# Presentation: 045175

## CDC’s HIV Testing Initiatives

- Bernard M. Branson, M.D.
- Associate Director for Laboratory Diagnostics
- Division of HIV/AIDS Prevention
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
- U.S. Centers for Disease Control and Prevention

**CDC’s HIV Testing Initiatives**

## Awareness of HIV Status among 

- Estimated new infections          56,300
-    annually
- Number HIV infected           1,106,400
- Number unaware of
-   their HIV infection 	   	232,700  (21%)

- Awareness of HIV Status among
- Persons with HIV, United States

*Campsmith M et al, MMWR October 2008*

*Hall I, et al  JAMA August 2008*

## HIV/AIDS Diagnoses among Adults and Adolescents, by Transmission Category — 33 States, 2003–2006 

- MSM
- 66%

- IDU
- 13%

- Heterosexual
- 16%

- MSM/IDU 5%

- Other 0.5%

- Males
- (n ≈ 100,000)

- Females
- (n ≈ 52,000)

- Heterosexual
- 79%

- IDU
- 20%

- Other 1%

*HIV/AIDS Surveillance Report, 2006*

## New HIV Infections

- Test specimens from people newly diagnosed with HIV with BED assay (differentiates recent from long-standing infections)
- Compare with HIV case reports, testing and treatment history
- Estimate the number of new infections using mathematical models

## Estimated Percentage of New HIV Infections, by Sex and Age 50 U.S. States & DC, 2006

**Men, 73%**

**Women, 27%**

**13-29, 34%**

**30-39, 31%**

**40-49, 25%**

**50-99, 10%**

## Estimated Percentage of New HIV Infections, by Transmission Category

**Men who have sex with men, 53%**

**Men who have sex with men and inject drugs, 4%**

**Injection drug users, 12%**

**Heterosexual contact, 31%**

**50 U.S. States & DC, 2006**

*- 2006 HIV Incidence Surveillance, JAMA 2008*

## Estimated HIV/AIDS Prevalence and U.S. Population by Race/Ethnicity, 2006

**White, not Hispanic**

**Black, not Hispanic**

**Hispanic**

**Asian/PI**

**35%**

**46%**

**18%**

**66%**

**12%**

**15%**

**5%**

**1%**

**HIVAIDS Prevalence**

**U.S. Population**

*- HIV Prevalence Estimates, MMWR 2008*

## Estimated Percentage of New HIV Infections, by Race/Ethnicity

**White, 35%**

**Black, 45%**

**Hispanic,**
** ****17%**

**Asian/Pacific Islander****, 2%**

**American Indian/Alaska Native****, 1%**

**Estimated Percentage of New HIV Infections, by Race/Ethnicity**

**50 U.S. States & DC, 2006**

## Estimated Rates of new HIV Infections by Race/ethnicity 50 U.S. States & DC, 2006

- Total Male: 34.3 per 100,000

- Total female: 11.9 per 100,000

## HIV Prevalence, NHANES 1999-2002

** ****White **
**M**

**White **
**F**

**Black ****M**

**Black **
**F**

** ****Hispanic **
**F**

** ****Hispanic **
**M**

** ****White **
**M**

**White **
**F**

**Black ****M**

**Black **
**F**

** ****Hispanic **
**M**

** ****Hispanic **
**F**

- Age 18-39 years

- Age 40-49 years

*- McQuillan et al, NCHS:  JAIDS April 2006*

- Prevalence of HIV Antibody

## National Health Interview Survey

- Annual, cross-sectional household probability sample of the U.S. population conducted by National Center for Health Statistics
- Provides estimates for a broad range of health measures for the U.S. population, including HIV testing.

## HIV Testing: 2006

- 40% of adults tested for HIV at least once
*Estimated 71.5 million persons*
- 10.4% tested in the preceding 12 months
-  *Estimated 17.8 million persons*

*- Duran et al, MMWR, August 2008*

## Persons Tested, Preceding 12 Months

| White | 8% |
| --- | --- |
| Black | 22% |
| Hispanic | 13% |
| Risk factors? |  |
|      Yes | 23% |
|      No | 10% |
| Pregnant? |  |
|      Yes | 61% |
|      No | 13% |

