Challenges and Progress: Implementing HIV Screening in Health-Care Settings

Challenges and Progress: Implementing HIV Screening in Health-Care Settings Bernard M. Branson, M.D. Associate Director for Laboratory Diagnostics Divisions of HIV/AIDS Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention

Legislative Changes Since 2006 Removed written informed consent or counseling requirements: Arizona California Iowa Illinois Indiana Louisiana Maine New Hampshire New Mexico

Legislative Changes Since 2006 Authorized opt-out prenatal testing Georgia Iowa Illinois Louisiana Maryland Nevada New Jersey Rhode Island Tennessee Virginia

Legislative Changes Since 2006 Introduced legislation re: consent or counseling Massachusetts Maryland Nebraska New York Pennsylvania Wisconsin Proposed legislation to eliminate written consent Veterans Administration

Legislative Changes Since 2006 Reviewed existing laws, found to be compatible: Florida Missouri Vermont No legislation to change written consent requirement: Hawaii Michigan

CDC Assistance to Priority Jurisdictions

President s HIV Testing Initiative -- 2007 $35 million for testing in priority jurisdictions $1.75 million for provider training by HRSA s AIDS Education and Training Centers (AETCs) $750,00 for national organizations (providers)

Funded Jurisdictions VT NYC Los Angeles County WA OR NV CA ID UT AZ MT WY CO NM ND MN SD NE KS OK TX WI IA MO AR LA IL MS KY TN AL Chicago NY MI PA OH IN WV VA GA NC SC ME NH MA RI NJ CT Philadelphia DE MD Washington, D.C. Funded FL Houston 1 Represents ~85% of black AIDS cases in the United States in 2005

New Clinical Tests by Venues Number of New Test by Clinical Venues (Total = 999,727) No. New Tests 450,000 400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 39% 393,614 Emergency Dept. 15% 23% 2% 4% 2% 1% 22,949 Inpatient 41,957 Urgent Care 146,210 229,716 ST D Clinics Correctional 24,776 Substance 9,432 TB Clinics Medical Clinics Health Abuse Units Facilities Treatment Centers Clinical Venue Type 13% 131,073 Community Health Centers

Support for Health-Care Providers HRSA AIDS Education & Training Centers Over 1,000 training sessions since 9/06 >15,000 health care providers HIV Testing Training Exchange Collaborative: testing@aidsetc.org National Resource Center www.aids-ed.org

Technical Resources for HIV Testing Initiative AETC National Clinicians Consultation Center AETC National Resource Center AETC National Evaluation Center

www.ucsf.edu/hivcntr

President s HIV Testing Initiative -- 2007 $1 million for evaluation of adoption (AHITS) $4.1 million for social marketing to professionals One Test, Two Lives Prevention is Care Routine Testing

Provider Toolkits

EDHIVtestguide.org

www.sgim.org/go/hiv

Expanded HIV Testing in Primary Care - CME http://cme.medscape.com/viewprogram/9084 Expanded HIV Testing in the Emergency Department http://cme.medscape.com/viewprogram/9083 Opt-out HIV Testing as a Public Health Tool CME/CE http://cme.medscape.com/viewprogram/9085 Expanded HIV Testing -- Implementing the CDC Recommendations: Guidance for Nurses CE http://cme.medscape.com/viewprogram/9090

CME.medscape.com/viewprogram/9090

Technical Resources for HIV Testing Initiative National organizations for provider support Univ of Washington: web-based CME ACOG: toolkits for providers NBAAC: substance abuse providers Public Health Foundation: STD clinics HRET: implementation guidance FXB: toolkits for other health-care settings

Implementation Guidance 1. Emergency Departments Complete 2. Community Health Centers External Review 3. Correctional Health Facilities External Review 4. Hospital Inpatient Services Authors Review 5. Primary Care Providers Authors Review 6. Adolescent Medicine/Pediatrics Drafted 7. Family Planning/Gynecology OPA collaboration 8. Labor and Delivery Update 9. Substance Abuse Treatment Centers SAMHSA collaboration 10. STD Clinics PTC Centers 11. Prenatal Care Clinics Drafted

Block grants SAMHSA - CSAT Up to 5% of $1.68 billion ($60 million) for expanded testing in 22 states MAI discretionary portfolio $60 million for integrated testing 80% minimum HIV testing requirement Partner testing permitted

SAMHSA - CSAP Strategic Prevention Framework CBO applications due April 1 Anticipate 46 organizations, awards up to $400,000 Up to 5% of grant dollars for rapid or conventional HIV testing 5 Regional Training Centers Centers for Application of Prevention Technology Effective interventions Rapid HIV testing

SAMHSA - CDC Agreement SAMHSA to develop implementation strategies for clinical and non-clinical substance abuse treatment centers CDC to process and analyze testing data from clients in substance abuse treatment centers

