# Presentation: 264478

## Implementation of the Revised Recommendations for HIV Testing in Health Care Settings

- Associate Director for Prevention in Care
- Division of HIV/AIDS Prevention
- Centers for Disease Control and Prevention
- February 27, 2007

**Implementation of the Revised Recommendations for HIV Testing in Health Care Settings**

## Outline

- Overview of the Revised Recommendations for HIV testing in healthcare settings
- Engaging partners
- Implementation plan
- Emergency departments
- Community health centers
- Jails and correctional facilities
- HIV Screening in other clinical settings
-  State and local considerations
- Future Activities

## Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care SettingsMMWR  2006;55(No. RR-14):1-17Published September 22, 2006

- http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

## Source of HIV Tests and Positive Tests

|  | HIV tests* | HIV+ tests** |
| --- | --- | --- |
| Private doctor/HMO | 44% | 17% |
| Hospital, ED, Outpatient | 22% | 27% |
| Community clinic (public) | 9% | 21% |
| HIV counseling/testing | 5% | 9% |
| Correctional facility | 0.6% | 5% |
| STD clinic | 0.1% | 6% |
| Drug treatment clinic | 0.7% | 2% |

**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.

## Revised RecommendationsAdults and Adolescents - I

- Routine, voluntary HIV screening for all persons 13-64 in health care settings, not based on risk
- Repeat HIV screening of persons with known risk at least annually
- Opt-out HIV screening with the opportunity to ask questions and the option to decline
- Include HIV consent with general consent for care; separate signed informed consent not recommended
- Prevention counseling in conjunctions with HIV screening in health care settings is not required

## Revised RecommendationsAdults and Adolescents - II

- Intended for all health care settings, including inpatient services, EDs, urgent care clinics, STD clinics, TB clinics, public health clinics, community clinics, substance abuse treatment centers, correctional health facilities, primary care settings
- Communicate test results in same manner as other diagnostic/screening tests
- Provide clinical HIV care or establish reliable referral to qualified providers

**Notes:**
(bullets from slide)

## Revised RecommendationsAdults and Adolescents - III

- Low prevalence settings:
- Initiate screening
- If yield from screening is less than 1 per 1000, continued screening is not warranted
- Steps should be considered to resolve conflicts between the recommendations and state or local regulations
- Updated HIV Testing Laws at the National HIV/AIDS Clinicians’ Consultation Center:  http://www.ucsf.edu/hivcntr/PDFs/WEB2006State%20Laws.pdf

## Revised RecommendationsPregnant Women - I

- Universal opt-out HIV screening
- Include HIV in routine panel of prenatal screening tests
- Consent for prenatal care includes HIV testing
- Notification and option to decline
- Second test in 3rd trimester for pregnant women:
- Known to be at risk for HIV
- In jurisdictions with elevated HIV incidence
- In high HIV prevalence health care facilities

## Revised RecommendationsPregnant Women - II

- Opt-out rapid testing with option to decline for women with undocumented HIV status in L&D
- Initiate ARV prophylaxis on basis of rapid test result
- Rapid testing of newborn recommended if mother’s status unknown at delivery
- Initiate ARV prophylaxis within 12 hours of birth on basis of rapid test result

**Notes:**
(slide)

## Engaging Partners

## Consultation with National Medical Organizations, Atlanta, Oct 16, 2006

- Consulted with key medical organizations and insurers to:
- Identify tools currently available to assist clinicians
- Propose modifications to increase utility of tools
- Identify gaps and recommend development of additional tools
- Identify process for promotion/dissemination of tools through existing communication networks
- Identify regulatory/legislative barriers and strategies to address them
- Identify strategies to seek reimbursement for HIV screening
- Provide input on implementation guidance

## Recommendations from Consultation

- Develop resources to support implementation
- Implementation guidance addressing operational and system issues
- Educational materials for patients
- Tools tailored to different type of providers
- Need to tailor strategies to individual settings
- Private – public
- Hospitals – community clinics
- Specialty programs (STD, substance abuse)
- Need to identify and disseminate best practices and models
- Provide access to state-specific resources
- State laws and regulations
- Resources to facilitate referrals to care & treatment and prevention services

## Challenges

- Policy – existing state and local laws and regulations
- Reimbursement
- Health plans and Medicaid coverage for screening
- Limited resources to cover cost of testing uninsured patients
- Limited resources to assist with follow up care and HIV prevention services

## Strengthening Partnerships

- Strengthen partnerships with National organizations to assist CDC in the development of tools, resources and strategies for the private and public sectors.
- Establish private-public working groups to expedite development of tools and resources.

