ROUTINE HIV SCREENING

How-to Guide for DC Medical Providers ROUTINE HIV SCREENING IMPLEMENTATION HANDBOOK

NEW INDICATION: DC s Standard of Care is for Medical Providers to Conduct Routine, Opt-Out HIV Screening What is Routine, Opt-Out HIV Screening? Routine Opt-Out HIV testing means that all DC practitioners should inform patients 13 and older that they should have an HIV test every year and give them the option of refusing or opting-out. The District of Columbia expects practitioners to include informed HIV testing as they do cholesterol, blood sugar and other standard health screens, in a patient s examination. There is no required separate written consent in DC. Also, pre-test risk assessment and extensive counseling are neither required nor recommended. The DC Department of Health maintains a policy, first announced in June 2006, that routine opt-out HIV testing in medical settings is the District s standard of care. This policy is fully supported by the Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings issued by the U.S. Centers for Disease Control and Prevention (CDC) in September 2006. The Department of Health has worked with many DC medical providers to implement the practice of routine HIV testing and is advancing this policy to all. LET S ELIMINATE THE SPREAD OF HIV IN DC! 1

2 IT S IMPORTANT FOR YOU TO GET INVOLVED WITH ROUTINE HIV SCREENING! The District of Columbia has the highest AIDS case rates in the nation! The DC Department of Health s 2008 Epidemiology Update reports that 3% of all District residents are currently diagnosed and living with HIV/AIDS. However, based on behavioral studies, as many as one-third to one-half more of DC residents are infected but unaware of their diagnosis. If you think you know which patients are at risk and do targeted testing, you ll miss patients with undiagnosed HIV infection. No Missed Opportunities: data from the DC HIV Health Behavior Study showed that 75% of the newly diagnosed participants had been to at least one medical provider in the past twelve months, but had not been diagnosed. One of the most effective prevention measures that we can take to combat HIV/AIDS is to fully implement routine HIV screening for all adolescent and adult patients in health care settings. As with most chronic illnesses, early detection of HIV infection and linkage to care and prevention services is essential for positive health outcomes. What is NOT Routine HIV Screening? The above describes what routine Opt-Out HIV screening is and the following covers the practical steps to implement it. However, it is valuable to clarify what routine HIV screening is not. It is not secret It is not testing without telling patients It is not mandatory It is not asking patients IF they want HIV testing GETTING STARTED The DC Department of Health expects that all medical providers perform routine, opt-out HIV screening. Opt-out screening is the practice of informing the patient that the test will be done (such as, cholesterol or blood sugar tests) then performing the test. The patient is afforded the right to refuse screening. Studies show that more patients consent to HIV screening when it is offered to everyone equally, as a part of routine care. Here are the five steps to implement this medical practice: 1. How to Inform Patients DC surveys show that patients in our city will readily accept an HIV test when initiated by a practitioner. Try this: As a part of routine care, we test everyone for HIV, unless they refuse, just like we test cholesterol, blood sugar levels and other serious or common conditions. You can post a sign stating that all patients will be tested for HIV unless they refuse. You can also add a sentence to your general consent for treatment form. 2. What Test to Use There are several methods of HIV screening. Most providers do testing either by adding the test to blood already being drawn or by performing screenings using rapid test technology. Implement the best testing methodology for your practice. 3. What Documentation is Needed Consent Obtaining consent for HIV screening has never been easier! DC does NOT require or recommend separate written consent for HIV screening. 3

4 Once you have informed your patient of your intention to perform the test, you can proceed with the screening, unless they have declined. Additionally, you can add a routine opt-out HIV screening statement to your general consent forms. If patients decline HIV testing, try to address their reason for refusal. If they still refuse, the DC Department of Health can provide you a card that lets them know they have decided to reject an important health test and they can change their mind any time. Document refusal of HIV test in patient s chart and be sure to bring it up again at the next visit. Reporting Report all confirmed HIV/AIDS cases to the Department of Health. Report forms are available by visiting (www.doh.dc.gov/hiv). 4. How to Bill for HIV Testing The Department of Health understands that issues around billing and payment greatly impact your ability to implement new protocols. DC has made significant progress in this area. The following billing hints can maximize reimbursements. For Medical Settings: The AMA has summarized clinical billing codes. These codes can be used for both rapid test technology and conventional HIV testing. For additional information, including specific ICD9 and CPT codes, please visit http://www.ama-assn.org/ama1/pub/upload/ mm/36/hiv_cpt_guidance.pdf. New For Emergency Departments: Under the Insurance Coverage for Emergency Department HIV Testing Amendment Act of 2008, health insurers are required to reimburse for a voluntary HIV test performed during an insured s visit, despite the reason for that ED visit. 5. Linkage to Care: Creating Pathways for Positives You need to link HIV positive patients into HIV care and treatment! Early detection of HIV infection leads to better health outcomes and can ONLY 7% OF help stop HIV transmission. PATIENTS You should DIAGNOSED BY provide your patient with a PRIVATE DOCTORS follow up appointment for RECEIVED HIV HIV medical care TREATMENT immediately after delivering either WITHIN THE a preliminary or confirmatory FIRST 6 MONTHS positive test result. OF DIAGNOSIS. Identify an HIV Specialist to whom you will refer your patients, like you do for all other specialty care. Fortunately, the District has an abundance of medical and social service providers for people with HIV/AIDS. For more information on publicly supported medical and social service providers go to www.doh.dc.gov/hiv. 6. DC expects providers to offer Partner Services to all HIV positive patients. The DC Department of Health supports this expectation by providing tools for providers, as well as partner notification services, which inform partners of possible exposure to HIV without disclosing your patients names. Don t wait to implement routine HIV screening in your practice! Determine the screening protocols for your practice and start testing! DC DOH offers technical assistance. 5

