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HIV testing in North Carolina- A pathway to Universal Access

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1 HIV testing in North Carolina- A pathway to Universal Access
Peter A. Leone, MD Professor of Medicine University of North Carolina Medical Director NC HIV/STD Prevention and Care NCDHHS 1

2 Stemming the Tide of HIV Transmission in the United States
Number Infected Number unaware of their HIV infection Estimated new infections annually Those with unrecognized infection account for ~51% of new infections 1,039,000-1,185,000 220, ,000 (~21%) 56,000 ~29,000 Onset of symptoms or illness acts as a cue for testing 42% of HIV positive in U.S. tested due to illness (MMWR 2003) Glynn M, Rhodes P HIV Prevention Conference 2

3 Using a biological marker of recent HIV infection and a stratified extrapolation approach based on a sample survey method of estimating a population from a sample, CDC estimated the HIV incidence among people age 13 years or older in 22 states in The total was extrapolated to all 50 states and the District of Columbia by applying the HIV incidence to AIDS ratio in the 22 states to the number of AIDS cases in the non-incidence areas. Based on the stratified extrapolation approach the incidence of HIV in the US for 2006 was 56,300 new infections, with a 95% confidence interval of 48,200 to 64,500. An extended back-calculation corroboration of HIV incidence for the period yielded an estimate of 55,400 new infections per year for The extended back-calculation approach provides an average over 4 years and is less suited to identify very recent changes. The new national estimate of 56,300 does not reflect an increase in new HIV infections from previous years, but a more accurate direct measurement of incidence. Although these results are within the range of previous estimates, the back-calculation suggests that the previous CDC estimate of approximately 40,000 cases/year underestimated the severity of the epidemic. The 22 states with HIV incidence surveillance that provided data for the incidence estimate are Alabama, Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Louisiana, Michigan, Mississippi, Missouri, New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington. Data have been adjusted for reporting delay and cases without risk factor information were proportionately re-distributed. 3

4 HIV incidence Hall et al, JAMA 2008

5 HIV Diagnosis in Men Hall et al. JAIDS 2009

6 Estimates of New Infections, 2006, By Race/Ethnicity, Risk Group, and Gender,
for the Most Affected U.S. Subpopulations*

7 Based on the stratified extrapolation approach, using a biological marker of recent HIV infection, CDC estimated the incidence of HIV infections in 2006 as 56,300 new infections, with a 95% confidence interval of 48,200 to 64,500.  Of the 56,300 new HIV infections in 2006, CDC estimated that 73% were in men and 27% were in women. The 22 states with HIV incidence surveillance that provided data for the incidence estimate are Alabama, Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Louisiana, Michigan, Mississippi, Missouri, New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington. Incidence estimates were extrapolated to the 50 states and the District of Columbia. Data have been adjusted for reporting delay. 7

8 Based on a stratified extrapolation approach, using a biological marker of recent HIV infection, CDC estimated the incidence of HIV infections in 2006 as 56,300 new infections, with a 95% confidence interval of 48,200 to 64,500. Of the estimated 56,300 new HIV infections in the US in 2006, CDC estimated that 45% of the new infections were among blacks/African Americans, 35% among whites and 17% among Hispanics.  Asians/Pacific Islanders and American Indians/Alaska Natives made up 2% and 1% of new infections respectively. CDC’s incidence estimates confirm that blacks/African Americans are more severely and disproportionately affected by HIV than any other racial/ethnic group in the United States. Although blacks/African Americans comprise only 12% of the US population, 45% of new HIV infections occurred in blacks/African Americans. Hispanics/Latinos make up 15% of the US population yet 17% of new HIV infections occurred in Hispanic/Latinos. The 22 states with HIV incidence surveillance that provided data for the incidence estimate are Alabama, Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Louisiana, Michigan, Mississippi, Missouri, New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington. Incidence estimates were extrapolated to the 50 states and the District of Columbia. Data have been adjusted for reporting delay. 8

9 Based on a stratified extrapolation approach, using a biological marker of recent HIV infection, CDC estimated the incidence of HIV infections in 2006 as 56,300 new infections, with a 95% confidence interval of 48,200 to 64,500. Of the estimated 56,300 new HIV infections in the US in 2006, CDC estimated the rate of new infections by race was 14.6/100,000 in American Indians/Alaska Natives, 10.3/100,000 in Asians/Pacific Islanders, 83.7/100,000 in blacks/African Americans, 29.3/100,000 in Hispanics/Latinos, and 11.5/100,000 in whites. In 2006, the rate of new infections among blacks/African Americans was 7 times the rate among whites (83.7 versus 11.5 new infections per 100,000 population). The rate of new HIV infections among Hispanics/Latinos in 2006 was nearly 3 times the rate among whites (29.3 versus 11.5 per 100,000). The 22 states with HIV incidence surveillance that provided data for the incidence estimate are Alabama, Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Louisiana, Michigan, Mississippi, Missouri, New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington. Incidence estimates were extrapolated to the 50 states and the District of Columbia. Data have been adjusted for reporting delay. 9

