1. Slide 1 Barriers and Facilitations to HIV Testing in Private Care Settings Michael Horberg, MD MAS FACP Director, HIV/AIDS Kaiser Permanente Clinical Lead, HIV/AIDS, Care Management Institute HIVI HIV Initiative of Kaiser Permanente and Care Management Institute

2. Conflicting National Guidelines (1)  CDC Guidelines Routine testing of all Americans aged 13-64 However, no consideration of older Americans and risk assessment  USPSTF Guidelines No recommendation for routine testing (C Level) Recommend at-risk testing (A Level) All pregnant women (A Level) Evidence-based but too restrictive Slide 2

3. Conflicting National Guidelines (2)  Private insurers usually defer to USPSTF  Some insurers are developing own guidelines  KP is bridge of USPSTF and CDC  Professional societies are not uniform in opinion  ACP, IDSA, AMA, ACOG, AAP support CDC  AAFP does not recommend routine testing of all Slide 3

4. Statutes as Barriers  Written informed consent considered hardship by providers  Time consuming, burdensome  Not for other sexually transmitted infections or routine blood tests  Laws changing  40+ states and DC no longer require written consent  Only California and DC mandate coverage of testing costs Slide 4

5. Lack of Quality Metrics  No nationally accepted metric on HIV testing  None in HEDIS, AMA PQRI  VA and KP measure stage of disease at time of diagnosis  There are HIV care metrics  (see next slide)  Many have called for HIV testing measurements Slide 5

6. AMA/HIVMA/HRSA/NCQA Measures  No HIV diagnosis or access to care measure  Other Screening Measures 1.TB, gonorrhea/chlamydia, syphilis 2.Hepatitis B and C 3.High risk sexual behavior 4.Substance use  Process Measures 1.Retention in care 2.CD4 cell count 3.Appropriate PCP prophylaxis and ART 4.Influenza, Pneumococcus, and Hepatitis B immunization  Outcome Measures 1.HIV RNA control Slide 6

7. Reimbursement Issues (1)  Targeted testing has not been an issue  Cost of test vs. cost of testing  Some issues with routine testing reimbursement  Many insurance companies have relaxed reimbursement policy  Don’t usually look at HIV risk when handling claim  AMA and AAHIVM published guidelines for coding for testing and services Slide 7

8. Reimbursement Issues (2)  CMS now covering targeted HIV testing  Thought will cover most patients at risk  Recognizes increased sexual activity among older adults  Anticipated that private insurers will follow suit  Unclear how CMS changes affect Medicaid  Preventive services included in healthcare reform  Again, California and DC mandate coverage Slide 8

9. Slide 9 KP HIV Demographics--Overview  Largest private provider of HIV care in US  >19,000 in 2009  regional variation (~200 to >6500)  Demographics reflect states we serve  Aging, but not dying  Mortality 1.6%--less than national average (3.4%)  Employ a multi-disciplinary specialty model

10. KP HIV Testing (1)  Performs >340,000 HIV tests annually  <25% of our total patient population  55.8% tested for HIV if diagnosed with STI  However, 43.4% if include Hepatitis B/C  27.1% new HIV+ met AIDS criteria (CD4 <200/µL)  87-96% prenatal testing rates  All of these numbers are improving Slide 10

11. KP HIV Testing (2) Slide 11

12. KP HIV Testing Quality Improvement Expanded HIV testing guidelines  More universal but targets at-risk populations Especially patients diagnosed with STI  No upper age limits  All pregnant women (and consideration of continued risk during pregnancy)  Looking to expand Include Adolescents Include evidence-based counseling and prevention Slide 12

13. Access to Care and Outcomes (KP) 2007 data:  88.6% newly recognized HIV+ in care within 90 days  76.8% retention in care  86.8% appropriately given ART  Median adherence 93.8% HIV+ on ART  92.9% HIV+ on ART with maximal viral control Slide 13