Future of HIV in VA

VETERANS HEALTH ADMINISTRATION

Future of HIV in VAOffice of Public HealthDepartment of Veterans Affairs

Maggie Czarnogorski, MDDeputy Director, HIV, Hepatitis, and Public Health Pathogens [email protected]

April 2012


Office of National AIDS Policy


National HIV/AIDS Strategy Goals

• Reducing New HIV infections • Improving Access to Care and Health Outcomes• Reducing Health Disparities• Working across federal agencies


Engagement in Care Cascade:VA vs. Community

Gardner EM, et al. Clin Infect Dis. 2011;52:793-800

HIV Infecte

d

HIV Diagnosed

Linked to

Care

Retained in HIV Care

Need Antiretrovira

l Therp

ay

On Antiretrovira

l Therapy

Undetectable

0

5000

10000

15000

20000

25000

3000023,863 23,761

20,282 18,53617,685

13,163

Number and Percentage of Veterans HIV Engagement in Care VA 2012

30,000

25,000

20,000

15,000

10,000

5,000

0


VA HIV Testing Policy Changes August 17, 2009 • VA National HIV Testing Policy revised

– After Section 124 repealed, VA was able to revise policy to promote widespread routine HIV testing

– Routinely offer HIV testing to all Veterans– Eliminate written informed consent and prescribed pre- and post-

test counseling– Verbal consent still required and must be documented in medical

record– Written educational materials about HIV testing must be provided to

patients

VHA Informed Consent Handbook 1004.01: August 17th, 2009

VHA Directive 2009-036, August 17, 2009


VA HIV Testing Rates: Data Collection Methods• Data Extract Routine installed at all facilities to

generate HIV test reports by Calendar Year (CY)• Data collected on all outpatients in that CY

– Number with HIV test ever done – Number with HIV test done in that CY – Number with positive result in that CY

• In 2011, added Gender, Race/Ethnicity, Age information


Veterans Ever Tested for HIV by Year2009-2011

9.2% Ever Tested n=524,267

2009

Outpatient Visits n= 5,713,265

13.5% Ever Tested n= 795,126


2010 2011


20% Ever Tested n= 1,221,328


Percent of Veterans EVER Tested for HIV, by VISN: 2009, 2010, 2011

0%

5%

10%

15%

20%

25%

30%

35%200920102011

VISN

Perc

ent O

utpa

tient

s EVE

R Te

sted

for H

IV


Percentage of HIV Positive Tests in CY 2011, by VISN

0tan18a566018

0tan22a566022

0tan10a566010

0tan1a56601

0tan16a566016

0tan5a56605

0tan20a566020

0tan17a566017

0tan11a566011

0tan9a56609

0tan19a566019

0tan29a566029

0tan3a56603

0tan14a566014

0tan2a56602

0tan8a56608

0tan6a56606

0tan7a56607

0tan4a56604

0tan15a566015

0tan21a566021.000%

.100%

.200%

.300%

.400%

.500%

.600%

.700%

% H

IV Te

sts P

erfo

rmed

in 2

010

that

wer

e Po

sitiv

e

VISN

Mean: 0.38%Median: 0.35%Range: 0.14-0.64%

*

*CDC Threshold for routine HIV testing

0.7%

0.6%

0.5%

0.4%

0.3%

0.2%

0.1%


Percentage EVER Tested by Race/Ethnicity – CY2011

Hispanic (N=295,900)

American Indian/Alaska Native (N=43,677)

Asian/Pacific Islander (N=93,341)

Black (N=839,702)

White (N=3,957,475)

Unknown Race (N=1,267,025)

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

33.20%

22.54%

23.12%

37.21%

17.59%

15.93%


Percentage EVER Tested by Age and Gender – CY2011

Under age 30 Age 30 to 49 Age 50 to 69 Age 70 and older

0%5%

10%15%20%25%30%35%40%45%50%

25.22% 27.27%

22.97%

9.89%

34.11% 35.74%

28.68%

9.5%

MaleFemale


Gender and Age of Veterans with HIV Positive Test Results in CY 2011 (n= 2,149)

6.75%

Gender

MaleFemale

6.42%

30.11%57.5

6%

5.86%

Age

Under 3030 to 4950 to 6970 and older

93.25%


HIV Seropositivity in CY 2011 by Age and Gender

Under age 30 Age 30 to 49 Age 50 to 69 Age 70 and older

.000%

.100%

.200%

.300%

.400%

.500%

.600%

.700%

0.41%

0.65%

0.43%

0.14%0.17%

0.26%

0.55%

0.22%

MaleFemale

0.0%

0.7%

0.6%

0.5%

0.4%

0.3%

0.2%

0.1%


HIV Seropositivity in CY 2011 by Race/Ethnicity

Hispanic (N=44,291)

American Indian/Alaska Native (N=4,363)

Asian/Pacific Islander (N=9.857)

Black (N=123,177)

White (N=298,341)

Unknown Race/Ethnicity (N=95,661)

-.0020 .0000 .0020 .0040 .0060 .0080 .0100

0.39%

0.55%

0.38%

0.78%

0.28%

0.31%

0.8%0.6%0.4%0.2% 1.0%0.0%


VA National HIV Testing Data for 2009, 2010 and 2011

Variable 2009 2010 2011

Number of Veterans with an outpatient visit in CY

5, 713, 265 5, 888, 599 6, 114, 034

Number and % of Veterans with an outpatient visit ever tested for HIV

524, 267 (9.2%)

795, 126 (13.5%)

1,221,328(20.0%)

Number of Veterans with HIV tests performed in CY

142, 345 341, 414 523,361

Number of Veterans with HIV positive tests in CY

1,739 2,233 2,149

Seropositivity rate of Veterans tested in CY

1.2% 0.7% 0.41%

Abbreviations: CY= calendar year; HIV = human immunodeficiency virus


VA Initiatives to Improve HIV Testing Rates 2009-2011• Legislative and Policy Changes

– Verbal consent for testing– Routine offer of HIV testing to Veterans

• Routine HIV test clinical reminder• Funding for facility-level quality improvement projects

– Clinical HIV testing– Laboratory– Women’s Health– Homeless Veteran Stand Downs

• Social marketing campaign


Conclusions• VA is the largest US provider of HIV care• The quality of HIV care VA provides is excellent • The percentage of Veterans ever tested for HIV more than

doubled in two years• Many Veterans in VA care have still not been tested for HIV• In 2011, all VISNs had an HIV seropositivity rate above the

CDC threshold (>0.1%) for routine HIV testing • Routine HIV testing is warranted in VA• VA will continue to provide timely linkage of care


The Future• Continued Excellence of Care• Improve Access and Expand Workforce– Telehealth/SCAN-ECHO– Patient Centered Teams

• Targeted approaches with Special Populations to decrease disparities– New Veterans– Women– Homeless, Incarcerated– Regional


Office of Public Healthwww.hiv.va.gov

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Future of HIV in VA