Determination of HIV Infection Among TB Patients in

California, 2008

Darryl Kong1, Jennifer Flood1, Suzanne Marks2, James Watt1

1California Department of Public Health,

Tuberculosis Control Branch2Centers for Disease Control and Prevention,

Division of Tuberculosis Elimination

CSTE Conference June 14, 2011,

Pittsburgh, Pennsylvania1

Background: Poor Outcomes of HIV and Tuberculosis Co-morbidity

Persons with tuberculosis (TB) disease among persons living with HIV infection are more likely to:– Be diagnosed with TB at death or die

during TB treatment– Experience TB recurrence– Acquire TB drug resistance

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Background: Public Health Department’s Role in

Prevention of Poor HIV/TB outcomes

Detect HIV/TB co-morbidity– CDC recommends routine opt-out HIV testing of

all TB suspects and patients

Co-manage both diseases– Ensure HIV and TB treatment for HIV/TB patients

Closely monitor TB treatment to prevent poor outcomes– Provide directly observed therapy (DOT) for TB

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Background: HIV Testing Recommendations and Laws

CDC MMWR 2006;55(RR-14): – “all patients initiating treatment for TB should be screened

routinely for HIV infection”– “HIV screening is recommended for patients in all health-

care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening)”

CDC’s Advisory Council for the Elimination of TB, March 21, 2007: “endorses routine HIV testing in TB programs using opt-out methodology for persons with documented active TB, TB suspects, and persons identified in TB contact investigations.”

On January 1, 2008, CA law became compatible with CDC opt-out testing recommendations. However, re-disclosure of HIV status to CA DOH TB and STD programs only became legal in January 2011.

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Rationale for Current Evaluation Study: Unknown HIV/TB prevalence in California

In California (CA), HIV status was not routinely recorded from 1993-2010 in the Report of Verified Case of Tuberculosis (RVCT) used for surveillance and reported to the CA TB Control Program 

Estimates of HIV/TB prevalence relied on a match of state AIDS and TB registries from 1994-2004 (4% HIV positivity in 2004, a likely underestimation) 

2002 field assessment in 4 CA counties revealed that HIV status was known in only 55% of TB cases

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CA Evaluation Study Questions

How complete is HIV status determination?

What factors are associated with having a known HIV status?

When is HIV status determined?

What types of providers are reporting HIV status?

In what settings are HIV testing and TB diagnosis taking place?

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Methods I: Cohort of All TB Patients Reported to CA Department of Health

in 2008

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1. Data Collection

Source: local public health medical recordsHIV status (Positive, Negative, Unknown)

Source: State TB registry

Age, sex, race, nativity, history of TB

Homelessness, incarceration, excess alcohol use or illicit drug use

Type of provider for TB care

2. Analysis

Proportion of patients with a known HIV status

Factors associated with known HIV: Adjusted odds ratios from multivariate logistic regression

Definitions: HIV Status

HIV negative if any of the following before TB Tx completion but ≤ 1 year before TB Dx: – a negative HIV test result or – physician report of negative status

HIV positive if any of the following before TB Tx completion: – a positive HIV test result, – a report of HAART medication, – documentation of a positive status from a previous or

referring clinician, or – self-report of a positive status

HIV unknown: All others

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Definitions: Public vs. Private TB Provider

Public Provider: – were part of or overseen by a CA Department of Public Health TB program

Private Provider: – All others

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Definitions: TB Diagnosis Date

Date of TB Diagnosis, the first of the following:

– Report date from the local health department

– Specimen collection date of the first positive specimen culture

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Methods II: Simple Random Sample of 300 TB Patients from Jurisdictions Reporting at Least 5 Patients in 2008

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2. Analysis

Proportion with a previously known HIV status*

Proportion with initial private provider involvement

1. Data Collection

Source: local public health medical recordsTiming of HIV status determination

Types of TB providers at specific stages of TB care

*> 3 months before TB diagnosis

Results:Completeness of HIV Status Determination

• 2,697 TB patients reported to the CA DOH• Study N=2,667 (99%) of patients’ TB records

reviewed

• 1,752 TB patients (66% of 2667) had a known HIV positive or negative status

• 132 HIV/TB patients– 4.9% of reviewed patients– 7.5% of patients with known HIV status

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Results: How HIV Status Determination in CA Compared to the Rest of the U.S., 2008

