HIV Counseling and Testing

Thomas J. Coates, PhDMichael and Sue Steinberg Professor of Global AIDS Research

Director, UCLA Center for World Health

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Varieties of Community HCT ModalitiesFacility-based

Mobile

House-to-house

Index

Self-testing

Workplace

School

Church

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VCT: Historical Perspectives: 1985Antibody tests licensed

(protect the blood supply)

Anonymous testing the norm

Had to include pre- and post-test counseling

Strong testing campaigns in the US

Not so much in Europe

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VCT: Historical Perspectives: 1985$70m allocated for AIDS research

Ryan White refused entry to middle school

Rock Hudson dies at UCLA

First AIDS conference in Atlanta

hosted by WHO and CDC

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VCT: Historical Perspectives: 1986Reagan says “AIDS” for the first time and vows to make

AIDS a priority (thank you Elizabeth Taylor)

National Minority AIDS Council formed

First panel of AIDS quilt sewn

HIV is named

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VCT: Historical Perspectives: 1987Global Program on AIDS launched at WHO

AZT approved

ACT UP founded by Larry Kramer

First National Conference on HIV and Communities of Color in New York

First candidate vaccine tested

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VCT: Historical Perspectives: 1987CDC testing guidelines released

Ray house burned in Florida

Western Blot test approved

Liberace dies of AIDS

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VCT: Historical Perspectives: 1988

Helms Amendment passes;

Presidential AIDS Commission formed

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VCT: Historical Perspectives: 1989Precursor to the Ryan White Care Act

funded by Congress

100,000 reported AIDS cases in the US

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VCT: Historical Perspectives: 1990Ryan White dies

Ryan White Care Act passed by Congress

HIV prevention counseling model adopted by the CDC--client-centered approach

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VCT: Historical Perspectives: 1991HOPWA enacted

CDC recommends restrictions on HIV+ health care workers

First National Skills Building Conference hosted by NAPWA

Magic Johnson announces that he has AIDS

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VCT: Historical Perspectives: 19928th International Conference on AIDS moved from

Boston to Amsterdam

AIDS is the #1 cause of death for men 25-44

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VCT: Historical Perspectives: 19928th International Conference on AIDS moved from

Boston to Amsterdam

AIDS is the #1 cause of death for men 25-44

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VCT: Historical Perspectives: 1993President Clinton establishes the

Office of National AIDS Policy at The White House

CDC establishes the community planning process to better target local prevention efforts

Philadelphia released

Angels in America receives the Tony

Case definition of AIDS expanded (<200 CD4)

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VCT: Historical Perspectives: 1994AIDS is the leading cause of death

for all Americans 25-44

Randy Shilts and Peter Zamora die

AZT recommended for pregnant HIV+ women to prevent mother-to-child transmission of HIV

NIH addresses the appropriate inclusion of women and minorities in HIV clinical research

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VCT: Historical Perspectives: 1995Greg Louganis discloses that he has HIV

Eric Lynn Wright (Eazy-E) dies one month after being diagnosed with HIV

500,000 cases of AIDS reported in the US

First White House Conference on AIDS convened

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VCT: Historical Perspectives: 1996HAART unveiled at Vancouver AIDS Conference

Number of reported AIDS cases declines for the first time in the US

UNAIDS formed

AIDS Memorial Quilt covers the entire Mall in DC

Ryan White Care Act reauthorized

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VCT: Historical Perspectives: 1997AIDS deaths decline

Combination therapy approved by FDA

UNAIDS estimates 30m people with HIV worldwide

Clinton establishes goal of HIV vaccine in 10 years

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VCT: Historical Perspectives: 1998African-Americans account for 49% of AIDS-related

deaths; AIDS related mortality 10x that of whites and 3x that of Latinos

Clinton announces a special package of initiatives aimed at HIV in minority communities; Minority AIDS Initiative

passed by Congress with $156m

Shalala announces that needle exchange programs are effective

The Supremes say that the ADA covers people with HIV

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VCT: Historical Perspectives: 1999WHO announces that AIDS is the 4th biggest killer

worldwide; 33m infected; 16m have died

VaxGen vaccine trial starts in Thailand

Clinton announces new global initiative for HIV

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VCT: Historical Perspectives: 2000United Nations Security Council discusses AIDS as a

global security issue (#1 for any health issue)

Durban AIDS Conference

Clinton announces Executive Order to permit developing countries to import generic drugs