10 Based on a stratified extrapolation approach, using a biological marker of recent HIV infection, CDC estimated the incidence of HIV infections in 2006 as 56,300 new infections, with a 95% confidence interval of 48,200 to 64,500. Among MSM with new HIV infections, 13,200 were white, 10,130 were black/African American and 5,370 were Hispanic/Latino. Within these racial/ethnic subpopulations, there are differences in the age at infection. There was a greater number of new HIV infections among young black/African American MSM age years than any other age-race/ethnicity group of MSM - over 5,000 new HIV infections in In MSM age years the number of new infections in blacks/African Americans was 1.6 times the number in whites, and 2.3 times the number in Hispanics/Latinos. In Hispanic/Latino MSM the highest number of new infections was also in the youngest age group with over 2,000 new HIV infections in Hispanic/Latino MSM age years. In contrast, among white MSM the highest number of new HIV infections (over 4,500) occurred in those age years. Among black/African American MSM, more than half (52%) of new HIV infections were in men age years, 25% age years, 18% age years and 6% age 50 years and older. Among Hispanic/Latino MSM, 43% of new HIV infections were in men age years, 35% age years, 18% age years and 4% age 50 years and older. Among white MSM, 25% of new HIV infections were in men age years, 35% age years, 28% age years and 11% age 50 years and older. Please note that data are presented on this slide for whites, black/African American, and Hispanic/Latinos only.  Asians/Pacific Islanders and American Indians/Alaska Natives made up a combined total of 2.6% of the national estimate of new infections, and as a result, additional stratification in those populations was not possible.  Data have been adjusted for reporting delay and cases without risk factor information were proportionately re-distributed. 10

11 Impact of HIV/STD on MSM
HIV: 53% all new infections Syphilis: 65% all P&S infections Evidence of growing role in other STD GC (20+% of cases in GISP) Prevalence of GC, CT underestimated due to limited rectal, pharyngeal screening Outbreaks of LGV High rates of HIV co-infection (syphilis 40-60%, GC 5-10%)

12 HIV/STD disparities among African-Americans in the U.S.
Est. annual B:W Incidence / % all cases incidence Prevalence Ratio in blacks HIV , :1 45% GC , :1 70% CT m :1 48% P&S syphilis , :1 46% Trichomoniasis m :1 59% HSV m 3:1 30% Based on: HIV estimated incidence (JAMA 2008) STD Surveillance 2007 NHANES assessments of HSV-2 and Trichomoniasis Weinstock Persp Sex Rep Health 2004

13 HIV Incidence is High Among African American MSM
HIV incidence among African American men aged % HIV incidence among African American men aged % MMWR, HIV incidence among young MSM – 7 US Cities, , June 01, 2001

14 African American MSM have very high HIV prevalence rates and unrecognized infection
HIV infection and Unrecognized Infection among MSM, 5 US Cities, aged >18: Black, Non-Hispanic 46% (67%) White, Non-Hispanic 21% (18%) Multiracial 19% (50%) Hispanic 17% (48%) Other 13% (50%) MMWR, HIV Prevalence, unrecognized infection and HIV Testing among MSM – 5 US Cities, June 2005, April, 2005, June 24, 2005.