## Partners

- National Medical Association
- American Medical Association
- American Academy of Pediatrics
- Society of General Internal Medicine
- American College of Obstetricians and Gynecologists
- HIV Medicine Association
- American Academy of HIV Medicine
- Health Research and Educational Trust of the American Hospital Association
- National Association of Community Health Centers
- National Association of Social Workers

## Implementation Activities

## CDC Implementation Plans

- Domains:
- Implementation guidance
- Monitoring and evaluation
- Reimbursement
- Policies, laws and regulations
- Follow-up care
- Collaboration with health departments
- Professional education
- Community partners
- Corrections
- Social marketing
- Laboratories

## Implementation Guidance

- Develop implementation guidance for various types of settings in collaboration with key stakeholders:
- Hospitals (EDs, inpatient, L&D)
- STD clinics
- Substance abuse treatment centers
- Community health centers
- Correctional health facilities
- Primary care settings
- Urgent care clinics
- Prenatal care  clinics & FP clinics

## Reimbursement Issues

- Worked with AMA to obtain current procedural terminology (CPT) codes for HIV screening tests
- Contacted CMS to discuss procedures to seek reimbursement for HIV screening under Medicaid
- Working with America’s Health Insurance Plans and its members to discuss issues related to reimbursement of HIV screening

## Emergency Departments

## Health Research & Educational Trust (HRET)

- HRET is supporting CDC on a number of projects related to the implementation of HIV testing in hospital settings
- Independent, research affiliate of the American Hospital Association
- Conducts research & education on critical issues for hospitals/health systems and the communities they serve.

## Health Research & Educational Trust - II

- HRET Activities:
- Conducted a baseline assessment of the number of hospitals conducting HIV testing in the ED before recommendations were published in September
- Developing an web-based tool to assist hospitals in initiating or expanding HIV testing in the ED and UCC
- Conducting an in-depth evaluation of ED and UCC HIV testing programs, including cost assessment
- Planning to conduct ongoing monitoring of US hospitals to assess uptake

## HRET Online Guide

## Multi-Site Evaluation of HIV Testing Programs in Emergency Departments

- 6 case studies of different approaches to routine HIV testing in EDs
- Outcomes evaluation of different models
- Cost analysis of various approaches and models
- Collaborators
- Rich Rothman, Johns Hopkins University (co-PI)
- Harold Pollack, University of Chicago (CEA Adviser)

## HIV Testing Workshops

- 6 Regional strategic planning workshops for ED staff
- 10 hospitals per workshop
- Commitment to develop an action plan addressing implementation steps and challenges identified during workshop

## Community Health Centers

## Collaboration with National Association of Community Health Centers (NACHC)

- NACHC, in collaboration with CDC and HRSA
- Analyzed HIV testing, prevention, and linkage to care policies
- Developed operational guide to help community centers
- NACHC is working with 6 community health centers (17 treatment sites) through on-site TA to incorporate HIV testing into routine care and arrange follow up care for HIV-infected patients

## CHCs Screening for HIV

- Aaron E. Henry Community Health Services Center, Inc., Clarksdale, MS
- Mantachie Rural Health Care, Mantachie, MS
- Northeast Mississippi Health Care, Mt. Pleasant, MS
- Blue Ridge Community Health Services,Hendersonville, NC
- Greene County Health Care, Inc., Snow Hill, NC
- Rural Health Services, Clearwater, SC
- 5 sites are using Unigold (under the 340-B program)
- 1 site is using Orasure

## Lessons Learned Within the Health Center

- Leadership buy in and support is key
- HIV screening has not increased patient cycle time
- Staff have been very engaged and enthusiastic, there has been no push back or stigma experiences
- Access to kits continues to be a challenge
- Reimbursement and/or funding for testing needs to be solved for it to be sustainable
- All staff need to be trained at the same time, it needs to start at all levels in the organization

## Other Lessons

- Experiences are different for Ryan White funded health centers and those that are not.
- Non-Ryan White health centers have no relationship with the HIV network, building these relationships can be time consuming.  Follow up care needs to be arranged before clinic starts testing.
- There is no communication infrastructure for non-Ryan White programs.
- Individuals who have worked in the field for a long time are experiencing a learning curve and challenged by what to let go of; how to retool their work.

