1. HIV Screening and Testing San Francisco Area AIDS Education and Training Center University of California, San Francisco at San Francisco General Hospital

2. 2 About this Presentation These slides were developed by the UCSF San Francisco Area AIDS Education and Center as a component of the SFAETC HIV Screening and Testing Training Curriculum Guide. The intended audience is experienced AETC trainers, clinical faculty, and training participants. Users are cautioned that concepts of HIV management and clinical care continue to evolve rapidly, and this information may become outdated. The information contained herein is not intended to constitute or substitute for medical advice from a licensed health care professional.

3. 3 Welcome! Please sign in Please complete: 1.Participant Information Form & Pre-Test (bubble form) NOW 2.Program Evaluation & Post-Test Later Please silence cell phones and pagers

4. 4 Learning Objectives At the end of this session you will be able to: Explain rationale for revised HIV screening recommendations Clarify definitions of HIV testing Review CDC routine HIV testing recommendations Discuss HIV testing modalities Apply routine HIV screening recommendations in clinical practice

5. 5 HIV Testing: James Curran, dean of public health at Emory University and director of the university's Center for AIDS Research, was head of the Centers for Disease Control task force as the HIV epidemic unfolded in the early 1980s. 1985

6. 6 HIV Testing: 2008 A 38 year-old man presents to urgent care with complaints of burning while urinating for the past 2 days. He denies fevers, flank pain, or penile discharge. He is sexually active with both men and women and uses condoms sporadically.

7. 7 Would you include an HIV test as part of his visit? 1.Yes 2.No 3.Maybe/Depends 4.I have no idea

8. 8 HIV Testing: 2008 A 38 year-old man presents to clinic to establish care. His only complaint is of a sore ankle for the past week after an injury while playing soccer. He states he is otherwise healthy.

9. 9 Would you include an HIV test as part of his visit? 1.Yes 2.No 3.Maybe/Depends 4.I have no idea

10. 10 Case Discussions YES!! Answer for both case scenarios: YES!!

11. 11 According to the CDC, what percentage of people infected with HIV in the U.S. do not know they are infected? About 25%

12. 12 The CDC has estimated that approximately how many persons in the U.S. become infected with HIV each year? Approximately 56,000 per year

13. 13 HIV Incidence in the U.S.

14. 14 HIV Incidence in the U.S. Transmission is higher among people unaware of infection Risk behavior is reduced with awareness of HIV+ status: 68% reduction in unprotected sex

15. 15 What weve learned so far... Individuals remain untested Routine HIV testing reduces stigma Routine HIV screening is highly effective: Perinatal transmission reduced from 25-30% to <2% w/ interventions

16. 16 CDC Recommendations: Objectives Increase HIV screening Detect disease earlier ID & counsel HIV+ patients Link patients to services Further reduce perinatal transmission

17. 17 CDC Recommendations: Routine Testing for HIV Routine, voluntary testing for all patients ages 13-64 Opt-out testing; no separate consent for HIV Pretest counseling not required Repeat testing at providers discretion

18. 18 Definitions The Old Opt-in screening: performing an HIV test after assessing patients risk, obtaining informed consent, and conducting pre-/post-test counseling The New Opt-out screening: performing an HIV test after notifying patient that the test will be done; consent is inferred unless patient declines

19. 19 Definitions Routine testing: performing an HIV test for all persons in a defined population Diagnostic testing: performing an HIV test for persons with clinical signs or symptoms of HIV infection Targeted testing: performing an HIV test for subpopulations of persons at higher risk based on behavioral, clinical or demographic characteristics

20. 20 So, Who Should Be Tested? Everyone ages 13-64 in all healthcare settings Everyone beginning treatment for TB Everyone seeking treatment for STDs All pregnant women For all: no separate consent or required prevention counseling (opt-out)

21. 21 Who Needs Repeat Testing? High-risk patients: Who is included? How frequently? Anyone engaging in a new relationship Occupational exposure to blood or bloody fluid which can contain HIV Pregnant women in 3 rd trimester in high HIV prevalence areas