SOME COMMON EXCUSES WHY HIV IS NOT THE JOB OF PRACTITIONERS There have been many reasons given or adopted for why practitioners have not included HIV in their medical screening. Here are a few: HIV is difficult. It s tough to give positive results. Practitioners have been told for years that HIV is not in their arena, because of the difficulty of positive test results. Yet, practitioners readily give diagnoses of cancer, diabetes, heart disease, and other chronic conditions. I don t have the time to do the counseling. DC s standard of care does not require practitioners to provide pre-test or other counseling. DC expects practitioners to be able to give results and connect patients to HIV specialists. Practitioners will be inundated by HIV positive results. The DC Department of Health estimates approximately 100 patients are diagnosed with HIV every month. The majority of practitioners may diagnose only 2 or 3 patients at the most each year. My patients don t get HIV. My patients are older and HIV is a young person s disease. HIV is mostly an adult disease in DC. More than 70% of cases are 40 and older. One in 7 new cases is among 55 and older. HIV crosses all population groups, ages and genders. It s only the people having lots of sex that get HIV. Given the high prevalence of HIV in DC, it only takes one sexual partner or one instance of unprotected sex to be exposed to HIV. I can tell by looking or talking with patients to decide who needs an HIV test. The DC Department of Health does not expect practitioners to assess whether or not their patients may be at risk for HIV. There is no longer a requirement to ask about behaviors and calculate, as in a Rubik s cube, whether or not the test is required. Based on the across the board impact of HIV among all populations in the city, the Department of Health is making it easier for practitioners by making HIV testing a standard for all adolescent and adult patients. 6 7

ROUTINE HIV SCREENING CHECKLIST PATIENT PRESENTS FOR MEDICAL APPONTMENT Inform patient that Routine HIV Screening is administered to all patients, unless they decline. For negative results: explain the importance of regular HIV testing every year. For positive results: explain the result immediately and LINK your patient to an HIV specialist for on-going HIV care. Inform Patient About Opt-Out HIV Screening Accepts Perform Test Declines Provide Patient Opt-Out Card Encourage patients to tell a friend or family member as having support is helpful to them. Report HIV positive patients to Department of Health. Perform HIV Screening: Rapid or Panel Negative Provide Patient with Test Result Card NOTES Positive Provide Result and Answer Questions Link Patient to HIV Care Provide Result Card and Risk Reduction Report Positive to DOH 8 9

RESOURCES For additional information on routine and expanded screening in DC, please contact: HIV Testing Expansion Coordinator DC Department of Health HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA) (202) 671-5061 avemaria.smith@dc.gov DOH/HAHSTA hosts regular trainings on OraQuick rapid HIV screening devices. For more information, contact Training Coordinator, at (202) 671-5079. For assistance with Partner Services, call (202) 727-9860. For a list of services for people with HIV/AIDS, visit www.doh.dc.gov/hiv or call (202) 671-4900. LET S ELIMINATE THE SPREAD OF HIV IN DC! GOVERNMENT OF THE DISTRICT OF COLUMBIA HIV/AIDS, Hepatitis, STD, Tuberculosis Administration (HAHSTA)

