1. VETERANS HEALTH ADMINISTRATION Future of HIV in VA Office of Public Health Department of Veterans Affairs Maggie Czarnogorski, MD Deputy Director, HIV, Hepatitis, and Public Health Pathogens Program Maggie.czarnogorski@va.gov April 2012

2. VETERANS HEALTH ADMINISTRATION Office of National AIDS Policy

3. VETERANS HEALTH ADMINISTRATION National HIV/AIDS Strategy Goals Reducing New HIV infections Improving Access to Care and Health Outcomes Reducing Health Disparities Working across federal agencies

4. VETERANS HEALTH ADMINISTRATION Engagement in Care Cascade: VA vs. Community Gardner EM, et al. Clin Infect Dis. 2011;52:793-800

5. VETERANS HEALTH ADMINISTRATION Engagement in Care Cascade: VA vs. Community Gardner EM, et al. Clin Infect Dis. 2011;52:793-800 30,000 25,000 20,000 15,000 10,000 5,000 0

6. VETERANS HEALTH ADMINISTRATION VA HIV Testing Policy Changes August 17, 2009 VA National HIV Testing Policy revised – After Section 124 repealed, VA was able to revise policy to promote widespread routine HIV testing – Routinely offer HIV testing to all Veterans – Eliminate written informed consent and prescribed pre- and post-test counseling – Verbal consent still required and must be documented in medical record – Written educational materials about HIV testing must be provided to patients VHA Informed Consent Handbook 1004.01: August 17 th, 2009 VHA Directive 2009-036, August 17, 2009

7. VETERANS HEALTH ADMINISTRATION VA HIV Testing Rates: Data Collection Methods Data Extract Routine installed at all facilities to generate HIV test reports by Calendar Year (CY) Data collected on all outpatients in that CY – Number with HIV test ever done – Number with HIV test done in that CY – Number with positive result in that CY In 2011, added Gender, Race/Ethnicity, Age information

8. VETERANS HEALTH ADMINISTRATION Veterans Ever Tested for HIV by Year 2009-2011 9.2% Ever Tested n=524,267 2009 Outpatient Visits n= 5,713,265 13.5% Ever Tested n= 795,126 Outpatient Visits n= 5,888,599 2010 2011 Outpatient Visits n= 6,114,034 20% Ever Tested n= 1,221,328

9. VETERANS HEALTH ADMINISTRATION Percent of Veterans EVER Tested for HIV, by VISN: 2009, 2010, 2011 VISN Percent Outpatients EVER Tested for HIV

10. VETERANS HEALTH ADMINISTRATION Percentage of HIV Positive Tests in CY 2011, by VISN % HIV Tests Performed in 2010 that were Positive VISN Mean: 0.38% Median: 0.35% Range: 0.14-0.64% * * CDC Threshold for routine HIV testing

11. VETERANS HEALTH ADMINISTRATION Percentage of HIV Positive Tests in CY 2011, by VISN % HIV Tests Performed in 2010 that were Positive VISN Mean: 0.38% Median: 0.35% Range: 0.14-0.64% * * CDC Threshold for routine HIV testing 0.7% 0.6% 0.5% 0.4% 0.3% 0.2% 0.1%

12. VETERANS HEALTH ADMINISTRATION Percentage EVER Tested by Race/Ethnicity – CY2011

13. VETERANS HEALTH ADMINISTRATION Percentage EVER Tested by Age and Gender – CY2011

14. VETERANS HEALTH ADMINISTRATION Gender and Age of Veterans with HIV Positive Test Results in CY 2011 (n= 2,149) 93.25%

15. VETERANS HEALTH ADMINISTRATION HIV Seropositivity in CY 2011 by Age and Gender 0.0% 0.7% 0.6% 0.5% 0.4% 0.3% 0.2% 0.1%

16. VETERANS HEALTH ADMINISTRATION HIV Seropositivity in CY 2011 by Race/Ethnicity 0.8% 0.6% 0.4% 0.2% 1.0% 0.0%

17. VETERANS HEALTH ADMINISTRATION VA National HIV Testing Data for 2009, 2010 and 2011 Variable200920102011 Number of Veterans with an outpatient visit in CY 5, 713, 2655, 888, 5996, 114, 034 Number and % of Veterans with an outpatient visit ever tested for HIV 524, 267 (9.2%) 795, 126 (13.5%) 1,221,328 (20.0%) Number of Veterans with HIV tests performed in CY 142, 345341, 414523,361 Number of Veterans with HIV positive tests in CY 1,7392,2332,149 Seropositivity rate of Veterans tested in CY 1.2%0.7%0.41% Abbreviations: CY= calendar year; HIV = human immunodeficiency virus

18. VETERANS HEALTH ADMINISTRATION VA Initiatives to Improve HIV Testing Rates 2009-2011 Legislative and Policy Changes – Verbal consent for testing – Routine offer of HIV testing to Veterans Routine HIV test clinical reminder Funding for facility-level quality improvement projects – Clinical HIV testing – Laboratory – Women’s Health – Homeless Veteran Stand Downs Social marketing campaign

19. VETERANS HEALTH ADMINISTRATION Conclusions VA is the largest US provider of HIV care The quality of HIV care VA provides is excellent The percentage of Veterans ever tested for HIV more than doubled in two years Many Veterans in VA care have still not been tested for HIV In 2011, all VISNs had an HIV seropositivity rate above the CDC threshold (>0.1%) for routine HIV testing Routine HIV testing is warranted in VA VA will continue to provide timely linkage of care

20. VETERANS HEALTH ADMINISTRATION The Future Continued Excellence of Care Improve Access and Expand Workforce – Telehealth/SCAN-ECHO – Patient Centered Teams Targeted approaches with Special Populations to decrease disparities – New Veterans – Women – Homeless, Incarcerated – Regional

21. VETERANS HEALTH ADMINISTRATION Office of Public Health www.hiv.va.gov