HIV Testing Update

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HIV Screening for Patients 13-64 years:

A Guide for TB Clinic Providers

Best Practices in TB Control - August 28, 2012

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Philip J. Peters, MD Medical Officer

Division of HIV/AIDS Prevention Centers for Disease Control and Prevention

Atlanta, GA

Disclosures

• Conflicts of Interest: None

• Disclaimer: The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention

HIV Testing Update

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Question

What is responsible for the greater than 95% decline in perinatally acquired AIDS in the US?

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1. Widespread HIV screening of all pregnant women

2. Antiretroviral use during the antenatal, perinatal, and newborn periods

3. Reduction in number of pregnant women with HIV infection

4. 1 & 2

2006 Revised Recommendations

4

Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.

HIV Testing Update

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CDC’s Recommendations

• HIV screening for all patients aged 13 to 64 years

– Opt-out screening: patients should be told screening

will be performed but may decline testing

– Prevalence of undiagnosed HIV infection > 0.1%

• Written consent and prevention counseling not

required

• Annual HIV screening for those at high risk for HIV

• Prompt clinical care for HIV-infected persons

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Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.

Learning Objectives

• Analyze the rationale for HIV screening recommendations

• Assess clinical benefits of routine HIV screening

• Formulate approaches to simplify routine HIV screening in practice

• Update on selecting HIV tests

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HIV Testing Update

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Estimated HIV Prevalence in the United States, 2008

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Campsmith ML, et al. CDC. Morb Mortal Wkly Rep. (MMWR). 2008;57(39):1073-1076. Campsmith ML, et al. J Acquir Immune Defic Syndr. 2010 Apr;53(5):619-24. CDC. HIV surveillance—United States, 1981-2008. MMWR 2011;60: 689-693.

1,178,350 persons living with HIV infection

Prevalence = 448 per 100,000 population

0.4% of population living with HIV infection

20% unaware of their diagnosis

Rate of Tuberculosis Cases per 100,000 Population – United States, 2011

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Rate of AIDS Diagnoses by MSA* of Residence - United States and Puerto Rico, 2008

* MSA = Metropolitan Statistical Area

Centers for Disease Control and Prevention. Rates of AIDS Diagnoses by Metropolitan Statistical Area (MSA) of Residence, 2008 - United States and Puerto Rico. Areas. Slide set. http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm. Accessed May 27,2011.

Centers for Disease Control and Prevention. Trends in Tuberculosis - United States, 2011. MMWR Morb Mortal Wkly Rep. 2012 Mar 23;61(11):181-5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm. Accessed August 1, 2012.

Geographic Comparison of Rates of AIDS Diagnoses and Tuberculosis Cases in the United States

HIV Testing Update

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Why Routine Screening?

• Patients do not always disclose or may not be aware of their risk1

– 39% of men who had sex with a man within the past year did not disclose to their health care provider2

– 51% of rapid test positive patients identified in Emergency Department (ED) screening had no identified risk3

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1. Chou R, et al. Ann Intern Med. 2005;143:55-73. 2. Bernstein KT, et al. Arch Intern Med. 2008;168(13):1458-1464. 3. Lyss SB, et al. J Acquir Immune Defic Syndr. 2007;44(4): 435-442.

Risk-Based HIV Testing Has Become Less Effective

• Patients with HIV infection often have multiple health-care visits before diagnosis – median of 7 visits over 5 years in one study1

• Risk-based testing frequently misses2,3:

– Young people (< 24 years) – Women and heterosexual men – Members of racial and ethnic minorities – People residing outside of urban areas

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1. Klein D, et al. J Acquir Immune Defic Syndr. 2003; 32(2): 143-152.

2. Institute of Medicine. Washington, DC: National Academy Press; 2001. 3. CDC. HIV surveillance—United States, 1981-2008. MMWR 2011;60: 689-693.

HIV Testing Update

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Late Diagnosis of HIV Infection

32%

68%

Percentage of Patients Diagnosed with HIV

Late in the Course of Infection 2009, US*

Late Diagnosis:AIDS Diagnosed within ayear of receiving HIVdiagnosis

Early Diagnosis

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* 46 states with confidential name-based HIV infection reporting (n= 45,336) Centers for Disease Control and Prevention. HIV Surveillance Report, 2010; vol. 22.

Probability Curve of Mortality According to Baseline CD4 Cell Count

0-24

25-49

50-99100-199

200-249

>=350

CD4 cell count (cells/µL)

0.00

0.05

0.10

0.15

0.20

Pro

ba

bili

ty o

f death

0 1 2 3 4 5

>=5

3-4.99

Viral Load (log10[copies/mL])

0.00

0.05

0.10

0.15

0.20

Pro

ba

bili

ty o

f death

0 1 2 3 4 5

AIDS

No AIDS

Clinical stage (CDC classification)

0.00

0.05

0.10

0.15

0.20

Pro

ba

bili

ty o

f death

0 1 2 3 4 5

Injection drug use

No injection drug use

Transmission group

0.00

0.05

0.10

0.15

0.20

Pro

ba

bili

ty o

f death

0 1 2 3 4 5

>=50

40-49

30-3916-29

Age(years)

0.00

0.05

0.10

0.15

0.20

Pro

ba

bili

ty o

f death

0 1 2 3 4 5

0-24

25-4950-99

100-199

200-249

>=350

CD4 cell count (cells/µL)

