1. HIV Screening for Patients 13-64 years: A Guide for TB Clinic Providers Best Practices in TB Control - August 28, 2012 1 Philip J. Peters, MD Medical Officer Division of HIV/AIDS Prevention Centers for Disease Control and Prevention Atlanta, GA

2. Disclosures Conflicts of Interest: None Disclaimer: The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention

3. Question What is responsible for the greater than 95% decline in perinatally acquired AIDS in the US? 3 1.Widespread HIV screening of all pregnant women 2.Antiretroviral use during the antenatal, perinatal, and newborn periods 3.Reduction in number of pregnant women with HIV infection 4.1 & 2

4. 2006 Revised Recommendations 4 Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.

5. CDC’s Recommendations HIV screening for all patients aged 13 to 64 years – Opt-out screening: patients should be told screening will be performed but may decline testing – Prevalence of undiagnosed HIV infection > 0.1% Written consent and prevention counseling not required Annual HIV screening for those at high risk for HIV Prompt clinical care for HIV-infected persons 5 Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.

6. Learning Objectives Analyze the rationale for HIV screening recommendations Assess clinical benefits of routine HIV screening Formulate approaches to simplify routine HIV screening in practice Update on selecting HIV tests 6

7. Estimated HIV Prevalence in the United States, 2008 7 Campsmith ML, et al. CDC. Morb Mortal Wkly Rep. (MMWR). 2008;57(39):1073-1076. Campsmith ML, et al. J Acquir Immune Defic Syndr. 2010 Apr;53(5):619-24. CDC. HIV surveillance—United States, 1981-2008. MMWR 2011;60: 689-693. 1,178,350 persons living with HIV infection Prevalence = 448 per 100,000 population 0.4% of population living with HIV infection 20% unaware of their diagnosis

8. Rate of Tuberculosis Cases per 100,000 Population – United States, 2011 8 Rate of AIDS Diagnoses by MSA* of Residence - United States and Puerto Rico, 2008 * MSA = Metropolitan Statistical Area Centers for Disease Control and Prevention. Rates of AIDS Diagnoses by Metropolitan Statistical Area (MSA) of Residence, 2008 - United States and Puerto Rico. Areas. Slide set. http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm. Accessed May 27,2011. http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm Centers for Disease Control and Prevention. Trends in Tuberculosis - United States, 2011. MMWR Morb Mortal Wkly Rep. 2012 Mar 23;61(11):181-5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm. Accessed August 1, 2012. Geographic Comparison of Rates of AIDS Diagnoses and Tuberculosis Cases in the United States

9. Why Routine Screening? Patients do not always disclose or may not be aware of their risk 1 – 39% of men who had sex with a man within the past year did not disclose to their health care provider 2 – 51% of rapid test positive patients identified in Emergency Department (ED) screening had no identified risk 3 9 1. Chou R, et al. Ann Intern Med. 2005;143:55-73. 2. Bernstein KT, et al. Arch Intern Med. 2008;168(13):1458-1464. 3. Lyss SB, et al. J Acquir Immune Defic Syndr. 2007;44(4): 435-442.

10. Risk-Based HIV Testing Has Become Less Effective Patients with HIV infection often have multiple health-care visits before diagnosis – median of 7 visits over 5 years in one study 1 Risk-based testing frequently misses 2,3 : – Young people (< 24 years) – Women and heterosexual men – Members of racial and ethnic minorities – People residing outside of urban areas 10 1. Klein D, et al. J Acquir Immune Defic Syndr. 2003; 32(2): 143-152. 2. Institute of Medicine. Washington, DC: National Academy Press; 2001. 3. CDC. HIV surveillance—United States, 1981-2008. MMWR 2011;60: 689-693.

11. Late Diagnosis of HIV Infection 11 * 46 states with confidential name-based HIV infection reporting (n= 45,336) Centers for Disease Control and Prevention. HIV Surveillance Report, 2010; vol. 22.

12. Probability Curve of Mortality According to Baseline CD4 Cell Count May M, et al. AIDS. 2007;21;1185 ART-CC. Years from starting antiretroviral therapy (ART) 12

13. Tuberculosis and HIV 13 A high proportion (7.9%) of people with tuberculosis disease in the US are HIV infected [1] Compared with HIV-negative patients, HIV-infected patients with Mycobacterium tuberculosis infection are markedly (21 – 34 times) more likely to develop active tuberculosis disease [2] 1. Centers for Disease Control and Prevention. Trends in Tuberculosis - United States, 2011. MMWR Morb Mortal Wkly Rep. 2012 Mar 23;61(11):181-5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm. Accessed August 1, 2012.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm 2. World Health Organization. Global Tuberculosis Control. 2011. Available at http://www.who.int/tb/publications/global_report/2011/en/index.html. Accessed January 31, 2012. http://www.who.int/tb/publications/global_report/2011/en/index.html

14. 14 Antiretroviral Therapy Reduces Rates of Sexual Transmission of HIV HPTN 052: Antiretroviral therapy reduced HIV transmission by 96% in discordant couples Cohen MS, et al. N Engl J Med 2011;365:493-505.

15. Desired Outcome of Routine HIV Screening 15 HIV Screening HIV Diagnosis Improve Survival and Quality of Life Improve Survival and Quality of Life Prevent New HIV Infections Link to Care

16. Implementing HIV Screening Integrating HIV Screening into Practice Train staff to perform HIV opt-out screening Provide easily understood patient informational materials Be prepared for commonly asked questions Include testing reminders in patient’s electronic medical record 16 Address Patients’ Misperceptions Many patients believe they were previously tested for HIV, particularly if blood was drawn Many patients assume an HIV test was performed and if they didn’t receive a call from the doctor, that they do not have HIV

17. Implementing HIV Screening (cont’d) State Laws Regarding HIV Testing Requirements to obtain written consent are being phased out. Refer to National HIV/AIDS Clinicians’ Consultation Center’s Compendium of State HIV Testing Laws for questions about your state: http://www.nccc.ucsf.edu/ 17 Compendium of State HIV Testing Laws. National HIV/AIDS Clinicians’ Consultation Center (NCCC) Web site. http://www.nccc.ucsf.edu/consultation_library/state_hiv_testing_laws/.

18. Communicating Positive HIV Test Result Provide result by direct personal contact Provide result confidentially Ensure patient understands test result Connect to services 18 Positive + Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.

19. Uni-Gold Recombigen Reveal G3 OraQuick Advance Clearview Complete HIV 1/2 Clearview HIV 1/2 Stat Pak INSTI Rapid HIV Tests 19

20. Rapid HIV Tests Advantages Ensures patient receives test result Option for an oral swab or finger stick instead of blood draw Limitations Results are manually read and charted Training and oversight necessary Can overburden nursing and other staff More expensive 20

21. Time to detection of HIV RNA, p24 antigen, and antibody during early HIV infection

23.  Detects p24 antigen and HIV antibody  Time to result: 29 minutes  100 results/hour  FDA-approved June 22, 2010 4 th Generation Combo Ag/Ab Assay 23

24. HIV Screening. Standard Care. Free materials for providers – Annotated Guide to CDC Recommendations – Resource Guide – AMA/AAHIVM CPT Coding Guide – ACP Guidance Statements – National HIV/AIDS Clinicians Consultation Center Flyer Free patient materials ( available in English and Spanish) – Brochure – Poster 24 Download at www.cdc.gov/HIVStandardCarewww.cdc.gov/HIVStandardCare Order free of charge from screenforHIV@cdc.govscreenforHIV@cdc.gov The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention