BVCOG HRSA/HAB Tier 2 and 3 Performance Measures Lisa Cornelius, MD, MPH July 2010

An estimated 850,000 to 950,000 people are infected with HIV in the United States.

Screening and Vaccination Measures Adherence Tb Cervical Cancer Hepatitis B Hepatitis C Influenza Pneumococcal MAC prophylaxis

Adherence Assessment % of clients with HIV infection on ARVs who were assessed and counseled for adherence 2 or more times in the measurement year

DiPerrri HARRT in the New Century Sept 2004 S4-7

Tuberculosis (Tb) Screening % of clients with HIV infection who received testing with results documented for latent Tb infection (LTBI) since HIV diagnosis

Tb and HIV At least 1/3 of HIV-infected patients worldwide are infected with Tb 8-10% of patients develop clinical disease each year 456,000 deaths from Tb in HIV-infected patients each year worldwide Swaminathan CID 2010;50(10):

Tb and HIV Without treatment, HIV and TB can work together to shorten the life of the person infected. Someone with untreated LTBI and HIV infection is much more likely to develop active TB disease during his lifetime than someone without HIV infection. Among people with LTBI, HIV infection is the strongest known risk factor for progressing to active TB disease. A person who has both HIV infection and active TB disease has an AIDS-defining condition.

Cervical Cancer Screening % of women with HIV infection who have a Pap screening in the measurement year

Viral Hepatitis (B and C) Screening % of clients who have been screened for HCV and HBV infection at least once since diagnosis of HIV infection

Hepatitis B Vaccination % of clients with HIV infection who completed the vaccination series for HBV

HBV and HIV Both are bloodborne viruses transmitted primarily through sexual contact and injection drug use. Because of these shared modes of transmission, a high proportion of adults at risk for HIV infection are also at risk for HBV infection. HIV-positive persons who become infected with Hepatitis B virus (HBV) are at increased risk for developing chronic HBV infection and should be tested. In addition, persons who are co-infected with HIV and HBV can have serious medical complications, including an increased risk for liver-related morbidity and mortality. The Advisory Committee on Immunization Practices recommends universal Hepatitis B vaccination of susceptible patients with HIV/AIDS.

HCV and HIV 1/4 of HIV-infected persons in the United States are also infected with Hepatitis C virus (HCV). HCV is a bloodborne virus transmitted through direct contact with the blood of an infected person. Thus, coinfection with HIV and HCV is common (50%–90%) among HIV-infected injection drug users. HCV is one of the most important causes of chronic liver disease in the United States and HCV infection progresses more rapidly to liver damage in HIV-infected persons. HCV infection may also impact the course and management of HIV infection.

Influenza Vaccination % of clients with HIV infection who have received influenza vaccination within the measurement period

Influenza and HIV People with HIV/AIDS are considered at increased risk from serious influenza-related complications. Studies have shown an increased risk for heart- and lung-related hospitalizations in people infected with HIV during influenza season and a higher risk of influenza-related death in HIV-infected people. Other studies have indicated that influenza symptoms might be prolonged and the risk of influenza-related complications higher for certain HIV-infected people. Because influenza can result in serious illness, HIV- infected persons are recommended for vaccination. During the setting of vaccine shortage, people with HIV/AIDS are among the priority groups that should get flu shots.

BOX 2. Summary of influenza vaccination recommendations, 2009: adults Annual vaccination against influenza is recommended for any adult who wants to reduce the risk of becoming ill with influenza or of transmitting it to others. Vaccination is recommended for all adults without contraindications in the following groups, because these persons either are at higher risk for influenza complications, or are close contacts of persons at higher risk: persons aged 50 years and older; women who will be pregnant during the influenza season; persons who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, cognitive, neurologic/neuromuscular, hematological or metabolic disorders (including diabetes mellitus); persons who have immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus; residents of nursing homes and other long-term care facilities; health-care personnel; household contacts and caregivers of children aged <5 years and adults aged 50 years and older, with particular emphasis on vaccinating contacts of children aged <6 months; and household contacts and caregivers of persons with medical conditions that put them at higher risk for severe complications from influenza. Prevention &Control of Seasonal Influenza with Vaccines –Recommendations of the Advisory Committee on Immunization Practices (ACIP) 2009Prevention &Control of Seasonal Influenza with Vaccines –Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR 2009 Jul 24; Early Release:1-52.

CDC’s Advisory Committee on Immunization Practices (ACIP) A panel of immunization experts voted on February 24, 2010 to expand the recommendation for annual influenza vaccination to include all people aged 6 months and older. The expanded recommendation is to take effect in the 2010 – 2011 influenza season. The new recommendation seeks to remove barriers to influenza immunization and signals the importance of preventing influenza across the entire population.

Pneumococcal Vaccination % of clients with HIV infection who ever received pneumococcal vaccine

Pneumococcal Pneumonia Globally, pneumonia causes more deaths than any other infectious disease, such as AIDS, malaria or tuberculosis. Certain people are more likely to become ill with pneumonia. – This includes adults 65 years of age or older and children less than 5 years of age. – People up through 64 years of age who have underlying medical conditions (like diabetes or HIV/AIDS) and – people 19 through 64 who smoke cigarettes or have asthma are also at increased risk for getting pneumonia. In the U.S., the most common bacterial cause of pneumonia is Streptococcus pneumoniae (pneumococcus)

The 1997 ACIP recommendations for prevention of pneumococcal disease. Available at:

Mycobacterium avium Complex (MAC) % of clients with HIV infection with CD4 count <50 cells/mm 3 who were prescribed MAC prophylaxis within the measurement year

MAC Mycobacterium avium complex = comprising M. avium and M.intracellulare. In HIV infected persons, manifestations are of multi-organ infection: night sweats, weight loss, abdominal pain, fatigue, diarrhea, and anemia. Most likely environmentally acquired through inhalation or ingestion. Risk Groups: HIV-infected persons. – Rarely in children or nonimmuno-compromised persons.

MAC In the absence of ART or prophylaxis for those with AIDS-associated immunosuppression, incidence of disseminated MAC disease is 20-40% For those with CD4 count <100cells who are receiving effective prophylaxis or have responded to ART, incidence is 2 cases per 100-person years

MAC risk factors CD4 counts <50 cells/mm 3 High plasma HIV RNA levels (>100,000 copies/ml) Previous opportunistic infections Previous colonization of the respiratory or gastrointestinal tract

Screening and Vaccination Measures: Summary Adherence Tb Cervical Cancer Hepatitis B Hepatitis C Influenza Pneumococcal MAC prophylaxis