15 HIV Prevalence: General US Population
Add Health1: Young adults (%, 95% CI) NHANES2: Aged 18 to 39 (%, 95% CI) Aged 40 to 49 (%, 95% CI) Whites 0.022 (0, 0.64) 0.26 (0.05, 1.24) 0 (0, 0.45) Blacks .492 (0.18, 0.87) 1.42 (0.71, 2.84) 3.58 (1.88, 6.71) White men n/a 0.52 (0.11, 2.45) 0 (0, 0.89) White women 0 (0, 0.31) 0 (0, 0.92) Black men 1.93 (0.77, 4.72) 4.54 (2.24, 8.97) Black women 1.01 (0.36, 2.84) 2.78 (1.00, 7.45) There are few current HIV seroprevalence studies of the general US population - but available evidence suggests that HIV seroprevalence is high among blacks - much higher than among whites. Among the more than 13K young adults and adolescents in the national population-based study, Add Health, HIV seroprev among blacks was estimated to be almost 0.5% - ie., 20-fold greater than that of whites. National Health and Nutrition Examination Surveys (NHANES), another national population-based study estimated that: White rates are low .26% among yr olds - but much higher among blacks - 1% among young black women, 2.8% among older black women - and even higher among black men - almost 2% among young black men and 4.5% among older black men. Important to keep in mind that these figures estimate the US civilian noninstitutionalized population - and do not include the homeless, the incarcerated - whose rates are substantially higher. n/a, not available. 1. Morris M et al. Am J Public Health. 2006;96(6): 2. McQuillan GM et al. J Acquir Immune Defic Syndr. 2006;41(5): 15

16 2005 HIV PREVALENCE REPORTED IN UNAIDS 2006 REPORT ON THE GLOBAL AIDS EPIDEMIC
Burkina Faso 2.0 Cameroon 5.4 Ghana 2.3 Rwanda 3.1 Senegal 0.9 Uganda 6.7 Cambodia 1.6 India Haiti 3.8 ((I credit Wafaa El-Sadr with the observation that)) The NHANES estimates for US blacks are striking in their similarity to and also in the fact that they’re in some cases higher than the national population-based seroprevalences reported by several countries in Sub-Saharan Africa and elsewhere. UNAIDS AIDS Epidemic Update 16

17 Slide 1: Estimated rates (per 100,000 population) for adults and adolescents living with HIV infection (not AIDS), states and 5 U.S. dependent areas At the end of 2007, in the 39 areas with confidential name-based HIV infection reporting since at least 2003, the prevalence rate of HIV infection (not AIDS) among adults and adolescents was estimated to be per 100,000. The estimated prevalence rate for adults and adolescents living with HIV infection (not AIDS) ranged from 2.2 per 100,000 (American Samoa) to per 100,000 (New York). 17

18 HIV 2006 (incidence estimates) 22 States Participating NC ranked 4th (FL, NY, LA)
2,356 persons (32.2/100,000) - 40% higher than the US Males represented 72% Blacks represented 67% Black rate was 9 times the rate for whites US 56,300 persons (22.8/100,000) Males represented 73% Blacks represented 45% Black rate was 7 times the rate for whites

19 AHI in North Carolina AHI were more likely to be adolescents (≤21 years old) and less likely to be women vs. prevalent infection 28% of AHI (N=35) were adolescents of whom 51% (N=18) were identified from (versus , p=0.03). Adolescent AHI were predominately MSM of color (74%), compared to only 23% of adult acutes (p< ). Kuruc et al. IAS 2009

20 N.C. Population and new HIV Disease Reports, 2007
Black, non-Hispanic White, non-Hispanic Asian/PI, 2% AI/AN, 1% Asian/PI, <1% AI/AN, 1% Hispanic

21 NC adult/adolescent HIV disease 2007

22 Disparities for Males 2007 HIV Disease
15.7/100,000 White males 85.2/100,000 Black or African American males (more than 5 times that of Whites) 38.0/100,000 Hispanic males (more than 2 times that of Whites )

23 Disparities for Females 2007 HIV Disease
2.8/100,000 White females 42.9/100,000 Black or African American females (more than 15 times that of Whites) 12.2/100,000 Hispanic females (more than 4 times that of Whites)

24 Late HIV Diagnosis in North Carolina
~35,000 living with HIV Each year ~ percent of new HIV disease cases in North Carolina represent persons diagnosed concurrently with both HIV infection and AIDS.

25 AIDS Rates : U.S. and N.C.

26 Missed opportunities for HIV diagnosis in the South
In a South Carolina there were 4315 cases of HIV reported between )* 41% had AIDS diagnosis within 1 year of AIDS diagnosis 16.5 had AIDS diagnosis within 30 days Of 1748 late testers, 1303 (~75%) had a health care visit(s) from Number of health care visits with no HIV test: 7988 (average 4 per person Visits with diagnosis that should trigger HIV testing: 1711 No risk at visit: 6277 * CDC MMWR Weekly Report Dec. 1, 2006

27 Identification of HIV Status to Reduce Transmission
Goal of new CDC recommendations to increase number who know HIV+ status People do not perceive risk Clinicians do not offer test Stigma more with “identified” risk and infection less so with testing itself Knowing HIV+ status can reduce transmission by: Behavior change - Addressing Co-morbidity - HAART reducing viral load MMWR 55:1-7, 2006 Inungu J. AIDS atient Care STDs 16:293, 2002