*-Duran et al, MMWR August 2008*

*2006 National Health Interview Survey*

## Where were persons tested for HIV?

|  | 2003 | 2006 |
| --- | --- | --- |
| Private doctor/HMO | 44% | 53% |
| Hospital, ED, Outpatient | 22% | 18% |
| Community clinic (public) | 9% | 9% |
| HIV counseling/testing | 5% | 5% |
| Correctional facility | 0.6% | 0.4% |
| STD clinic | 0.1% | 0.1% |
| Drug treatment clinic | 0.7% | 0.4% |

*- 2006 National Health Interview Survey*

## Percent of Persons Ever Tested and Tested in the Preceding 12 Months - NHIS 2002-2006 

*- MMWR   August 8, 2008*

**Notes:**
Percent of persons who reported ever being tested for HIV are represented by the red line and among those who reported a test in the preceding 12 months are represented by the yellow line. This trend chart shows a steady increase in the percentage of persons ever having an HIV test from 6% in 1987 to 39% in 2002. This percent has been constant from 2002-2006, between 39% and 40%, although 10-11% of respondents each year reported having an HIV test in the preceding 12 months. A possible explanation for this finding is that the people who are having an HIV test every year are the same (i.e., repeat testers), which in fact won’t have any effect on the ever tested line.

In 2006, 40% of the adults 18-64 y/o living in the Unites States indicated ever having an HIV test, which is equivalent to 71M of the U.S. population. For the same year, among those who reported having an HIV test, 10% indicated it was conducted in the preceding 12 months, which is an estimated 18 M people.

This data suggest that a change has been needed in HIV testing strategy to increase the number of people having an HIV test at least once in their lifetime and to identify unaware HIV infected individuals.

## Early Indications of Progress

|  | Ever Tested | Last 12 months |
| --- | --- | --- |
| 2005 | 70,036,336  (39.9%) | 18,042,610  (10.4%) |
| 2006 | 71,468,420  (40.4%) | 17,775,006  (10.4%) |
| 2007 | 73,848,002  (41.3%) | 18,791,895  (10.7%) |

## Legal or Regulatory Constraints

- 2006 CDC Recommendations:
- Opt-out testing with the option to decline after notifying the patient testing will be done
- No separate written informed consent in health-care settings

## Legal or Regulatory Constraints

- At the time of CDC’s 2006 recommendations, 20 states had laws or regulations that required written informed consent for HIV testing.

## Legislative Changes Since 2006

- Arizona
- California
- Iowa
- Illinois
- Indiana
- Louisiana

- Maine
- Maryland
- New Hampshire
- New Mexico
- North Carolina

-  11 states have removed written informed consent    	requirements:

## Legislative Changes Since 2006

- Hawaii
- Massachusetts
- Nebraska
- New York
- Connecticut

- Pennsylvania
- Rhode Island
- Wisconsin
- Michigan

-  7 states proposed legislation to remove written 	consent that was not enacted:

-  No legislative action regarding written consent 	requirements in 2 states:

## www.nccc.ucsf.edu

**www.nccc.ucsf.edu**

## Examples: Expanded Testing Programs

## Expanded HIV Testing Initiative:New York Health and Hospitals Corporation

- Largest municipal health-care delivery system in the U.S. for New York City residents
- 4,934,000 annual visits
- 19,000 patients with HIV infection in care
- Signed informed consent for HIV testing

## Annual Unique HIV Tests

**56,212**

**58,785**

**92,123**

**133,859**

**160,900**

## Number of Positive HIV Tests More Than Doubled

**670**

**720**

**1514**

**1630**

**1863**

## Not All Positive Tests Represent New HIV Diagnoses

**1514**

**1630**

**1863**

**774**

**864**

**767**

## Percent of Patients with a Concurrent AIDS Diagnosis

**FY06**

**FY07**

**FY08**

**Notes:**
 This is concurrently diagnosed in the reporting month
Potential Policy Impact Requiring Further Study:Routine HIV testing at HHC will reduce the number of patients who receive a concurrent AIDS diagnosis

## 44% of Unique Eligible Patients Have Now Been Tested for HIV

- 6.3%

- 9.3%

- 13.4%

- 15.5%

## President’s Testing Initiative

- Increase HIV testing opportunities for populations disproportionately affected by HIV- primarily African Americans who are unaware of their HIV status.
- $35 million awarded September 2007 to 23 jurisdictions with highest number of AIDS cases among African Americans

## Expanded HIV Testing Initiative:  Chicago

- Initiated October 2007
- Rapid testing in
- 4 emergency departments
- 6 STD clinics
- Correctional health facility
- 3 CBO clinics

