1. HIV Testing- What’s Your Routine?
Susanne Doblecki-Lewis, MD, MSPH, FIDSA
University of Miami Miller School of Medicine

2. No disclosures

3. Learning Objectives Understand the rationale for routine HIV testing
Describe current guidance regarding HIV testing in healthcare settings
Identify candidates for enhanced HIV prevention care after completion of HIV testing

4. Why Routine Screening?
HIV is a serious health issue that can be detected and treated before symptoms develop
Many new infections are transmitted by people who do not know they are infected
Treatment is effective in improving health and cuts the risk of transmission by as much as 96%
People who know their status are more likely to take other protective measures
(accessed Sept 2018)

5. Marks, et al. AIDS 2006; 20:

6. visits per patient without HIV testing prior to positive test
Missed Opportunities
Average of 4
healthcare
visits per patient without HIV testing prior to positive test
MMWR. 2006;55:1269.

7. And most of those who were tested late were tested because they were ill – they had already developed symptoms. This chart shows the reasons people said they were tested – late testers in red, and early testers in blue.
Part of CDC’s intention, through the new strategies to make testing a routine part of medical care, is to shift
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this curve, so that more people are tested as part of routine check-ups, and more infections are diagnosed earlier.

8. Risk-based screening misses many people
39% of men who had sex with a man within the past year did not disclose their same-sex sexual activity to their health care provider
51% of rapid test positive patients identified in Emergency Department (ED) screening had no identified risk
Sources:
1. Chou R, et al. Screening for HIV: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2005;143:55-73.
2. Bernstein KT, et al. Same-sex attraction disclosure to health care providers among New York City men who have sex with men. Arch Intern Med. 2008;168(13):
3. Lyss SB, at al. Detecting unsuspected HIV infection with a rapid whole-blood HIV test in an urban emergency department. J Acquir Immune Defic Syndr. 2007;44(4):
Bernstein KT, et al. Archives of Internal Medicine. 2008;168(13): Lyss SB, et al. Journal of Acquired Immune Deficiency Syndromes. 2007;44(4):

9. Desired Outcome of Routine HIV Screening
The goals of routine HIV screening are two-fold: improve the quality of life and survival of patients who have HIV infection and decrease the risk of transmission of infection to others.
Prompt referral of HIV-infected individuals to HIV care is a critical step in this process.
In an effort to increase the likelihood that a person living with HIV infection can benefit from treatment and care plus reduce the chance of spreading the infection to others, CDC, through their revised recommendations, seeks to increase the number of physicians offering routine HIV screening as a standard part of care.

10. Routinization = Reduced Stigma

11. Routine HIV Testing is Standard of Care
Centers for Disease Control and Prevention 2006 Revised Recommendations:
HIV screening is recommended for all patients ages in all health care settings after the patient is notified that testing will be done unless the patient declines (opt-out screening).
Persons at high-risk for HIV infection should be screened for HIV at least annually.
Separate written consent for HIV testing should not be required. General consent for medical care should be considered sufficient to encompass consent for HIV testing.
Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health care settings.
HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women, and HIV screening is recommended after the patient is notified that testing will be done unless the patient declines (opt-out screening).

12. US Preventive Services Task Force

13. Affordable Care Act
Affordable Care Act, requires that beginning in 2010 qualified health plans provide at a minimum coverage without cost-sharing for preventive services rated A or B by the U.S. Preventive Services Task Force (USPSTF)

14. Importance of USPSTF Rating
HIV screening has an “A” rating from the USPSTF.
Therefore -- It is a covered service by Medicare, Medicaid and ACA qualified health plans.
The USPSTF has not recommended specific screening intervals, but has some guidance:
Once for all years regardless of risk
Annually for those at “very high risk” including local prevalence >1%
Every 3-5 years for those at “increased risk”

15. When to test? Test everyone at least once.
Hospital admissions if no recent test available (in chart / documented)
Test those with ongoing risk, multiple partners, drug use at least annually
Test sexually active MSM, others at higher risk quarterly

16. Florida’s Testing Laws
In 2015, the Florida statues were amended to allow routine testing for HIV in healthcare settings
Removes need for written informed consent before HIV testing in healthcare settings

17. What is Required Before HIV Testing?
Must inform patient that test is being ordered
Patient must have opportunity to refuse (“opt-out”) of testing – document if refuses
Must let patient know that positive results will be reported to the Florida Department of Health

18. How May I Notify Patients of Routine HIV Testing in a Healthcare Setting?
General consent for medical treatment may include HIV testing
Poster in office
Pamphlet / brochure on testing
Verbal notification
Other forms of notification

19. You are seeing a 30 year old male due to concern regarding HIV exposure. He has multiple male partners, and in particular is concerned about an episode of condomless anal receptive intercourse 10 days ago with someone he suspects was HIV positive.
What would your testing strategy be?
Why?

20. How to test? Standard EIA tests Ab/Ag “4th generation” tests
RNA detection

21. HIV testing and detection of Acute HIV
Symptoms
(~60%)
p24 Antigen
HIV RNA
HIV Ab EIAs
HIV infection can be detected weeks before antibody tests turn positive
The presence of HIV can be detected using tests that detect HIV directly in the blood, as early as 1-2 weeks after infection. Antibody tests take one to nine weeks longer.
The big question is: do people show up for HIV tests during the first few weeks after infection? If not, the question of when different tests detect HIV would be moot. BUT IF THEY DO, we could be missing a lot of HIV infections with our HIV testing practices, which rely on HIV antibody detection alone.
Weeks Since Infection

22. Nucleic Acid Testing (RNA, DNA, NAAT, Viral Load)
Not for diagnosis unless you are thinking of acute HIV infection
80% of new infections develop symptoms but most will not associate with possible HIV infection:
Fever
Rash
Headache
Sore throat
Average 1-6 weeks after exposure
Window period = 7-14 days
Remember, the eclipse period (first 4-7 days of infection) – no current test will detect infection

23. What is the Benefit of Rapid Testing?
Increased receipt of test results
Increase feasibility of testing in acute care settings
Increase number and type of venues where testing can be offered to individuals at increased risk

24. HIV Ab/Ag Test “4th Generation”
Antigen detection before antibody is detectable
Window period days
Increased sensitivity in early infection compared with Ab only test

25. You are seeing a 30 year old male due to concern regarding HIV exposure. He has multiple male partners, and in particular is concerned about an episode of condomless anal receptive intercourse 10 days ago with someone he suspects was HIV positive.
What would your testing strategy be?
How would you counsel him?
Why?

26. Follow-up on Testing: What Next?
Reactive tests, with confirmation:
Refer immediately to HIV provider
Inform re: secondary transmission
DOH does partner notification / testing
Baseline testing and selection of regimen

27. Follow-up on Negative Tests
Evaluate for risk (sexual, injection drugs)
Window periods
What are your plans for staying negative?
Condom use
Pre-exposure prophylaxis (PrEP)
Post-exposure prophylaxis (nPEP)
Recommendations for follow-up testing
STI testing

28. Using Antiretroviral Medications for HIV-1 Prevention
Prior to exposure
Time of transmission
After infection
PrEP
PEP
ART

29. References / Additional Resources
AAHIVM Provider Resource Guide
NASTAD