28 New CDC Recommendations
In health care settings: · HIV screening is recommended in all health care settings, after notifying the patient that testing will be done unless the patient declines (opt-out screening) · Persons at high risk for HIV infection should be screened for HIV at least annually · Separate written consent for HIV testing is not required. General consent for medical care is sufficient to encompass consent for HIV testing · Prevention counseling need not be conducted in conjunction with HIV testing

29 Knowledge of HIV Infection and Behavior
Results: The analysis integrating all 11 findings indicated that the prevalence of UAV with any partner was an average of 53% (95% confidence interval [CI]: 45%–60%) lower in HIV+ persons aware of their status relative to HIV+ persons unaware of their status. There was a 68% reduction (95% CI: 59%–76%) after adjusting the data of the primary studies to focus on UAV with partners who were not already HIV+. The reductions were larger in between-group comparisons than in within-subject comparisons. Findings for men and women were highly similar. Reduction in unprotected anal or vaginal intercourse with HIV Negative partners - HIV positive aware vs HIV positive unaware: 68% (95% CI: 59%–76%) Source: Marks G, et al. Meta-analysis of high risk sexual behavior, aware vs unaware. JAIDS. 2005 29

30 Forth coming CDC Recommendations for HIV testing in non-health care settings
Single positive EIA is adequate for referral Ryan White Funds can be used for initial evaluation and confirmation Strong component for linkage and retention to care – 50% by 3 months; 75% by 6 mo. Further define frequency of testing for high risk individuals

31 North Carolina Rules and Statutes

32 Branch Strategies for HIV
Expand and make HIV testing routine Continue NC STAT program Get newly diagnosed persons into care CD4 and Vl on all newly Dx individuals Keep persons diagnosed with HIV in care

33 Changes to NC Administrative Code Nov. 1, 2007
Opt-out HIV screening in medical settings and for prenatal and STD visits Pretest counseling not required Post-test counseling required only for positives HIV tests at first prenatal visit and 3rd trimester Mandatory HIV test at L&D for all women for whom HIV status is unknown and in infant if test not obtained from mother

34 Further Modification to “Routinize” HIV testing in Medical Care Settings
"Testing for HIV may be offered as part of routine laboratory testing panels using a general consent which is obtained from the patient for treatment and routine laboratory testing,so long as the patient is notified that they are being tested for HIV and given the opportunity to refuse testing."

35 Web site addresses http://www.epi.state.nc.us/epi/hiv/regulations.html
For CDC testing guidelines, go to For the changes to North Carolina testing rules, go to For epidemiological data in North Carolina, go to

36 North Carolina HIV Testing Initiatives
DOC opt-out screening Jail Screening 28 county sites ED screening/testing- 3 EDs in Triangle Rapid HIV testing in 25 counties Community Health Centers screening GRGT Free Neonatal testing (2010)

37 HIV Tests North Carolina DHHS Laboratory

38 North Carolina HIV Disease Reports
Trailheads Geeklog Site - Ordinary talent....Extraordinary imagination!

39 NC ED in Syphilis HMA Missed opportunities
142,470 visits to the ED during the study period 420 (0.3%) patients had an HIV test 6% positive (25/420) 554 (0.4%) patients had an RPR test 5.8% positive (32/554) Agreement between RPR and HIV test orders was low (kappa = 0.35, 95% CI: 0.30, 0.40). Only 31% (173/554) of patients receiving an RPR test also had an HIV test performed. Of these, 8 (4.6%) tested positive for HIV and 15 (8.7%) tested positive for syphilis; 4 (2.3%) were co-infected with both HIV and syphilis Klein et al CDC STD Prevention Conference 2010

40 North Carolina AHI Initial Presentation to Care n=128
Majority through the ED (n=46), health dept next 27) McKellar et al. North Carolina Acute HIV Infection Research Consortium 2009 40

41 Number of healthcare visits prior to diagnosis of AHI
Diagnosed at first contact 51 (40%) 1 visit before HIV diagnosis 41 (32%) > 2 visits before HIV diagnosis 25 (20%) Previous data suggested 52% of AHI seen >3x before diagnosed with AHI Better than previously reported. Amy Weintrob looked at this same population in 2001 – 52% seen at least 3 time or more Weintrob 2001 McKellar et al. North Carolina Acute HIV Infection Research Consortium 2009 41