CAUS excluding CA2015 Objective

0 10066% 80% 89%

Percent with Known HIV Status

CDC standard is universal testing of all TB cases13

Se-ries1

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

132 1620 915

Results: CA HIV Status, 2008, N=2667

Se-ries

1

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

164 154 597

Unknown HIV Status, N=915

5% 61% 34%

18% 17% 65%

Results: Known HIV Status,N=2667 (slide 1)

n Known HIV Statusn (%)

HIV Positive n (%)

Age (years)

0-14 155 52 (33.5) 0 (0.0)

15-29 490 395 (80.6) 20 (5.1)

30-44 587 452 (77.0) 70 (15.5)

45-59 626 447 (71.4) 36 (8.1)

60+ 809 406 (50.2) 6 (1.5)

Sex

Male 1635 1109 (67.8) 110 (9.9)

Female 1032 643 (62.3) 22 (3.4)

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Results: Known HIV Status N=2667 (slide 2)

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n Known HIV Status n (%)

HIV Positive n (%)

US-born

White 193 125 (64.8) 17 (13.6)

Black 155 111 (71.6) 21 (18.9)

Hispanic 244 137 (56.1) 12 (8.8)

Asian 55 23 (41.8) 0 (0.0)

AI or AN 7 6 (85.7) 1 (16.7)

Foreign-born

White 62 35 (56.5) 0 (0.0)

Black 54 41 (75.9) 6 (14.6)

Hispanic 802 609 (75.9) 65 (10.7)

Asian 1093 664 (60.8) 10 (1.5)

AI or AN 1 1 (100.0) 0 (0.0)

Results: Known HIV Status N=2,667 (slide 3)

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n

Known HIV Status n (%)

HIV Positive n (%)

Previous TB

No 2534 1652 (65.2) 125 ( 7.6)

Yes 133 100 (75.2) 7 (7.0)

History of homelessness, incarceration, excess alcohol use, or illicit drug use

No 2239 1410 (63.0) 80 (5.7)

Yes 428 342 (79.9) 52 (15.2)

TB Provider Type

Any Public Management

1799 1343 (74.7) 89 (6.6)

Only Private Management

819 377 (46.0) 40 (10.6)

Results: Factors Associated with Known HIV Status, N=2,618 (slide 1)

n Adjusted OR 95% CI

Age (years)

0-14 154 0.15 [0.10 – 0.24]

15-29 478 1.16 [0.84 – 1.59]

30-44 579 - Ref

45-59 610 0.67 [0.50 – 0.88]

60+ 797 0.30 [0.23 – 0.39]

Sex

Male 1609 - Ref

Female 1009 0.78 [0.65 – 0.95]

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Results: Factors Associated with Known HIV Status, N=2,618 (slide 2)

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n Adjusted OR

95% CI

US-born

White 193 - Reference

Black 155 0.93 [0.56 – 1.54]

Hispanic 239 0.70 [0.44 – 1.12]

Asian 54 0.44 [0.21 – 0.90]

AI or AN 7 1.67 [0.18 – 15.24]

Foreign-born

White 62 - Reference

Black 54 2.09 [0.87 – 5.04]

Hispanic 785 1.72 [0.97 – 3.08]

Asian 1068 1.26 [0.71 – 2.21]

AI or AN 1

Results: Factors Associated with Known HIV Status, N=2,618 (slide 3)

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n Adjusted

OR95% CI

Previous TB

No 2488 - Reference

Yes 130 1.72 [1.11 – 2.67]

History of homelessness, incarceration, excess alcohol use, or illicit drug use

No 2201 - Reference

Yes 417 1.46 [1.09 – 1.97]

TB Provider Type

Any Public Management

1799 - Reference

Only Private Management

819 0.28 (0.23 – 0.34)

Results: Timing of HIV status Determination, N=297

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Cases Reviewed

297*

Previously Unknown280 (94%)

Previously Known**12 (4%)

Dead at Diagnosis

5 (2%)

Tested171 (61%)

Untested109 (39%)

HIV-Positive8 (67%)

HIV-Negative4 (33%)

HIV-Positive7 (4%)

HIV-Negative164 (96%)

HIV-Negative7 (6%)

Unknown 102 (94%)

* Of the random sample of 300 TB patients, 3 patients’ charts were unavailable.** Known > 3 months prior to TB diagnosis

Results: Type of TB Provider for TB Patients Without a Previously

Known HIV Status, N=280

01020304050607080

Public Private

Pe

rce

nt

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Results: Days from TB diagnosis to HIV Test by TB Provider Type, N=154

23

-90

-75

-60

-45

-30

-15 0 15 30 45 60 75 90 10

512

013

515

016

518

019

50

5

10

15

20

25

30

35

40

210

Co

un

t

-90

-75

-60

-45

-30

-15 0 15 30 45 60 75 90 10

512

013

515

016

518

019

50

5

10

15

20

25

30

35

40

210Days From TB Diagnosis to HIV Test

Co

un

t

Private

Public

N = 65Median = 0 days

N = 89Median = 11 days

Wilcoxon test:P < 0.0001

Results: Where was HIV testing done for HIV-infected TB patients?

