1. HIV Testing in Medical Settings Mark Thrun, MD Denver Public Health Mark.thrun@dhha.org

2. Prevention is Spectrum Spans the spectrum of care of persons at risk for HIV Positive HIV Test Screening for STD/HIV Prevention discussions/ counseling Personal assessment/ acknowledgement of risk Ongoing personal behavior modification

3. Prevention is Spectrum Spans the spectrum of care of persons living with HIV Positive HIV Test Linkage into HIV care Prevention discussions/ screening in care Compliance with care Return to HIV care

4. Updated CDC recommendations for HIV screening in clinical care settings All patients between 13 – 64 years of age – an initial screening test All patients being evaluated for possible TB All patients being evaluated for possible STD Annual screening for persons at increased risk –Men who have sex with men –Persons with > 1 sexual partner –Drug users

5. Awareness of Serostatus Among People with HIV and Estimates of Transmission ~25% Unaware of Infection ~75% Aware of Infection People Living with HIV/AIDS: 1,039,000- 1,185,000 New Sexual Infections Each Year: ~32,000 Accounting for: ~54% of New Infections ~46% of New Infections Marks, et al AIDS 2006;20:1447-50

6. Uni-Gold Recombigen Multispot HIV-1/HIV-2 Reveal G2 OraQuick Advance Knowledge is Power

7. Persons aware of HIV infection less likely to have risk of transmission Marks, JAIDS 2005

8. Source of HIV Tests and Positive Tests HIV+ tests**HIV tests* 17%44%Private doctor/HMO 27%22%Hospital, ED, Outpatient 2% 6% 5% 9% 21% 0.7%Drug treatment clinic 0.1%STD clinic 0.6%Correctional facility 5%HIV counseling/testing 9%Community clinic (public) *National Health Interview Survey, 2002 **Suppl. to HIV/AIDS surveillance, 2000-2003 38% - 44% of adults age 18-64 have been tested 16-22 million persons age 18-64 tested annually in U.S.

9. Many persons living with HIV seek care outside HIV clinic HIV clinic 2006 : 220 people at risk for transmitting HIV –1000 patients x 22% high risk STD clinic 2006: 167 people at risk for transmitting HIV –Clients asked HIV status or offered HIV test ED estimate 2006: 315 people at risk for transmitting HIV –3.5% in DH ED HIV+; 0.7% previously unrecognized infection x approx 45K unique visits/yr (Goggin, J Emerg Med, 2000)

10. Emergency Department

11. ED Testing and Counseling Haukoos, Acad Emerg Med, 2007

12. Targeted testing Tested for HIV681 HIV Positive15 (2.2%) Linked into Care12 (80%)* * 1 died, 1 incarcerated, 1 homeless

13. Routine HIV Testing Opt-out Consent

14. STD Clinic

15. Changes in the clinic re: HIV testing HIV testing acceptance and HIV test positivity was evaluated for 4 time periods: –Period 1: The year before introduction of rapid testing December 2002 – November 2003 –Period 2: The 6 months following introduction or rapid testing, before logistical adjustment in the clinic and discontinuation of the standard test December 2003 – May 2004 –Period 3: The 10 months following logistical adjustment, but before introduction of the electronic medical record and opt-out testing June 2004 – March 2005 –Period 4: The 6 months following opt-out testing April 2005 – September 2005

16. HIV Testing Acceptance Period 1: Before introduction of rapid testing Period 2: Following Period 1, before logistical adjustments Period 3: Following Period 2, before opt-out consent Period 4: After Introduction of opt-out %

17. HIV Positivity Period 1: Before introduction of rapid testing Period 2: Following Period 1, before logistical adjustments Period 3: Following Period 2, before opt-out consent Period 4: After Introduction of opt-out %

18. Rapid Testing Trends 9/01/03 – 9/31/04 Number of Tests Performed Rapid testing only. Change in clinic logistics

19. Impacts of Rapid Testing Denver Metro Health Clinic Percentage of patients who received their positive test results: Before: After: 66%100%

20. Caveat: False positive tests

21. Positive predictive values Single EIA Test Specificity HIV Prevalence Predictive Value, Positive Test 10%99%98%92% 5%98%96%85% 2%95%91%69% 1%91%83%53% 0.5%83%71%36% 0.3%75%60%25% 0.1%50%33%10% OraQuickReveal 99.9%99.8%99.1% 97% 95% 87% 77% 63% 50% 25% Uni-Gold 99.7%

22. Caveat: Routine HIV testing may mean more staff time Lessons in positive predictive value Example 1: Test 1,000 persons Test Specificity 99.6% HIV Prevalence 10% True Positives: 100False Positives: 4 Positive predictive value:100/104 = 96% Example 2: Test 1,000 persons Test Specificity 99.6% HIV Prevalence 0.4% True Positives: 4False Positives: 4 Positive predictive value:4/8 = 50%

23. Caveat: What happens when people test positive

24. Disposition and Linkage into Care Haukoos, Acad Emerg Med, 2007

25. Coordination of referrals Haukoos, Acad Emerg Med, 2007

26. Linkage to care/ Additional prevention counseling

27. Patients referred to LTC staff: 366 Confirmed linked to care: 220 (71%) Linkage to Care: Denver 2005 - 6/2007 Patients seen by LTC staff: 311

28. Training Needs Related to Expansion of Testing New technologies require staff to be brought up to speed Emphasis of training may need to shift –Less didactic class time –More technical assistance Training must be ongoing and collaborative Training needs may fall outside “target” topic area: e.g. testing and linkage to care

29. Acknowledgements Kees Rietmeijer Jason Haukoos Emily Hopkins Bill Burman Tom Deem Marshall Gourley Reina Lopez Ryan Westergaard