Determination of HIV Infection Among TB Patients in California, 2008 Darryl Kong 1, Jennifer Flood 1, Suzanne Marks 2, James Watt 1 1 California Department of Public Health, Tuberculosis Control Branch 2 Centers for Disease Control and Prevention, Division of Tuberculosis Elimination CSTE Conference June 14, 2011, Pittsburgh, Pennsylvania 1

Background: Poor Outcomes of HIV and Tuberculosis Co-morbidity Persons with tuberculosis (TB) disease among persons living with HIV infection are more likely to: – –Be diagnosed with TB at death or die during TB treatment – –Experience TB recurrence – –Acquire TB drug resistance 2

Background: Public Health Department’s Role in Prevention of Poor HIV/TB outcomes Detect HIV/TB co-morbidity – –CDC recommends routine opt-out HIV testing of all TB suspects and patients Co-manage both diseases – –Ensure HIV and TB treatment for HIV/TB patients Closely monitor TB treatment to prevent poor outcomes – –Provide directly observed therapy (DOT) for TB 3

Background: HIV Testing Recommendations and Laws CDC MMWR 2006;55(RR-14): – –“all patients initiating treatment for TB should be screened routinely for HIV infection” – –“HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening)” CDC’s Advisory Council for the Elimination of TB, March 21, 2007: “endorses routine HIV testing in TB programs using opt- out methodology for persons with documented active TB, TB suspects, and persons identified in TB contact investigations.” On January 1, 2008, CA law became compatible with CDC opt- out testing recommendations. However, re-disclosure of HIV status to CA DOH TB and STD programs only became legal in January

Rationale for Current Evaluation Study: Unknown HIV/TB prevalence in California In California (CA), HIV status was not routinely recorded from in the Report of Verified Case of Tuberculosis (RVCT) used for surveillance and reported to the CA TB Control Program Estimates of HIV/TB prevalence relied on a match of state AIDS and TB registries from (4% HIV positivity in 2004, a likely underestimation) 2002 field assessment in 4 CA counties revealed that HIV status was known in only 55% of TB cases 5

CA Evaluation Study Questions How complete is HIV status determination? What factors are associated with having a known HIV status? When is HIV status determined? What types of providers are reporting HIV status? In what settings are HIV testing and TB diagnosis taking place? 6

Methods I: Cohort of All TB Patients Reported to CA Department of Health in Data Collection Source: local public health medical records HIV status (Positive, Negative, Unknown) Source: State TB registry Age, sex, race, nativity, history of TB Homelessness, incarceration, excess alcohol use or illicit drug use Type of provider for TB care 2.Analysis Proportion of patients with a known HIV status Factors associated with known HIV: Adjusted odds ratios from multivariate logistic regression

Definitions: HIV Status HIV negative if any of the following before TB Tx completion but ≤ 1 year before TB Dx: – –a negative HIV test result or – –physician report of negative status HIV positive if any of the following before TB Tx completion: – –a positive HIV test result, – –a report of HAART medication, – –documentation of a positive status from a previous or referring clinician, or – –self-report of a positive status HIV unknown: All others 8

Definitions: Public vs. Private TB Provider Public Provider: – –were part of or overseen by a CA Department of Public Health TB program Private Provider: – –All others 9

Definitions: TB Diagnosis Date Date of TB Diagnosis, the first of the following: – –Report date from the local health department – –Specimen collection date of the first positive specimen culture 10

Methods II: Simple Random Sample of 300 TB Patients from Jurisdictions Reporting at Least 5 Patients in Analysis Proportion with a previously known HIV status* Proportion with initial private provider involvement 1.Data Collection Source: local public health medical records Timing of HIV status determination Types of TB providers at specific stages of TB care *> 3 months before TB diagnosis

Results: Completeness of HIV Status Determination 2,697 TB patients reported to the CA DOH Study N=2,667 (99%) of patients’ TB records reviewed 1,752 TB patients (66% of 2667) had a known HIV positive or negative status 132 HIV/TB patients – –4.9% of reviewed patients – –7.5% of patients with known HIV status 12

Results: How HIV Status Determination in CA Compared to the Rest of the U.S., 2008 CDC standard is universal testing of all TB cases 13

5% 61% 34% 18%17%65%

Results: Known HIV Status, N=2667 (slide 1) nKnown HIV Status n (%) HIV Positive n (%) Age (years) (33.5)0 (0.0) (80.6)20 (5.1) (77.0)70 (15.5) (71.4)36 (8.1) (50.2)6 (1.5) Sex Male (67.8)110 (9.9) Female (62.3)22 (3.4) 15

Results: Known HIV Status N=2667 (slide 2) 16 nKnown HIV Status n (%) HIV Positive n (%) US-born White (64.8)17 (13.6) Black (71.6)21 (18.9) Hispanic (56.1)12 (8.8) Asian5523 (41.8)0 (0.0) AI or AN76 (85.7)1 (16.7) Foreign-born White6235 (56.5)0 (0.0) Black5441 (75.9)6 (14.6) Hispanic (75.9)65 (10.7) Asian (60.8)10 (1.5) AI or AN11 (100.0)0 (0.0)

Results: Known HIV Status N=2,667 (slide 3) 17 n Known HIV Status n (%) HIV Positive n (%) Previous TB No (65.2)125 ( 7.6) Yes (75.2)7 (7.0) History of homelessness, incarceration, excess alcohol use, or illicit drug use No (63.0)80 (5.7) Yes (79.9)52 (15.2) TB Provider Type Any Public Management (74.7)89 (6.6) Only Private Management (46.0)40 (10.6)