65% Hospital

2% ER

16% Outpatient

17% Unknown

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N=63 HIV-infected TB patients who had previously unknown HIV status and were HIV tested during TB diagnosis. 90% of TB patients tested for HIV in hospitals were tested by private providers.

Results: Stage of Immunosuppression,Newly Identified HIV/TB patients, 2008*

CD4 count*

83% with count <250 (most below 150)

Viral load**

88% with VL ≥10,000

* N=47 newly identified HIV-infected during TB diagnosis who had CD4 count data

** N=32 newly identified HIV-infected during TB diagnosis who had documented viral loads.

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Limitations

HIV information from TB public health records may be incomplete, especially for privately managed patients

Evaluation assessed data from 2008 only, and practices might have changed

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Summary: HIV Status Determination Was Not Universal

Only 66% of CA TB patients in 2008 had an HIV status known to the TB program, much lower than in the rest of the U.S.– 5% to 8% HIV/TB prevalence

HIV status determination appeared to be based on provider perceived risk for HIV (especially by age and sex)

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Known HIV Status and Reasons for Undetermined Status for TB Cases by Age,

U.S. Excluding CA, 2008

Age ≤ 14 yearsCases

≤ 14 yearspercentage

≥ 65 yearsCases

≥ 65 yearspercentage

Total 626 100 1876 100

HIV positive 7 1.1 15 0.8

HIV negative

307 49.0 1121 59.8

Refused testing

50 8.0 232 12.4

Not Offered 248 39.6 403 21.5

Unknown 14 2.2 105 5.6

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Summary: Private Providers’ Role is Important

• Over 800 patients had only private provider management

• Patients with only private management were less likely to have an HIV status known to the public health TB program.• From the sample: 96% did not have a known HIV status at TB

diagnosis

• Private TB providers diagnosed TB in two-thirds of the patients.• From the sample, diagnosis took place mostly in hospitals

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Conclusions CA needs to improve implementation of routine opt-out provider initiated HIV testing of TB patients as recommended by CDC

Private providers have the first opportunity to test for HIV during TB diagnosis and can identify HIV/TB co-morbidity earlier than public providers, which can translate to earlier linkage to HIV care and better TB treatment outcomes

Public health practitioners need to reach out to private providers and let them know of the need to test and report HIV in TB suspects and patients

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Recommendations for CSTE

Consider the following actions– Advocate for improved testing and

reporting of HIV status of TB suspects and patients, especially among private sector providers and hospitals

– Promote sharing of data between HIV/AIDS surveillance and TB programs to improve known HIV status

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Study Follow-up: California HIV/TB initiative

Ensure universal opt-out HIV testing of TB patients as the standard

Educate private providers and hospitals on the need for HIV testing among TB suspects and patients

Monitor performance of local TB programs

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Acknowledgements

• Local California TB Programs

• California Department of

Public Health– Alicia Rodriguez– Nicolette Palermo

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Additional Slides

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TB Testing Recommendations for Persons Living with HIV

– LTBI Testing

All to be tested at HIV diagnosis

Those testing negative for LTBI – should be retested once they start ART and attain CD4 count >= 200 cells/ml– Annual testing for HIV-infected persons at high risk for exposure to TB (i.e.,

persons who are or who have been incarcerated, live in congregate settings, are active drug users, or have other socio-demographic risk factors for TB)

Those testing positive for LTBI should have a chest radiograph and clinical evaluation for TB

– TB disease testing:

Evaluation for suspected HIV/TB should include:– A chest radiograph– Obtaining sputum specimens for AFB smear – Culture sputum specimens for patients with pulmonary symptoms and

chest radiographic abnormalities

A normal chest radiograph does not exclude the possibility of active pulmonary TB and when suspicion for disease is high, sputum samples should still be obtained

Tuberculin skin tests (TST) and interferon gamma release assays (IGRAs) should not be relied upon for the diagnosis of TB disease.

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