HIV Counseling and Testing Thomas J. Coates, PhD Michael and Sue Steinberg Professor of Global AIDS Research Director, UCLA Center for World Health

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Varieties of Community HCT Modalities Facility-based Mobile House-to-house Index Self-testing Workplace School Church 5

VCT: Historical Perspectives: 1985 Antibody tests licensed (protect the blood supply) Anonymous testing the norm Had to include pre- and post-test counseling Strong testing campaigns in the US Not so much in Europe 6

VCT: Historical Perspectives: 1985 $70m allocated for AIDS research Ryan White refused entry to middle school Rock Hudson dies at UCLA First AIDS conference in Atlanta hosted by WHO and CDC 7

VCT: Historical Perspectives: 1986 Reagan says “AIDS” for the first time and vows to make AIDS a priority (thank you Elizabeth Taylor) National Minority AIDS Council formed First panel of AIDS quilt sewn HIV is named 8

VCT: Historical Perspectives: 1987 Global Program on AIDS launched at WHO AZT approved ACT UP founded by Larry Kramer First National Conference on HIV and Communities of Color in New York First candidate vaccine tested 9

VCT: Historical Perspectives: 1987 CDC testing guidelines released Ray house burned in Florida Western Blot test approved Liberace dies of AIDS 10

VCT: Historical Perspectives: 1988 Helms Amendment passes; Presidential AIDS Commission formed 11

VCT: Historical Perspectives: 1989 Precursor to the Ryan White Care Act funded by Congress 100,000 reported AIDS cases in the US 12

VCT: Historical Perspectives: 1990 Ryan White dies Ryan White Care Act passed by Congress HIV prevention counseling model adopted by the CDC-- client-centered approach 13

VCT: Historical Perspectives: 1991 HOPWA enacted CDC recommends restrictions on HIV+ health care workers First National Skills Building Conference hosted by NAPWA Magic Johnson announces that he has AIDS 14

VCT: Historical Perspectives: th International Conference on AIDS moved from Boston to Amsterdam AIDS is the #1 cause of death for men

VCT: Historical Perspectives: th International Conference on AIDS moved from Boston to Amsterdam AIDS is the #1 cause of death for men

VCT: Historical Perspectives: 1993 President Clinton establishes the Office of National AIDS Policy at The White House CDC establishes the community planning process to better target local prevention efforts Philadelphia released Angels in America receives the Tony Case definition of AIDS expanded (<200 CD4) 17

VCT: Historical Perspectives: 1994 AIDS is the leading cause of death for all Americans Randy Shilts and Peter Zamora die AZT recommended for pregnant HIV+ women to prevent mother-to-child transmission of HIV NIH addresses the appropriate inclusion of women and minorities in HIV clinical research 18

VCT: Historical Perspectives: 1995 Greg Louganis discloses that he has HIV Eric Lynn Wright (Eazy-E) dies one month after being diagnosed with HIV 500,000 cases of AIDS reported in the US First White House Conference on AIDS convened 19

VCT: Historical Perspectives: 1996 HAART unveiled at Vancouver AIDS Conference Number of reported AIDS cases declines for the first time in the US UNAIDS formed AIDS Memorial Quilt covers the entire Mall in DC Ryan White Care Act reauthorized 20

VCT: Historical Perspectives: 1997 AIDS deaths decline Combination therapy approved by FDA UNAIDS estimates 30m people with HIV worldwide Clinton establishes goal of HIV vaccine in 10 years 21

VCT: Historical Perspectives: 1998 African-Americans account for 49% of AIDS-related deaths; AIDS related mortality 10x that of whites and 3x that of Latinos Clinton announces a special package of initiatives aimed at HIV in minority communities; Minority AIDS Initiative passed by Congress with $156m Shalala announces that needle exchange programs are effective The Supremes say that the ADA covers people with HIV 22

VCT: Historical Perspectives: 1999 WHO announces that AIDS is the 4 th biggest killer worldwide; 33m infected; 16m have died VaxGen vaccine trial starts in Thailand Clinton announces new global initiative for HIV 23

VCT: Historical Perspectives: 2000 United Nations Security Council discusses AIDS as a global security issue (#1 for any health issue) Durban AIDS Conference Clinton announces Executive Order to permit developing countries to import generic drugs Global AIDS and Relief Act of 2000 Ryan White Care Act reauthorized We announce the results of our study of HCT 24