22. 22 Law?? Recommendation?? State HIV Testing Laws Compendium http://www.ucsf.edu/hivcntr

23. 23 CA HIV/AIDS Testing Bill AB 682: Effective January 1, 2008 Paves the way for HIV screening to be a routine part of medical care Repeals written informed consent for HIV testing Patient can decline test and if so, should be noted in chart

24. 24 Necessary Documentation Accepts test: (Nothing!) Declines test: Patient declines HIV test

25. 25 Group Discussion 1.What SHOULD BE Advantages and disadvantages of routine HIV testing 2.What IS Misconceptions about HIV testing Barriers to implementation 3.What COULD BE Changes needed to implement HIV testing as part of routine medical care

26. 26 HIV Testing... ??? Rapid? ELISA? Western Blot? Blood test? Oral test? UniGold? OraQuick? IFA? Confirmatory? False positive?

27. 27 How is HIV Diagnostic Testing Done? Gold Standard: ELISA followed by Western Blot confirmatory test or immunofluorescence assay (IFA) Detects antibody to HIV virus Usually takes a few days for results May not be positive during window period Indeterminate result possible

28. 28 Window Period Virus in Blood Antibodies Detected Window Period Infection

29. 29 The Indeterminate Test Western Blot: looks for antibodies to specific HIV proteins and demonstrates presence by a change in color. Indeterminate Result: Some, but not all, bands are present. Causes: recent infection; advanced HIV; certain strains of HIV; cross reaction to other antibodies; HIV vaccine; lab error Next Steps: Retest in >6 weeks. Risk counseling if indicated.

30. 30 The Indeterminate Test Column 1: Positive Control Column 2: Negative Control Column A: Negative Test Column B: Indeterminate Test Column C: Positive Test

31. 31 ELISA: ~25% do not return for test results of standard test RAPID TESTS: Only ~2% leave before results of rapid HIV test The ELISA HIV Test: Perils of Waiting

32. 32 Rapid HIV Tests Uni-Gold Recombigen Reveal G2 Multispot HIV-1/HIV-2 OraQuick Advance Stat Pak Complete

33. 33 A patient has a rapid HIV test performed and it is positive. What does this mean? A.Patient has HIV. B.Patient most likely has HIV: repeat rapid test now. C.Patient most likely has HIV: order a Western Blot or IFA. D.Unclear if the patient has HIV: do another rapid test after window period.

34. 34 Rapid HIV Tests Results available in < 1 hour Most easy to perform High specificity: negative means negative except during window period! High sensitivity: positive means likely positive BUT… Important! Positive rapid test results must be confirmed for HIV diagnosis!

35. 35 Group Discussion 1.What are the advantages and disadvantages to using the rapid HIV test? 2.What changes would need to occur in your healthcare setting to implement use of the rapid HIV test? 3.What would you tell patients before and after running a rapid test?

36. 36 Summary All persons ages 13-64 should be screened for HIV No need for written informed consent or counseling High risk patients should be screened more frequently

37. 37 Resources http://www.hivtest.org/

38. 38 Resources AETC National Resource Center http://www.aids-etc.org/ http://www.aids-etc.org/ AIDSinfo DHHS Treatment Guidelines http://aidsinfo.nih.gov/ http://aidsinfo.nih.gov/ Centers for Disease Control & Prevention (CDC) http://www.cdc.gov/hiv/default.htm http://www.cdc.gov/hiv/default.htm HIV InSite http://hivinsite.ucsf.edu/InSite http://hivinsite.ucsf.edu/InSite National HIV/AIDS Clinicians Consultation Center Warmline, PEPline, Perinatal HIV Hotline http://www.ucsf.edu/hivcntr/ http://www.ucsf.edu/hivcntr/ Pacific AETC http://www.ucsf.edu/paetc http://www.ucsf.edu/paetc