1. Routine Opt-Out HIV Testing UCLA / Pacific AIDS Education & Training Center (UCLA PAETC) CDC Routine HIV Testing Project 2011

2. Educational Objectives At the end of this workshop participants will be able to: Review CDC HIV testing recommendations Discuss opt-out HIV testing in CA, LA Underscore the importance of early HIV testing and treatment Identify challenges/next steps for.. Implementation

3. On my commute this morning, I listened to… 1. Nothing…I need my quiet time. 2. Rock and Roll, Baby! 3. Radio News, Traffic, Weather 4. Other

4. My most recent HIV testing training was… 1. In the past 3 months 2. In the past 6 months 3. 1 year ago 4. More than 1 year ago

5. I have worked at XXXXXXX for… 1. Less than 1 year 2. 1-5 years 3. 5-10 years 4. More than 10 years

6. While working at XXXXXX, I have helped ____ number of patients deal with diabetes… 1. Zero/None 2. 1-5 3. 5-10 4. More than 10

7. What percentage of XXXXX patients aged 13-64 have been tested for HIV?… 1. Less than 30% 2. 30-50% 3. 50-70% 4. More 70%

8. I believe the number one challenge in implementing opt-out HIV testing here is… 1. None, it’s easy as pie 2. New EMR system 3. It takes too much time 4. Other

9. AETC Contacts Tom Donohoe donohoe@ucla.edu Warmline:(800) 933 – 3413 PEPline: (888) HIV – 4911 (888) 448 – 4911 Perinatal Hotline:(888) 448 – 8765 http://www.aids-etc.org http://www.psattc.org

10. Opt-Out: 2006 CDC Recommendations, Implementation, and Consequences of Late HIV Testing

11. In California in 2011, do you still need consent for HIV testing? 1.Yes 2.No

12. What percent of XXXX patients do you think would refuse HIV testing (opt-out)? 1.< 5% 2.5-25% 3.25-50% 4.>50%

13. Do you think some XXXXX patients will avoid clinic visits to avoid HIV testing? 1.Yes 2.No

14. Do you know how to connect your newly diagnosed HIV+ patients to local, free HIV care (treatment, medications, etc)? 1.Yes 2.No

15. Have you ever been involved with giving an HIV-positive test result to a patient? 1.Yes 2.No

16. All XXXXX patients with a positive STD test are tested for HIV: 1.True 2.False 3.Unsure

17. Clinical Case 32 yo female admitted to UCLA blood donation center to be informed she tested positive. –She has a 6 year old son –She is single and has never used drugs –She has history of depression and threatens suicide after being told of her HIV diagnosis

18. Case con’t Referred to RW Clinic Receives free counseling and antidepressants Receives free mental health services Receives free blood tests/medications CD4 133 at first test: Could have been hospitalized, ER or dead in 6 months without the test

20. Awareness of Serostatus Among People with HIV and Estimates of Transmission ~25% Unaware of Infection ~75% Aware of Infection People Living with HIV/AIDS: 1,039,000-1,185,000 New Sexual Infections Each Year: ~32,000 Accounting for: ~54% of New Infections ~46% of New Infections Marks, et al AIDS 2006;20:1447-50

22. HIV/AIDS Diagnoses among Adults and Adolescents, by Transmission Category — 33 States, 2001–2004 MSM 61% IDU 16% Heterosexual 17% MSM/IDU 5% Other 1% Males (n ≈ 112,000) Females (n ≈ 45,000) Heterosexual 76% IDU 21% Other 3% MMWR, Nov 18, 2005

24. “Down Low” 2/3 Latino MSM in Los Angeles report that persons of their ethnicity do not approve of MSMs—so they have to keep their sexuality hidden. Latina women with HIV+ rarely have traditional risk factors for HIV; IDU, multiple partners, etc.