42 Geography Aint enough: Still Not Getting to the Infected Population
RIOT Forsyth 603 Screened for Syphilis and HIV 3 new syphilis cases 4 new HIV Identified GRGT at Winston Salem State: 158 tested for HIV 157 tested for syphilis No new positives for HIV or syphilis One recent AHI : 11 HIV+ , 10 new syphilis dx, 7 co-infected (N=16)

43 Planned vs. Actual HIV Testing
<25% of individuals reporting medium or high risks reported an HIV test in the previous year. Those with a medium or high self-perceived HIV risk, and with heavier alcohol consumption did not match intent to test with actual testing The difference between intent and actual testing higher-risk > lower-risk groups regardless of whether tests obtained for any reason or only voluntary Ostermann et al. Arch Intern Med 2007

44 NC Delay to HIV Testing Over one-quarter of patients reported delayed seeking an HIV test for over 4 years. Patients who reported HIV infection in more recent calendar years had a shorter duration of testing delay. Self-reported HIV testing delay in North Carolina S Napravnik APHA 2009

45 Late Entry into Care UNC HIV Clinic 2000-03
SE reports greatest proportion of AIDS cases and deaths1,2 On presentation, HAART indicated for3: 75% of patients based on CD4 count, HIV RNA level, and an AIDS clinical condition 71% solely on CD4 count 78%, 57%, and 84% of patients entering HIV care ≤1 year, 1-2 years, and >2 years from HIV diagnosis, respectively (p=0.02) 1. CDC. First 500,000 AIDS cases–United States, MMWR Morb Mortal Wkly Rep 1995;44(46): 2. CDC. Update: AIDS–United States, MMWR Morb Mortal Wkly Rep 2002;51(27):592-5. 3. Gay CL et al. AIDS. 2006;20(5):775-8.

46 Why are we not getting to folks
Stigma of risk Stigma of HIV Infection Lack of access to health care or no primary care Co-morbidities HIV not perceived as lethal disease Testing as “risk reduction” Delay in linkage to care Sero-sorting

47 Mental Illness and Substance Abuse NC HIV Infected Individuals
Whetten et al. Southern Medical Journal 2005 Pence et al. JAIDS 2005

48 NC HIV Comorbidity Mental Illness:
- mood disorders (32% past year/21% past month) - anxiety (21%/17%) Substance use: 22%/11% 50% with past-year disorders and 40% with past-month disorders met the criteria for multiple diagnoses Comorbidity was associated with younger age, White non-Hispanic race/ethnicity, and greater HIV symptomatology. Gaynes et al Psychosomatic 2008

49 A Care Bridge Coordination Program: Linking HIV-infected Patients with Care in North Carolina
Emily S. Brouwer, Leslie Strayhorn, Arlene C. Sena, Heidi Swygard, Peter A. Leone, Evelyn M. Foust, Sonia Napravnik, and Joseph J. Eron University of North Carolina, Departments of Medicine and Epidemiology North Carolina Department of Health and Human Services University of North Carolina, Centers for AIDS Research

50 Care Bridge Coordination Program
Coordinator Testing sites Disease Intervention Specialists (DIS) Clinics Care Providers

51 Activities Received referrals beginning April, 2008
Received194 referrals to date 52 adults with newly diagnosed HIV 143 HIV-positive patients lost to follow-up Conducted 394 home visits Linked 137 patients to initial care or back to care 6 Refusals These are numbers from Durham county….

52 Care Bridge Coordination New Client Referral Sites
Other includes case managers from other counties, HPTN, self-referrals. *Includes: case managers from other counties, clinical trial sites, self-referral

53 Patients Some patients referred more than once and re-enrolled if lost-to-care 178 unique patients 73% Male, 27% Female 93% Black, 7% White or Hispanic Median age at referral: 41 years (Range: 16 years-77 years) 72 currently active Demographics are representative of the state’s demographics

54 The next wave is here: NC PSEL Syphilis Rates 1999-2009*
* Projected rate

55 PSEL Syphilis Rates by Gender, 2004-2009*
77%↑ 76%↑ rate ratios * Projected rate

56 Comorbidity (syphilis and HIV)

57 Distribution Male comorbidity cases Early Syphilis - HIV
%

58

59 We Can Not Test and Treat are way out of this Epidemic
Address Contextual/Structural issues Health Care/ Public Health reform Continue to expand HIV testing but must strengthen linkage to care Sexual Health and not Sexual Disease Comprehensive sexual health education Rights-based (Support same gender unions, etc) Use social network for prevention education and testing

60 Communicable Disease Branch Resource List http://www. epi. state. nc


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