Results: Factors Associated with Known HIV Status, N=2,618 (slide 1) nAdjusted OR95% CI Age (years) [0.10 – 0.24] [0.84 – 1.59] Ref [0.50 – 0.88] [0.23 – 0.39] Sex Male1609-Ref Female [0.65 – 0.95] 18

Results: Factors Associated with Known HIV Status, N=2,618 (slide 2) 19 nAdjusted OR 95% CI US-born White193-Reference Black [0.56 – 1.54] Hispanic [0.44 – 1.12] Asian540.44[0.21 – 0.90] AI or AN71.67[0.18 – 15.24] Foreign-born White62-Reference Black542.09[0.87 – 5.04] Hispanic [0.97 – 3.08] Asian [0.71 – 2.21] AI or AN1

Results: Factors Associated with Known HIV Status, N=2,618 (slide 3) 20 n Adjusted OR 95% CI Previous TB No2488-Reference Yes [1.11 – 2.67] History of homelessness, incarceration, excess alcohol use, or illicit drug use No2201-Reference Yes [1.09 – 1.97] TB Provider Type Any Public Management 1799-Reference Only Private Management (0.23 – 0.34)

Results: Timing of HIV status Determination, N= Cases Reviewed 297* Previously Unknown 280 (94%) Previously Known** 12 (4%) Dead at Diagnosis 5 (2%) Tested 171 (61%) Untested 109 (39%) HIV-Positive 8 (67%) HIV-Negative 4 (33%) HIV-Positive 7 (4%) HIV-Negative 164 (96%) HIV-Negative 7 (6%) Unknown 102 (94%) * Of the random sample of 300 TB patients, 3 patients’ charts were unavailable. ** Known > 3 months prior to TB diagnosis

Results: Type of TB Provider for TB Patients Without a Previously Known HIV Status, N=280 22

Results: Days from TB diagnosis to HIV Test by TB Provider Type, N= Private Public N = 65 Median = 0 days N = 89 Median = 11 days Wilcoxon test: P <

Results: Where was HIV testing done for HIV-infected TB patients? 65%Hospital 2%ER 16%Outpatient 17%Unknown 24 N=63 HIV-infected TB patients who had previously unknown HIV status and were HIV tested during TB diagnosis. 90% of TB patients tested for HIV in hospitals were tested by private providers.

Results: Stage of Immunosuppression, Newly Identified HIV/TB patients, 2008* CD4 count* 83% with count <250 (most below 150) Viral load** 88% with VL ≥10,000 * N=47 newly identified HIV-infected during TB diagnosis who had CD4 count data ** N=32 newly identified HIV-infected during TB diagnosis who had documented viral loads. 25

Limitations HIV information from TB public health records may be incomplete, especially for privately managed patients Evaluation assessed data from 2008 only, and practices might have changed 26

Summary: HIV Status Determination Was Not Universal Only 66% of CA TB patients in 2008 had an HIV status known to the TB program, much lower than in the rest of the U.S. – –5% to 8% HIV/TB prevalence HIV status determination appeared to be based on provider perceived risk for HIV (especially by age and sex) 27

Known HIV Status and Reasons for Undetermined Status for TB Cases by Age, U.S. Excluding CA, 2008 Age≤ 14 years Cases ≤ 14 years percentage ≥ 65 years Cases ≥ 65 years percentage Total HIV positive HIV negative Refused testing Not Offered Unknown

Summary: Private Providers’ Role is Important Over 800 patients had only private provider management Patients with only private management were less likely to have an HIV status known to the public health TB program. From the sample: 96% did not have a known HIV status at TB diagnosis Private TB providers diagnosed TB in two-thirds of the patients. From the sample, diagnosis took place mostly in hospitals 29

Conclusions CA needs to improve implementation of routine opt- out provider initiated HIV testing of TB patients as recommended by CDC Private providers have the first opportunity to test for HIV during TB diagnosis and can identify HIV/TB co-morbidity earlier than public providers, which can translate to earlier linkage to HIV care and better TB treatment outcomes Public health practitioners need to reach out to private providers and let them know of the need to test and report HIV in TB suspects and patients 30

Recommendations for CSTE Consider the following actions – –Advocate for improved testing and reporting of HIV status of TB suspects and patients, especially among private sector providers and hospitals – –Promote sharing of data between HIV/AIDS surveillance and TB programs to improve known HIV status 31

Study Follow-up: California HIV/TB initiative Ensure universal opt-out HIV testing of TB patients as the standard Educate private providers and hospitals on the need for HIV testing among TB suspects and patients Monitor performance of local TB programs 32

Acknowledgements Local California TB Programs California Department of Public Health – –Alicia Rodriguez – –Nicolette Palermo 33

Additional Slides 34

TB Testing Recommendations for Persons Living with HIV – –LTBI Testing All to be tested at HIV diagnosis Those testing negative for LTBI – –should be retested once they start ART and attain CD4 count >= 200 cells/ml – –Annual testing for HIV-infected persons at high risk for exposure to TB (i.e., persons who are or who have been incarcerated, live in congregate settings, are active drug users, or have other socio-demographic risk factors for TB) Those testing positive for LTBI should have a chest radiograph and clinical evaluation for TB – –TB disease testing: Evaluation for suspected HIV/TB should include: – –A chest radiograph – –Obtaining sputum specimens for AFB smear – –Culture sputum specimens for patients with pulmonary symptoms and chest radiographic abnormalities A normal chest radiograph does not exclude the possibility of active pulmonary TB and when suspicion for disease is high, sputum samples should still be obtained Tuberculin skin tests (TST) and interferon gamma release assays (IGRAs) should not be relied upon for the diagnosis of TB disease. 35