Routine HIV Screening in Health Care Settings David Spach, MD Clinical Director Northwest AIDS Education and Training Center Professor of Medicine, Division.

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Presentation transcript:

Routine HIV Screening in Health Care Settings David Spach, MD Clinical Director Northwest AIDS Education and Training Center Professor of Medicine, Division of Infectious Diseases University of Washington Seattle This project was funded under cooperative agreement number U65/PS from the Centers for Disease Control and Prevention (CDC). Background and Definitions

Routine HIV Screening in Health Care Settings Slide Set Topics Background & Definitions HIV Epidemiology Update Rationale for Routine HIV Screening 2006 CDC HIV Screening Recommendations Overcoming Barriers to Routine HIV Screening Diagnostic Tests Counseling and Linking to Care

Routine HIV Screening in Health Care Settings Master Slide Set Topics Background & Definitions HIV Epidemiology Update Rationale for Routine HIV Screening 2006 CDC HIV Screening Recommendations Overcoming Barriers to Routine HIV Screening Diagnostic Tests Counseling and Linking to Care

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Goal of Routine HIV Screening HIV Screening HIV Diagnosis Link to Care Prevention Services Medical Care

Desired Outcome of Routine HIV Screening HIV Screening HIV Diagnosis Improve Survival & Quality of Life Improve Survival & Quality of Life Prevent New HIV Infections Link to Care

Routine HIV Testing in Health Care Settings Definitions Diagnostic testing. Performing an HIV test for persons with clinical signs or symptoms consistent with HIV infection. Screening. Performing an HIV test for all persons in a defined population. Targeted Testing. Performing an HIV test for subpopulations of persons at higher risk, typically defined on the basis of behavior, clinical, or demographic characteristics. Informed Consent. A process of communication between patient and provider through which an informed patient can choose whether to undergo HIV testing or decline to do so. Opt-out Screening. Performing HIV screening after notifying the patient that 1) the test will be performed and 2) the patient may elect to decline or defer testing. Assent is inferred unless the patient declines testing. HIV-Prevention Counseling. An interactive process of assessing risk, recognizing specific behaviors that increase the risk for acquiring or transmitting HIV, and developing a plan to take specific steps to reduce risks. Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Missed Opportunities for Earlier HIV Diagnosis Source: Centers for Disease Control. MMWR. 2006;55: Study Background - Data analyzed for HIV cases in SC from HIV cases cross-linked to all health care visits - 4,315 cases of HIV in South Carolina

Missed Opportunities for Earlier HIV Diagnosis Source: Centers for Disease Control. MMWR. 2006;55: Late Tester = AIDS Diagnosed within 1 Year of HIV Diagnosis Late Tester 41.3% Other 58.7%

Missed Opportunities for Earlier HIV Diagnosis Source: Centers for Disease Control. MMWR. 2006;55: Late Tester = AIDS Diagnosed within 1 Year of HIV Diagnosis Late Tester 41.3% Other 58.7% Among All Late Testers 73% with Prior Visit to Health Care Facility

CDC Analysis of HIV Reporting Data, Source: Centers for Disease Control. MMWR. 2009;58: Study Background - Data analyzed from HIV reporting US states - N = 281,421 persons receiving diagnosis of HIV

Source: Centers for Disease Control. MMWR. 2009;58: HV Testing in Relation to AIDS Diagnosis Late Tester = AIDS diagnosis < 1 year of HIV diagnosis CDC Analysis of HIV Reporting Data, Late Tester 38.3% Other 61.7%

CD4 Cell Count at Time of HIV Diagnosis 36% with CD4 < 200 cells/mm 3 Source: Dybul M, et al. J Infect Dis. 2002;185: Study Background - N = 2223 HIV-infected persons - Community clinics in larger urban areas - Evaluated CD4 count at time of HIV diagnosis HIV Infection

CD4 Cell Count at Time of HIV Diagnosis 34% with CD4 < 200 cells/mm 3 Source: Ogbuanu ID, et al. Am J Pub Health. 2009;Suppl1: Study Background - N = 759 HIV-infected persons - Analysis of statewide data in South Carolina (2004-5) - Evaluated CD4 count at time of HIV diagnosis HIV Infection

Acute HIV: Clinical Manifestations Source: Vanhems P, et al. AIDS. 2000;14: Signs and Symptoms of 160 Patients with Acute HIV

Laboratory Studies with Initial HIV Infection High Level Viremia Precedes Detectable Antibodies Infection HIV RNA Antibody Titer Detectable Antibody

Laboratory Studies with Initial HIV Infection “Window Period” Window Period

Laboratory Studies with Acute HIV Acute HIV Infection Antibody Titer Detectable Antibody HIV RNA Positive HIV-1 RNA Assay and Negative HIV Antibody Test

Testing for HIV Recommended in Patients with Clinical Manifestations of HIV/AIDS Oral Hairy Leukoplakia Kaposi’s Sarcoma Pneumocystis pneumonia Images Source: HIV Web Study ( Oral Candidiasis

Mortality and HAART Use Over Time HIV Out-Patient Study, CDC, Source: Centers for Disease Control and Prevention.

Per Person Survival Gains with Various Interventions for Chronic Diseases in US Source: Walensky RP, et al. J Infect Dis. 2006;194: Figure Reproduced with permission from University of Chicago Press

Correlation of Baseline CD4 Cell Count and Outcome after Staring Antiretroviral Therapy Source: Egger M, et al. Lancet. 2002;360: Study Background - N = 12,574 HIV-infected adults starting antiretroviral therapy

Acknowledgement This project was funded under cooperative agreement number U65/PS from the Centers for Disease Control and Prevention (CDC).