VCT: Historical Perspectives: 2001 UN Secretary Kofi Annan calls for the global AIDS fund “war chest” US Secretary of State Colin Powell reaffirms that HIV/AIDS is a national security threat First Annual National Black AIDS Awareness Day in the US World Trade Organization announces DOHA Agreement to allow developing countries to buy or manufacture generics 25

VCT: Historical Perspectives: 2002 UNAIDS reports that women comprise about half of all adults living with HIV/AIDS worldwide HIV is leading cause of death worldwide among those aged Approval of OraQuick rapid HIV-1 Antibody Test by FDA; first rapid test to use finger prick 26

VCT: Historical Perspectives: by 5 Initiative announced by WHO South Africa announces new antiretroviral treatment programs William J. Clinton Presidential Foundation secures price reductions for HIV/AIDS drugs to benefit developing nations 27

VCT: Historical Perspectives: 2004 Global Fund holds first Partnership Forum in Bangkok with 400 participating dleegates UNAIDS launches the Global Coalition on Women and AIDS PEPFAR, President Bush’s Emergency Plan for AIDS Relief, begins first round of funding OraQuick Rapid HIV-1 Antibody Test approved for use with oral fluid by FDA 28

VCT: Historical Perspectives: 2005 World Economic Forum in Davos priorities include a focus on addressing HIV/AIDS in Africa First Annual National Asian and Pacific Islander HIV/AIDS Awareness Day in the United States Ranbaxy is the first Indian drug manufacturer to gain US FDA approval to produce generic antiretrovirals for PEPFAR 29

VCT: Historical Perspectives: 2006 First Annual National HIV/AIDS Awareness Day in the US CDC recommends routine HIV in health care settings First Annual National Women and Girls HIV/AIDS Awareness Day in the US 30

VCT: Historical Perspectives: 2007 President Bush calls on Congress to reauthorize PEPFAR at $30b over 5 years WHO and UNAIDS issue guidance recommending ‘provider initiated’ HIV testing in health care settings WHO and UNAIDS recommend that male circumcision should always be considered as part of a comprehensive HIV prevention package 31

VCT: Historical Perspectives: 2008 US Congress reauthorizes PEPFAR for 5 years at up to $48b 17 th International AIDS Conference ”Universal Action Now” in Mexico City First Annual National Gay Men’s HIV/AIDS Awareness Day in the United States CDC releases new HIV incidence estimates for the US, showing that the US epidemic is worst than thought 32

VCT: Historical Perspectives: 2009 Newly elected President Obama calls for the first ever National HIV/AIDS Strategy The Obama Administration lifts HIV travel and immigration ban by removing regulatory barriers to entry US Congress eliminates long-standing statutory ban on the use of Federal funding for needle exchange in the US 33

VCT: Historical Perspectives: 2010 Obama Administration releases first comprehensive HIV/AIDS strategy for the US South African investigators announce the results of CAPRISA004 showing that the use of a microbicide gel reduces risk of HIV infection by 39% iPrEx shows that the daily dose of a Truvada reduced risk of acquiring HIV among MSM by 43% 34

VCT: Historical Perspectives: 2011 HHS launches the 12 Cities Project to focus resources on the areas with the highest AIDS burden in the country Secretary Clinton and President Obama announce the goal of an AIDS-free generation HPTN 052 demonstrates the importance of treatment as prevention Elizabeth Taylor dies 35

VCT: Historical Perspectives: 2012 FDA approves OraQuick In-Home Test The first rapid over-the-counter rapid test that can be bought over the counter and read at home Truvada approved for PrEP 36

Varieties of Community HCT Modalities Acceptance of Testing Mobile—87% House-to-house—80% Index—88% Self-testing—87% Workplace—67% School—62% 37

Principles of HIV Counseling and Testing Screening donor blood and cellular products Diagnosis of HIV infection (sensitivity and specificity) Human rights (confidential, counseling, informed consent) Confidentiality Anonymous testing Routine testing 38

Uptake of HCT (Suthar et al, PLoS Medicine, 2013) 39

Community HCT Modalities Increased testing uptake—RR=10.65 ( ) Proportion of first-time testers—RR=1.23 ( ) Proportion of testers CD4 > 350—1.42 ( ) Lower positivity rate—RR=0.59 ( ) 40

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