25. Source of HIV Tests and Positive Tests HIV+ tests**HIV tests* 17%44%Private doctor/HMO 27%22%Hospital, ED, Outpatient 2% 6% 5% 9% 21% 0.7%Drug treatment clinic 0.1%STD clinic 0.6%Correctional facility 5%HIV counseling/testing 9%Community clinic (public) *National Health Interview Survey, 2002 **Suppl. to HIV/AIDS surveillance, 2000-2003 38% - 44% of adults age 18-64 have been tested 16-22 million persons age 18-64 tested annually in U.S.

26. Late HIV Testing is Common Supplement to HIV/AIDS Surveillance, 2000-2003 Among 4,127 persons with AIDS*, 45% were first diagnosed HIV-positive within 12 months of AIDS diagnosis (“late testers”) Late testers, compared to those tested early (>5 yrs before AIDS diagnosis) were more likely to be: Younger (18-29 yrs) Heterosexual Less educated African American or Hispanic MMWR June 27, 2003 *16 states

28. Reasons for testing: late versus early testers Supplement to HIV/AIDS Surveillance, 2000-2003 0% 20% 40% 60% 80% 100% IllnessSelf/partner at risk Wanted to know Routine check up RequiredOther Late (Tested < 1 yr before AIDS dx) Early (Tested >5 yrs before AIDS dx)

30. The Case for HIV Screening

31. Criteria that Justify Routine Screening 1. Serious health disorder that can be detected before symptoms develop 2. Treatment is more beneficial when begun before symptoms develop 3. Reliable, inexpensive, acceptable screening test 4. Costs of screening are reasonable in relation to anticipated benefits -WHO Public Health Paper, 1968 Principles and Practice of Screening for Disease

32. “HIV TESTING IS ROUTINE” How you offer the HIV test makes a difference in how patients will accept the test.

33. Opt-Out Screening Prenatal HIV testing for pregnant women: RCT of 4 counseling models with opt-in consent: (formal written consent with pre and post counseling) 35% accepted testing Some women felt accepting an HIV test indicated high risk behavior Testing offered as routine, opportunity to decline 88% accepted testing Significantly less anxious about testing Simpson W, et al, BMJ June,1999

34. Clinical Case 25 yo man told by his PMD that he is HIV+ Comes to UCLA for second opinion on treatment Brings parents, brother and sister to clinic. Girlfriend flown in from Manilia. Everyone in tears HIV Elisa +, Western blot negative, HIV PCR negative PMD can be sued for not waiting for the Western blot resutls

36. California Law AB 682 (Berg/Garcia/Huffman) in California Legislature to implement opt-out testing. Now law in January 2008 Verbal consent only needed If patient refuses HIV test, write in chart Posted signs enough for pre-counseling

37. Make it Easy Incorporate HIV test into general women’s lab form/ health panel: pap smear, mammogram, GC/Chlamydia screen/cholesterol Incorporate HIV test into routine tests for cholesterol, glucose, CBC, PSA Pair HIV tests with all other STD tests—no RPR, GC or Chlamydia test should be ordered WITHOUT an HIV test

38. HIV Treatment--and Training--is Available Ryan White funds available for indigent and/or undocumented patients for free HIV care: Website: Google “HIV LA” UCLA PAETC can conduct onsite training for providers working with HIV-infected migrants who may return to Mexico/Central America.

39. Positive Test Results Positive test results should NOT be delivered in an inappropriate manner (e.g., over the telephone, via a clerk, etc.) Positive test results should always be given face to face by an experienced clinician (RNP, MD, PA) or trained counselor who can refer patients appropriately for care. Linkage to HIV care is essential.

40. Summary Opt out testing is law in California Will increase new HIV diagnoses when patients are asymptomatic and prevent new transmissions Entire staff (medical assistants, nurses, PA’s and MD’s) should all be conscious of HIV testing Referral system should be updated/practiced by staff and available for ALL patients who test HIV+

41. HIV TESTING tdonohoe@mednet.ucla.edu

42. Signs for Medical Assistants/Nurses “Test for HIV with every gonorrhea, chlamydia, or syphilis test” “Test for HIV with every cholesterol test” “Test for HIV with every Pap smear” “PPD+? Test for HIV”