limitations –Medicare coverage limited to older adults and those with disabilities –Screening is not recommended or required –Testing based on risk, contrary to CDC Recommendations

Patient Don’t Always Disclose NYC National HIV Behavioral Surveillance project (2004–2005) –All men who reported at least one male sex partner in past year & self-reported HIV seronegative 39% with same-sex attraction did not disclose to healthcare provider –Black and Hispanic men who have sex with men (MSM) less likely to disclose than white MSM Bernstein et al. Arch Intern Med. 2008;168(13):

Sexual Identity Don’t Match Sexual Behavior Random digit-dialed telephone survey of NYC residents (2003) 12% reported sex with other men –Of those, 61% straight identified Racial minority, be foreign-born, have lower education and income levels, and be married –36% gay identified –3% bisexual identified Pathela et al. Ann Intern Med. 2006;145:

Missed Opportunities: Many HIV-Infected Persons Access Health Care But Are Not Tested Example: South Carolina –Of 4,300 newly reported HIV cases –3,100 (73%) made >20,000 health care visits prior to their first HIV diagnosis –77% did not have diagnosis code to prompt for HIV test CDC ED chart review findings of 195 HIV+ patients –Chest pain16(8.2%) –Bronchitis13 (6.6%) –Abd Pain11(5.6%) –Convulsions10 (5.1%) –Headache7 (3.6%) –Lumbago7 (3.6%) –Dizziness5 (2.6%) MMWR December 1, 2006

Kaiser Permanente Missed Opportunities 440 patients with new HIV diagnosis –Mean: 8.6 health-care contacts before positive HIV test –CD4 count at diagnosis: 62% < % < % <50 –Only 26% had risk factors documented in chart - Klein D, et al JAIDS 2003

Reported Reasons for Not Being Tested* Among 51% who say they have never been tested Source: Kaiser Family Foundation Survey of Americans on HIV/AIDS (conducted Jan. 26–March 8, 2009) *Interviewee may choose more than one reason, so total exceeds 100% Many people will not be tested if relying on patient to initiate testing encounter

Targeted Testing Difficulties in Finding Undiagnosed Cases While we may know neighborhoods with the highest rates of HIV, people may not necessarily want to be tested near home Non-gay-identifying MSM may not be found in traditional gay venues Difficulty in locating at-risk females –Their partners may have sex with men, but may not disclose information to female partner

Steps Leading to HIV Testing Identify persons at risk for HIV Find infected persons who are unaware of their HIV status Make offer of HIV test

Separate Consent for HIV Testing Six states still require separate consent for HIV testing Burdensome consent process is one of eight core physician barriers to routine HIV testing 1 1 Burke et al. AIDS. 2007:

HIV Testing in San Francisco Before/After Elimination of Consent Requirement Zetola, JAMA, March 14, 2007

Reimbursement for HIV Testing Insurance plans differ on amount of coverage for HIV testing In New York, different reimbursement codes for fee-for-service Medicaid vs. managed care Medicaid Rate of reimbursement often individually negotiated with plans

Steps Leading to HIV Testing Identify persons at risk for HIV Find infected persons who are unaware of their HIV status Make offer of HIV test Provide HIV test

Other Barriers to HIV Testing Stigma –Stigma associated with testing –Stigma associated with being infected Other nations have access to more state- of-the-art testing technologies than we do in US

Thank you Questions? The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the NYC Department of Health and Mental Hygiene