Global AIDS and Relief Act of 2000

Ryan White Care Act reauthorized

We announce the results of our study of HCT

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VCT: Historical Perspectives: 2001UN Secretary Kofi Annan calls for the global AIDS fund

“war chest”

US Secretary of State Colin Powell reaffirms that HIV/AIDS is a national security threat

First Annual National Black AIDS Awareness Day in the US

World Trade Organization announces DOHA Agreement to allow developing countries to buy or manufacture

generics

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VCT: Historical Perspectives: 2002UNAIDS reports that women comprise about half of all

adults living with HIV/AIDS worldwide

HIV is leading cause of death worldwide among those aged 15-59

Approval of OraQuick rapid HIV-1 Antibody Test by FDA; first rapid test to use finger prick

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VCT: Historical Perspectives: 20033 by 5 Initiative announced by WHO

South Africa announces new antiretroviral treatment programs

William J. Clinton Presidential Foundation secures price reductions for HIV/AIDS drugs to benefit

developing nations

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VCT: Historical Perspectives: 2004Global Fund holds first Partnership Forum in Bangkok

with 400 participating dleegates

UNAIDS launches the Global Coalition on Women and AIDS

PEPFAR, President Bush’s Emergency Plan for AIDS Relief, begins first round of funding

OraQuick Rapid HIV-1 Antibody Test approved for use with oral fluid by FDA

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VCT: Historical Perspectives: 2005World Economic Forum in Davos priorities include a

focus on addressing HIV/AIDS in Africa

First Annual National Asian and Pacific Islander HIV/AIDS Awareness Day in the United States

Ranbaxy is the first Indian drug manufacturer to gain US FDA approval to produce generic antiretrovirals for

PEPFAR

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VCT: Historical Perspectives: 2006First Annual National HIV/AIDS Awareness Day in the

US

CDC recommends routine HIV in health care settings

First Annual National Women and Girls HIV/AIDS Awareness Day in the US

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VCT: Historical Perspectives: 2007President Bush calls on Congress to reauthorize

PEPFAR at $30b over 5 years

WHO and UNAIDS issue guidance recommending ‘provider initiated’ HIV testing in health care settings

WHO and UNAIDS recommend that male circumcision should always be considered as part of a comprehensive

HIV prevention package

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VCT: Historical Perspectives: 2008US Congress reauthorizes PEPFAR for 5 years at up to

$48b

17th International AIDS Conference

”Universal Action Now” in Mexico City

First Annual National Gay Men’s HIV/AIDS Awareness Day in the United States

CDC releases new HIV incidence estimates for the US, showing that the US epidemic is worst than thought

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VCT: Historical Perspectives: 2009

Newly elected President Obama calls for the first ever National HIV/AIDS Strategy

The Obama Administration lifts HIV travel and immigration ban by removing regulatory barriers to entry

US Congress eliminates long-standing statutory ban on the use of Federal funding for needle exchange in the US

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VCT: Historical Perspectives: 2010

Obama Administration releases first comprehensive HIV/AIDS strategy for the US

South African investigators announce the results of CAPRISA004 showing that the use of a microbicide gel

reduces risk of HIV infection by 39%

iPrEx shows that the daily dose of a Truvada reduced risk of acquiring HIV among MSM by 43%

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VCT: Historical Perspectives: 2011

HHS launches the 12 Cities Project to focus resources on the areas with the highest AIDS burden in the country

Secretary Clinton and President Obama announce the goal of an AIDS-free generation

HPTN 052 demonstrates the importance of treatment as prevention

Elizabeth Taylor dies

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VCT: Historical Perspectives: 2012

FDA approves OraQuick In-Home Test

The first rapid over-the-counter rapid test that can be bought over the counter and read at home

Truvada approved for PrEP

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Varieties of Community HCT ModalitiesAcceptance of Testing

Mobile—87%

House-to-house—80%

Index—88%

Self-testing—87%

Workplace—67%

School—62%

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Principles of HIV Counseling and Testing

Screening donor blood and cellular products

Diagnosis of HIV infection (sensitivity and specificity)

Human rights (confidential, counseling, informed consent)

Confidentiality

Anonymous testing

Routine testing

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Uptake of HCT (Suthar et al, PLoS Medicine, 2013)

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Community HCT Modalities

Increased testing uptake—RR=10.65 (6.27-18.08)

Proportion of first-time testers—RR=1.23 (1.06-1.42)

Proportion of testers CD4 > 350—1.42 (1.16-1.74)

Lower positivity rate—RR=0.59 (0.37-0.96)

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