0.00

0.10

0.20

0.30

0.40

Pro

ba

bili

ty o

f A

IDS

or

de

ath

0 1 2 3 4 5

>=5

3-4.99

Viral Load (log10[copies/mL])

0.00

0.10

0.20

0.30

0.40

Pro

ba

bili

ty o

f A

IDS

or

de

ath

0 1 2 3 4 5

AIDS

No AIDS

Clinical stage (CDC classification)

0.00

0.10

0.20

0.30

0.40

Pro

ba

bili

ty o

f A

IDS

or

de

ath

0 1 2 3 4 5

Injection drug use

No injection drug use

Transmission group

0.00

0.10

0.20

0.30

0.40

Pro

ba

bili

ty o

f A

IDS

or

de

ath

0 1 2 3 4 5

>=5040-49

30-39

16-29

Age(years)

0.00

0.10

0.20

0.30

0.40

Pro

ba

bili

ty o

f A

IDS

or

de

ath

0 1 2 3 4 5

Years from starting HAART Years from starting HAART

AIDS or death Death

May M, et al. AIDS. 2007;21;1185 ART-CC.

Years from starting antiretroviral therapy (ART)

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HIV Testing Update

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Tuberculosis and HIV

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A high proportion (7.9%) of people with tuberculosis

disease in the US are HIV infected [1]

Compared with HIV-negative patients, HIV-infected

patients with Mycobacterium tuberculosis infection

are markedly (21 – 34 times) more likely to develop

active tuberculosis disease [2]

1. Centers for Disease Control and Prevention. Trends in Tuberculosis - United States, 2011. MMWR Morb Mortal Wkly Rep. 2012 Mar 23;61(11):181-5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm. Accessed August 1, 2012. 2. World Health Organization. Global Tuberculosis Control. 2011. Available at http://www.who.int/tb/publications/global_report/2011/en/index.html. Accessed January 31, 2012.

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Antiretroviral Therapy Reduces Rates of Sexual Transmission of HIV

HPTN 052:

Antiretroviral

therapy reduced

HIV transmission

by 96% in

discordant couples

Cohen MS, et al. N Engl J Med 2011;365:493-505.

HIV Testing Update

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Desired Outcome of Routine HIV Screening

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HIV Screening

HIV Diagnosis

Improve Survival

and Quality of Life

Prevent New HIV Infections

Link to Care

Implementing HIV Screening

Integrating HIV Screening into Practice

•Train staff to perform HIV opt-out screening

• Provide easily understood patient informational materials

•Be prepared for commonly asked questions

• Include testing reminders in patient’s electronic medical record

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Address Patients’ Misperceptions

•Many patients believe they were previously tested for HIV, particularly if blood was drawn

•Many patients assume an HIV test was performed and if they didn’t receive a call from the doctor, that they do not have HIV

HIV Testing Update

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Implementing HIV Screening (cont’d)

State Laws Regarding HIV Testing

• Requirements to obtain written consent are being phased out.

• Refer to National HIV/AIDS Clinicians’

Consultation Center’s Compendium of State HIV Testing Laws for questions about your state: http://www.nccc.ucsf.edu/

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Compendium of State HIV Testing Laws. National HIV/AIDS Clinicians’ Consultation Center (NCCC) Web site. http://www.nccc.ucsf.edu/consultation_library/state_hiv_testing_laws/.

Communicating Positive HIV Test Result

• Provide result by direct personal

contact

• Provide result confidentially

• Ensure patient understands test result

• Connect to services

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Positive

+

Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.

HIV Testing Update

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Uni-Gold Recombigen

Reveal G3 OraQuick Advance

Clearview Complete HIV 1/2

Clearview HIV 1/2 Stat Pak

INSTI

Rapid HIV Tests

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Rapid HIV Tests

Advantages

Ensures patient receives test result

Option for an oral swab or finger stick instead of blood draw

Limitations

Results are manually read and charted

Training and oversight necessary

Can overburden nursing and other staff

More expensive

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HIV Testing Update

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Time to detection of HIV RNA, p24 antigen, and antibody during early HIV infection

HIV RNA (plasma)

HIV Antibody

0 10 20 30 40 50 60 70 80 90 100

HIV p24 Antigen

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Eclipse Acute HIV Infection Established HIV Infection

Infection

Reference: Branson BM. JAIDS. 2010; 55(S2): S102-105.

Days

Phase of

Infection

Earliest Viral

Detection

Antibody Detection

by Western blot

Time to detection of HIV RNA, p24 antigen, and antibody during early HIV infection

HIV RNA (plasma)

HIV Antibody

0 10 20 30 40 50 60 70 80 90 100

HIV p24 Antigen

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Eclipse Acute HIV Infection Established HIV Infection

Infection

Reference: Branson BM. JAIDS. 2010; 55(S2): S102-105.

Days

Phase of

Infection

Earliest Viral

Detection

Antibody Detection

by Western blot

HIV Testing Update

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Detects p24 antigen and HIV antibody

Time to result: 29 minutes

100 results/hour

FDA-approved June 22, 2010

4th Generation Combo Ag/Ab Assay

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HIV Screening. Standard Care.

• Free materials for providers – Annotated Guide to CDC

Recommendations – Resource Guide – AMA/AAHIVM CPT Coding Guide – ACP Guidance Statements – National HIV/AIDS Clinicians

Consultation Center Flyer

• Free patient materials

(available in English and Spanish)

– Brochure – Poster

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Download at www.cdc.gov/HIVStandardCare

Order free of charge from screenforHIV@cdc.gov

The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for

Disease Control and Prevention