1. MultiVISN Quality Improvement Improving HIV Testing Rates Herschel Knapp, Ph.D.

2. Background l Many HIV infected patients do not know their status CDC: 21% of the 1.1 million HIV+ persons in the US are unawareCDC: 21% of the 1.1 million HIV+ persons in the US are unaware 50 - 70% of VA patients with risk factors have not been tested50 - 70% of VA patients with risk factors have not been tested l 50% of newly diagnosed patients have < 200 CD4 cells High risk of AIDS-related complicationsHigh risk of AIDS-related complications Less likelihood of immune recoveryLess likelihood of immune recovery Patients often have multiple, missed opportunities for early testingPatients often have multiple, missed opportunities for early testing

3. Benefits of Knowing HIV Status l Increases the benefits of anti-retroviral therapy Increased immune recoveryIncreased immune recovery Increased length of lifeIncreased length of life Increased quality of lifeIncreased quality of life l Lower viral loads reduce risk of transmission l Knowledge of infection reduces risky behavior

4. What is the MultiVISN Quality Improvement Project? l Objective Improve healthcare of veteransImprove healthcare of veterans l Goal Identify HIV positive veterans and refer for careIdentify HIV positive veterans and refer for care l Means Decision supportDecision support Policy supportPolicy support Staff engagementStaff engagement Multimedia resourcesMultimedia resources

5. Success to Date VISN 22 Los Angeles, Loma Linda, San Diego, and Southern Nevada VA facilities More than 200% increase in HIV testing among at-risk patients

6. Program implementation increases HIV testing rates two – threefold at all sites Intervention Year Control Site ASite BSite CSite DSite E Yearly HIV Testing Rate Pre- / Post-Intervention

7. QUERI-HIV Components

8. Clinical Reminder

9. HIV Clinical Reminder Triggers l Hepatitis B / C infection or risk factors l Substance abuse l Sexually transmitted disease l Needn’t wait for HIV Clinical Reminder to offer a test l Not a performance measure l Site-wide (not provider) level of analysis l Trigger for 10% - 15% of patients

10. Patient Media

11. Provider Media

12. Verbal Consent l As of 8/17/2009, written informed consent NO LONGER REQUIRED. l Verbal consent is sufficient. l HIV clinical reminder automatically pastes an entry in the NOTES: The patient has verbally consented to HIV testing. The patient has verbally consented to HIV testing. An HIV antibody test has been ordered.

13. l Quarterly statistical feedback HIV testing rateHIV testing rate Rate of clinical reminder resolutionRate of clinical reminder resolution l New materials & methods as needed Ongoing Support

14. Tips for Proposing HIV Testing Asymptomatic patients are unlikely to request a test; they’re waiting for us to offer the test.

15. Tips for Proposing HIV Testing l Would you like a free HIV test? l As a veteran, you’re entitled to an HIV test. l In addition to doing some tests to check for cholesterol, diabetes, etc., we’re now offering HIV testing. Would you like us to check for HIV infection?