A Ministry of the Archdiocese of Galveston-Houston A United Way Agency
Integrated Multidsciplinary Approach to Adapt Routine HIV Screening in a Safety Net Clinic Setting
Sherri D. Onyiego MD, PhD Baylor College of Medicine Assistant Professor Departments of Family and Community Medicine and Internal Medicine San José Clinic Medical Director
Disclosure and Industry Support - This activity is supported by unrestricted educational grant from Gilead Sciences
Learning Objectives: The Who What When and How 1. San Jose Clinic mission and make up 2. Understand the epidemiology of HIV global, national and on a local (Houston) level. 3. Describe the importance routine screening for HIV, especially targeting at risk populations. 4. Demonstrate a thorough understanding of the importance of early diagnosis and linking the patient to care. 5. Implementation procedure of routine screening in a safety net clinic.
San José Clinic Mission Statement To provide quality healthcare and education to those with limited access to such services in an environment which respects the dignity of each person.
Founder: Monsignor George T. Walsh The Clinic began with the vision of Monsignor Walsh, a donation of $50 from the Charity Guild of Catholic Women and volunteers from the community, who were united with a shared hope of breaking down barriers to healthcare for the underserved.
San José Clinic Working Towards Another 90 Years of Care In 2013, San José Clinic provided 36,240 visits to 4,523 patients. Service area extends to over 20 counties and more than 200 zip codes across Southeast Texas.
Who We Serve San José Clinic is a Charity Care Clinic Serves all individuals who are uninsured gross 250% or below the Federal Poverty Level Accepts contributions to care, based on a sliding fee scale 55% of the Clinic s patient population lives at or below the Federal Poverty Level Annual Income of $23,850 or less for a family of four
San José Clinic s Typical Patient Hispanic/Latino Female Age 50 Has 5 household members Living at or below 100% of the Federal Poverty Level Annual Income of $23,850 or less for a family of four
Patient Demographics - Ethnicity 76% 1% 5% 11% 7% Asian Black / African American Caucasian Hispanic / Latino Other
Global HIV/AIDS - An estimated 35.3 million people worldwide live with HIV/AIDS - >two - thirds living in Sub-Saharan Africa.
Persons living with AIDS: 1985-2009 www.cdc.gov
HIV- Increasing Prevalence 50,000 new infections annually
Undiagnosed HIV Infection 21% of patients with HIV infection in the US are undiagnosed (2006 estimates)1 1http://retroconference.org/2009/Abstracts/33682.htm
Estimated New HIV Infection in the United States, 2010, affected subpopulations
Awareness of HIV Serostatus: Estimates of Transmission HIV Percent 100 90 80 70 60 50 40 30 20 10 0 ~20% Unaware of Infection ~80% Aware of Infection People Living With HIV (1,148,000) ~49% of New Infections ~51% of New Infections New infections/year Hall I. et al AIDS. 2012;26:887-896.
Who Is At Risk?