Office of Population Affairs 77 HIV testing integration projects 47 projects continued 30 newly funded $10.3 million, 34 states and territories Training centers and implementation guidance for family planning & gyn

FPAR: HIV Testing Variable FPAR 2005 FPAR 2006 % Chg # HIV Tests (Confidential) 607,974 652,426 +7.3% Female 519,221 557,309 +7.3% Male 88,753 95,117 +7.2% Ratio Tests to Users 0.12 0.13 +7.5% Positive Test Results 1,114 1,337 +20.0% % Positive 0.18% 0.20% +11.1 # HIV Tests (Anonymous) 13,349 14,280 +7.0%

Counseling, Testing & Referral Outcome Cycle 1: (36 months) Oct-01 to Aug-04 N % Cycle 2: (36 months) Sep-04 to Sep-07 N % # clients counseled 365,461 n/a 576,398 n/a # tested 187,702 51% 377,286 65% # returning for results 97,067 53% 247,551 71%* # confirmed positive 693 0.37% 1,034 0.27% # positives referred for Tx 540 78% 984 95% *Data on the number of clients returning for rapid test results was not collected during Cycle 2 Period 1; thus the rate of return for results is calculated using data from Periods 2-5 only.

Positivity by Race/Ethnicity Black/African American, not Hispanic Hispanic or Latino (All Races) Native Hawaiian/Pacific Islander White, not Hispanic More than one race 1 positive per 1,000 tests Unknown or NR American Indian/Alaska Native Asian 0.00 % 0.05 % 0.10 % 0.15 % 0.20 % 0.25 % 0.30 % 0.35 % 0.40 % 0.45 % 0.50 % Cycle 2, Periods 2-5: July-05 to Sep-07

Public Health Service Regions

Male Positivity by Region Cycle 1 Cycle 2 1.80% 1.60% 1.40% 1.20% 1.00% 0.80% 0.60% 0.40% 0.20% 0.00% 1 positive per 1,000 tests I II III IV V VI VII VIII IX X Cycle 1, Periods 1-5 (Oct-01 to Aug-04) and Cycle 2, Periods 1-5 (Sep-04 to Sep-07)

Female Positivity by Region Cycle 1 Cycle 2 1.80% 1.60% 1.40% 1.20% 1.00% 0.80% 0.60% 0.40% 0.20% 0.00% 1 positive per 1,000 tests I II III IV V VI VII VIII IX X Cycle 1, Periods 1-5 (Oct-01 to Aug-04) and Cycle 2, Periods 1-5 (Sep-04 to Sep-07)

Priorities and Next Steps Endorsement by professional associations Address 3 rd- party reimbursement Develop practical materials for providers Evaluation

Policy Support for Expanded HIV Testing

Full Endorsement American College of Obstetricians and Gynecologists AIDS Healthcare Foundation American Academy of Pediatrics American College of Nurse-Midwives American College of Emergency Physicians American College of Physicians American Medical Association Association of State and Territorial Health Officials Emergency Nurses Association HIV Medicine Association National HIV/AIDS Clinicians' Consultation Center National Medical Association

Partial Endorsement American Academy of Family Physicians American Academy of HIV Medicine Association of Nurses in AIDS Care The Kaiser Family Foundation National Alliance of State and Territorial AIDS Directors National Association of Community Health Centers National Association of County and City Health Officials National Association of People with AIDS National Association of Social Workers National Business Group on Health National Governors Association National Minority AIDS Council

3 rd Party Reimbursement

ICDM-9 Codes for HIV Testing V70.0 routine general medical examination V69.8 other problems related to lifestyle (patient asymptomatic but in a known high risk group) 042 HIV disease, if the results are positive and the patient exhibits symptoms V73.89 Special screening for other specified viral diseases V65.44 HIV counseling (if counseling is provided; if the results are negative and counseling is provided V08 Asymptomatic HIV infection status (results positive, patient is asymptomatic

CPT Codes 86701 HIV-1 86702 HIV-2 86703 HIV 1/2 combination Alternative Laboratory Platform Testing (rapid tests): Add modifier - 92

Aetna, Inc. CIGNA HealthCare, Inc. Humana, Inc. HIP Health Plan of New York CareFirst, Inc. Blue Cross Blue Shield of Massachusetts Blue Cross and Blue Shield of Florida, Inc. Blue Cross Blue Shield of Minnesota Blue Cross Blue Shield of North Carolina Medical Mutual of Ohio Routine Screening X X X X X Targeted Screening X X X X X X X X X

Reimbursement for Screening New York Medicaid: $130 California Medicaid: $12.65

Resources AETC National Clinicians Consultation Center www.ucsf.edu/hivcntr 1-800-933-3413 Clinicians Consultation HRET Practical implementation guide for EDs www.edhivtestguide.org SGIM Implementation guide for primary care www.sgim.org/go/hiv