## Jails and Correctional Facilities

## HIV Testing in Corrections

-  Prisons  -- All provide HIV testing
-  Policies and State and Federal Statutes vary
-  Legislation has been proposed to change policies in some jurisdictions
-  Jails -- Less HIV testing
-  Survey, 18.5% since admission
-  Unknown how many inmates with HIV in custody
-  CDC Revised recommendations on HIV testing (9/06)

## CDC Activities

-  Advancing HIV Prevention: Demonstration Project on rapid HIV testing in Jails
-  4 States: 27 jails
-  Over 33,000 inmates
-  Notification of test result
- Link to services – inside jail & community services
- Florida and New York - continue to provide HIV testing

## CDC Activities - II

- Developing guidance document to make routine testing part of medical evaluation
- Collaboration with
- Health Departments
- Medical providers in corrections
- Department of Justice

## Other Settings

## HIV Screening in Other Settings

- Developing guidance in collaboration with SAMHSA and Division of STD Prevention.
- AAP is completing an online training program to help providers introduce HIV testing for adolescents in their practice.
- NMA is developing practice standards and training for physicians serving the African American Community.
- NMA is working in 5 mid-size cities to increase testing by primary care providers serving African Americans.

## HIV Screening in Other Settings - II

- SGIM will develop strategies to introduce HIV screening in residency programs and promote testing among their members.
- AMA and AAHIVM reaching out to other organizations to develop provider tools for primary care providers.

## State and Local Considerations

## State and Local Considerations

- Some require specific signed consent
- Some require specific counseling
- Screening can be implemented now within current laws, rules, and regulations

## Example: Texas Informed Consent Law

- Sec. 81.105.  Informed Consent.
-    (a) Except as otherwise provided by law, a person may not perform a test designed to identify HIV antibody without first obtaining the informed consent of the person to be tested.
- Sec. 81.106.  General Consent.
- 	(a) A person who has signed a general consent form for the performance of medical tests **is not required to also sign a specific consent** form relating to medical tests to determine HIV infection that will be performed on the person during the time in which the general consent form is in effect.

## Slide 41

## Future Activities

## New Rapid Testing Initiative (NRTI)

- In 2006 the President proposed $90 million for a rapid HIV testing program
- Congressional Justification for FY 2008 includes $63 million
- Goal:  to increase the proportion of HIV-infected persons that learn their status and to link them to medical care and prevention services.

## NRTI Secondary Goals

- Increase adoption of the Revised Recommendations
- Promote collaboration between HD, clinical entities and CBOs
- Allow HIV uninfected persons to learn their status and access prevention services
- Increase testing opportunities in geographic areas with greatest impact among African Americans

## NRTI Program Components

- Support testing in 10 jurisdictions with greates rates of new infections
- HIV screening will be offered in:
- Medical care settings
- Substance abuse treatment programs
- Correctional settings
- Funding to State Health Departments or City Health Departments

## Services Covered

- Rapid HIV tests
- Optional pre-test counseling
- Post-test counseling for HIV+
- Training and support for sites providing tests
- Linkage to medical care services
- Referral to local health departments for counseling, partner notification, testing of spouses and sex and drug using partners
- For drug users – linkage to substance abuse treatment and other effective interventions

## Expected Impact

|  | ~$63 million |
| --- | --- |
| # kits purchased | 2,051,075 |
| # persons tested (5% loss) | 1,948,522 |
| # infected |  |
| 1% positivity | 19,485 |
| 1.5% positivity | 29,228 |
| 2% positivity | 38,970 |

## Summary

**Testing is an important HIV prevention strategy**
**Testing is a key step in linking to care**
**Implementation of the revised testing recommendations will require new resources and new partnerships**
**Screening in health care settings is feasible**
**A number of activities to implement the recommendations are underway**