Burden Bearers: Minority Populations
HIV in Houston, TX
Diversity of HIV in Houston, TX
HIV in Houston, TX: New Diagnoses
Estimates of Persons Unaware of Their Status: Houston, TX Total Unaware of Status 26,424 5,549 (21%) Male 4,097 (74%) Female 1,452 (26%) White 1,490 (27%) Black/AA 2,718 (49%) Hispanic/Latino 1,253 (23%) 13-24 282 (5%) 25-34 1,025 (19%) 35-44 1,617 (29%) 45-54 1,730 (31%) 55+ 873 (16%) HIV Total = 26,424 Total Aware=20,875 Total Unaware = 5,549
Geography of HIV in Houston: San Jose Clinic HIV FOCUS partnership
FOCUS: In partnership with government agencies, health systems and others in 11 highly impacted cities, HIV FOCUS aims to: Make HIV screening a standard of care Increase HIV stakeholder dialogue Reduce undiagnosed and latediagnosed HIV infections Change public perceptions, overcome stigma Ensure linkage to care and treatment Keep patients in care
FOCUS Partners Houston: Bee Busy Baylor Teen Health Clinics Central Care Community Health Center City of Houston, Bureau of HIV/STD/Viral Hepatitis Prevention Healthcare for the Homeless Houston MD Anderson Cancer Center Memorial Hermann Hospital Texas Medical Center Harris Health System San Jose Clinic St. Hope Foundation
FOCUS Core Strategies: Routinizing Screening in Primary Care and Other Clinical Settings Integrating HIV Tests with Other Health Screenings Normalizing Attitudes Toward and Ending Stigma Associated with HIV Screening Partnerships with hospitals, community health centers and primary care providers Focus on implementing and monitoring routine screening in an efficient manner (for patients and providers alike) High rates of co-infection with HIV and other infectious diseases (STIs, hepatitis C) Uniting screening for these diseases can simplify processes, improve prevention, increase acceptance, and have a greater overall impact Community-wide approaches to increasing routine HIV screening are critical Continuing need for public education efforts to increase knowledge of the benefits of screening, and normalize and de-stigmatize HIV attitudes
Four Pillars of Routine Screening Routinizing Screening in Primary Care and Other Clinical Settings Partnerships with hospitals, community health centers and primary care providers Focus on implementing and monitoring routine screening in an efficient manner (for patients and providers alike) 1 2 3 4 Institutional policy change reflecting a multi-level, organization-wide commitment to implement routine HIV screening and diagnosis Integrated HIV screening processes to promote normalization and sustainability of HIV testing with other diagnostic and care services Electronic health records that prompt physicians to offer HIV testing, and better track patient uptake of screening services Staff education and training on best practices in the provision of HIV screening
CDC Routine Testing Recommendation: For patients in all health-care settings All patients aged 13 64 years in all healthcare settings should be tested (prevalence >.1%) Patients should be notified that testing will be performed, and can decline ( opt-out ) Those at high risk should be tested at least annually All patients at STD clinics should be screened routinely for HIV during each visit for a new complaint Separate written consent should not be required; general consent for medical care is sufficient Prevention counseling should not be required in HIV screening programs
US Preventative Services Task Force: The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. Grade: A Recommendation. The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. Grade: A Recommendation. Grade A Recommendation: The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service.
San Jose Clinic HIV Screening Implementation Process Stakeholder buy-in Administration, Providers, Staff EMR Pop up alert EMR HIV flowsheet Standing Orders Visual display of testing/screening Quarterly review of data Education and Training
EMR pop-up alert
EMR HIV tracking flowsheet
Getting the message to our patients San Jose Clinic Patient Brochure
Benefits of 4 th Generation Testing Earlier detection of HIV Detect Acute HIV Reach patients when they are most infectious Earlier entry into care and treatment Less likely to spread infection
HIV Infection and Laboratory Markers Acute Retroviral Symptoms HIV RNA (plasma) day 11 HIV Abs day 21-24 HIV p24 Ag day 16 Virus Undectable day 1-11 0 10 20 30 40 50 60 70 80 90 100 Infec1on 4th gen 3 rd gen Days 2 nd gen 1 st gen Modified after Busch et al. Am J Med. 1997; Slide courtesy Dr. Bernie Branson, CDC
New HIV Diagnostic Algorithm A1: 4 th generation HIV-1/2 immunoassay A1+ A2: HIV-1/HIV-2 differentiation immunoassay A1(-) Negative for HIV-1 and HIV-2 antibodies and p24 Ag HIV-1 + HIV-1 antibodies detected Initiate care (and viral load) HIV-2 + HIV-2 antibodies detected Initiate care RNA Acute HIV-1 infection Initiate care HIV-1&2 (-) RNA RNA Negative for HIV-1
San Jose Clinic Testing Data 350 San Jose' Clinic Testing Data 300 Total number of HIV tests 250 200 150 100 HIV tests offered HIV test performed 50 0 1 2 3 4 5 6 7 8 Month (January - August 2014)
Summary 1 in 5 persons in the US are unaware of their positive status Routinizing HIV screening is an integral part of patients care in all health care settings Newer 4 th generation testing detects acute cases of HIV Earlier detection reduces community transmission as well as financial burdens Safety net/charity clinic are well positioned to offer screening
Visit www.sanjoseclinic.org to learn more