NEW INDICATION

MYTHS & BARRIERS I don t know how to talk to people about HIV or do HIV counseling. HIV is a young person s disease. If I introduce HIV screening into my practice, I will become inundated with HIV+ patients. I don t have time to for routine HIV screening. I can tell which patients are at risk for HIV. My patients have to sign a separate consent form for HIV testing. In that case, routine testing can be secret testing. FACTS & FACILITATORS Doctors often diagnose serious chronic diseases. HIV is also a serious chronic disease, and the clinical skills used to deliver important news to patients directly apply. After testing positive, immediately link your patient to an HIV Specialist for more detailed expert support and planning. Most people newly diagnosed with HIV are 30+ years old. Most practice settings will have a very small number of new HIV diagnoses, fewer than one per one hundred patients tested. Incorporate HIV screening with other tests that you order. Offering testing only to persons with traditional higher risk behaviors will actually miss many persons who are positive. Test everyone routinely. DC does not require separate written consent for HIV testing. Routine testing is not secret testing or mandatory testing it is voluntary, and patients should be made aware that testing will be done unless they refuse. NEW INDICATION HIV TESTING It is now the standard of care to administer routine voluntary HIV testing to all patients ages 13 and older in all medical settings. Follow the steps below: ROUTINE HIV SCREENING CHECKLIST Inform patients that Routine HIV Screening is administered to all patients, unless they decline. For negative results: explain the result and the importance of regular HIV testing, at least annually. For positive results: explain the result and immediately LINK your patient to an HIV Specialist for on-going HIV care. Encourage patients to tell a friend or family member who can offer support. Report HIV positive patients to Department of Health within 48 hours of confirmatory test results. NOTES My patients will refuse the test. Testing is voluntary but encouraged. Explain that you test everyone and offer it to them again. LET S ELIMINATE THE SPREAD OF HIV IN DC!

RESOURCES For Providers Routine HIV testing is now the common practice in DC for a common disease. Approximately 3% of all Washington, DC residents, and 7.5% of those aged 40-49 years, are currently living with HIV/AIDS. HIV/AIDS is the #1 cause of premature death in DC. HIV is not just a young person s disease: most new HIV diagnoses in DC are among persons in their 30 s and 40 s; there are nearly as many new HIV diagnoses in persons 50 years old and older as in those 30 years old and younger. Anywhere from one-third to one-half of residents who are infected with HIV may be unaware of their status. The main purpose of routine HIV testing is to find people who don t know they are HIV-infected and link them to HIV care and support. It is now standard care to perform HIV testing along with other annual tests. If patients decline testing, explain that they are missing a chance to maintain their health and the health of others. DC does not require a separate written consent for HIV testing. Language matters. An example of opt-out language: HIV Screening is performed on all patients, unless they refuse. Do you have any questions? All clients testing HIV-positive should immediately be linked to an HIV expert to help provide information, support, and future options for HIV management. For CDC recommendations about HIV screening, visit www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm For more information on Routine and Expanded HIV Testing in DC, contact: HIV Testing Expansion Coordinator, 202.671.506, avemaria.smith@dc.gov For Patients For information on HIV in DC visit www.doh.dc.gov/hiv. For information on Partner Services, call (202) 727-9860 For facts about HIV, visit www.aids.gov/basic GOVERNMENT OF THE DISTRICT OF COLUMBIA HIV/AIDS, Hepatitis, STD, Tuberculosis Administration (HAHSTA)

YOUR HIV TEST RESULT TODAY IS NEGATIVE. TODAY S DATE This means: Your test result does not show HIV at this time. Tips to Stay Negative: > If you have had unprotected sex or shared needles in the past 3 months, get another HIV test in 90 days. > Know your partner s HIV status. > Know if it s just the two of you in the relationship. > Condoms keep you safe. Your doctor should test you every year to be sure that you are still HIV negative. If your doctor does not offer you a test, ask for one.

YOUR HIV TEST RESULT TODAY IS POSITIVE. This means: You can still have a healthy and productive life! HIV can be managed with proper treatment. You have been given an appointment to see an HIV specialist. It is VERY important that you go to that appointment. Follow your doctor s instructions carefully! Protect yourself and others! Use condoms! You and your medical provider should discuss testing your partner(s). Telling a friend or family member who can support helps! You are not alone! There are services available to help you. FOR MORE INFORMATION CONTACT THE HIV/AIDS ADMINISTRATION 202-671-4900 WWW.DOH.DC.GOV/HIV

YOU REFUSED AN HIV TEST TODAY You are missing an opportunity to take care of your health and the health of others HIV is a common disease in Washington, DC, affecting at least 3% of the population DC recommends yearly HIV tests to help keep you healthy By not taking the HIV test, you may have a medical condition that you and your doctor don t know about People who know their HIV status can make sure they don t give HIV to other people As many as 50% of people with HIV don t know they are infected Ask your doctor if you have questions about taking the test. You can always change your mind and get the test. FOR MORE INFORMATION ABOUT HIV TESTING, INCLUDING LOCATIONS, VISIT WWW.DOH.DC.GOV/HIV, CALL 202-671-4900 OR TEXT DCTEST TO 365247.