1. Streamlined HIV Screening in a Municipal STI Clinic Kees Rietmeijer, MD, PhD Denver Public Health Department 2006 National STD Prevention Conference Jacksonville, Florida

2. Denver Metro Health Clinic Largest STI clinic and HIV testing facility in Rocky Mountain region Provides: – Comprehensive STI services – confidential HIV testing in the STI clinic – confidential and anonymous testing in the HIV counseling and testing site integrated in the clinic Every year – 14,000 “new problem” visits – >10,000 HIV tests – >100 HIV diagnoses: 50% of new HIV infections in the Denver Metro area; 30% in Colorado.

3. Background DMHC was prompted to review its HIV testing policies due to: – Shifting prevention paradigm heralded in CDC’s Advancing HIV Prevention initiative – Availability of HIV rapid test – Only 66% of persons with a positive HIV test received results Rapid testing introduced in November, 2003

4. HIV Testing at Denver STI Clinic Before November 2003 General consent for all procedures and testing, except HIV testing, obtained at registration HIV testing offered by clinician during the clinic visit, based on risk assessment Blood drawn for syphilis and HIV (if accepted) testing during the clinic visit HIV test used: standard EIA

7. HIV Testing at Denver STI Clinic November 1, 2003:Rapid HIV testing (OraQuick) offered as optional alternative to standard EIA – After 6 weeks, >95% of clients in CTS preferred the rapid HIV test – Adoption in STD clinic significantly slower due to increased length of visit July 1, 2004: Standard testing discontinued

8. HIV Testing at Denver STI Clinic Change in Testing Logistics To avoid adding another 20 minutes to the visit, prior to clinic encounter: – Draw RPR blood before clinician sees patient – Offer HIV testing routinely – Obtain additional consent – Use RPR blood draw to collect extra tube for rapid HIV test Implemented in May, 2004

9. Transfer to Electronic Medical Record System

10. Opt-Out Consent for HIV Testing Prompted by the change-over to the electronic medical record in March, 2005

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

13. HIV Testing Acceptance % Rapid test Logistical Adjustments Opt-out Consent

14. HIV Testing Acceptance %

15. HIV Positivity %

16. Data suggest that increased testing uptake may have resulted in: – Inclusion of lower-risk MSM – Inclusion of higher-risk non-MSM Denying risk behaviors (e.g. male same-sex encounters) at intake Separate analysis: – Comparing over time the proportion of newly- diagnosed HIV infections who did not report high-risk behaviors at the time tested for HIV

17. New HIV Infections and Initial Versus Subsequent NIR Status Year# HIV+ NIR Initial Subsequent* 200339 3 (7.6%)3 (7.6%) 200448 6 (12.5%)5 (10.4%) 20055511(20.0%)6 (10.9%) 2006**13 3 (23.1%)2 (15.3%) *After interview with DIS or PCM **Through March 16, 2006

18. Opt-Out Analysis During the first 3 months of 2006 – 800/4,000 (20%) opted out Of those opting out: – 18% were HIV tested after further counseling – 39% were recently tested – 10% were follow-up visits – 3% were known to be HIV+ – 30% were not tested for unknown reasons

19. Opt-Out Analysis Those opting out for unknown reasons: – 50% were low-risk MSW – 9% were low-risk women – 13% were MSM Not known to the clinic to be HIV+ – 2% left before being seen/tested

20. Conclusions Enhancing HIV testing uptake at DMHC appeared to be principally a matter of logistics and convenience: – Rapid HIV Testing – Change in clinic logistics to avoid lengthier visits – Offer HIV testing on a routine basis rather than as part of risk assessment – Switch to opt-out consenting

21. Acknowledgements Christie Mettenbrink Brandy Mitchell Dean McEwen