## Expansion of HIV Testing, Chicago Oct 2007- Sept 2008

*Source: HIV Counseling Testing and Partner Services Unit, Division of STD/HIV/AIDS,  Chicago Department of Public Health*

**Provisional data as of 10/16/08**

## HIV Tests and Positive Tests, Chicago, Oct 2007- Sept 2008

|  | 
HIV Tests | New HIV Positive |
| --- | --- | --- |
| Emergency Depts | 12,685 | 115 (0.9%) |
| STD Clinics | 21,259 | 203 (1.0%) |
| Corrections | 6,468 | 58 (0.9%) |
| CBO clinic | 2,021 | 44 (2.0%) |
| Total | 42,433 | 420 (1.0%)  |

*Source: HIV Counseling Testing and Partner Services Unit, Division of STD/HIV/AIDS,  Chicago Department of Public Health*

**Provisional data as of 10/16/08**

## Race/Ethnicity of Persons with Positive HIV Diagnosis Chicago, Oct 2007- Sept 2008

*Source: HIV Counseling Testing and Partner Services Unit, Division of STD/HIV/AIDS,  Chicago Department of Public Health*

**Provisional data as of 10/16/08**

**African American, 71%**

**White, 19%**

**Hispanic, 8%**

**Asian-Pacific Islander, 1.4%**

**Other/Unidentified, 0.8%**

## Expanded HIV Testing Initiative:  Florida

- Rapid testing in
- 30 Medical settings
- 8 emergency departments
- 17 primary care clinics
- 4 community health centers
- 1 urgent care clinic
- 10 STD clinics
- 10 jails
- 10 CBOs
- 10 mobile units
- 1 substance abuse treatment center

## HIV Tests and Positive Tests, Florida, Oct 2007- July 2008

|  | Total tests | HIV-Positive (%) | New Positive (%) |
| --- | --- | --- | --- |
| Medical settings | 6,897 | 163 (2.4%) | 151 (1.2%) |
| STD clinics | 7,737 | 156 (2.0%) | 92 (1.2%) |
| Jails | 8,216 | 78 (0.95%) | 60 (0.7%) |
| CBO | 18,954 | 605 (3.2%) | 340 (1.8%) |
| Mobile unit | 2,321 | 37 (1.6%) | 32 (1.4%) |
| Drug treatment | 403 | 3 (0.7%) | 2 (0.5%) |
| Total | 44,528 | 1,042 (2.3%) | 677 (1.5%) |

## HIV tests and Positive Tests, Florida, Oct 2007 – July 2008

- Total tests in clinical settings:        25,574 (57%)
- New HIV infections:                      335 (1.3%)
- Total tests, non-clinical settings:    18,954 (43%)
- New HIV infections:		    342 (1.8%)

## Race/Ethnicity of Persons with New Positive HIV Diagnosis Florida, Oct 2007- July 2008

**African American, 66%**

**White, 15%**

**Hispanic, 18%**

**Other/Unidentified, 0.9%**

- Race/Ethnicity of Persons with New Positive HIV Diagnosis Florida, Oct 2007- July 2008

## Capacity Building

- Eight regional workshops for hospitals and emergency departments to develop strategic plans for HIV testing in EDs:
- New York		-- Washington DC
- Hartford		-- Miami
- Philadelphia	-- Boston
- Raleigh		-- San Antonio

## Capacity Building

- HRSA’s AIDS Education and Training Centers:
- Training and technical assistance for more than 20,000 health-care providers at 1,000 training sessions in 10 regions
- National Resource Center clearinghouse for informational materials and toolkits
- National Clinician Consultation Center “warmline” for health-care providers

## Remaining Challenges

- “Not my job”
- Too daunting to screen such large numbers
- Interferes with primary mission and patient flow
- Reimbursement

## Summary

- Signs of Progress
- Reduction in percentage of persons unaware of their infection from 25% to 21%
- The number of persons who have had an HIV test increased by 1.4 million in 2007
- Reductions in late diagnosis in NY hospitals after expanded HIV testing
- Legislative changes in 11 states to facilitate HIV testing in health-care settings

## Acknowledgements

- NYC Health and Hospitals Corporation
- Terry Hamilton
- Drew De Los Reyes
- Chicago Department of Public Health
- Will Wong

- Florida Bureau of HIV/AIDS
- Marlene Lalota
- CDC Program Evaluation Branch
- Denise Duran

- The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention