HIV Screening and TestingHIV Screening and TestingSan Francisco Area

AIDS Education and Training Center

University of California, San Francisco

at San Francisco General Hospital

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About this PresentationAbout this PresentationThese slides were developed by the UCSF San Francisco Area AIDS Education and Center as a component of the SFAETC HIV Screening and Testing Training Curriculum Guide. The intended audience is experienced AETC trainers, clinical faculty, and training participants.

Users are cautioned that concepts of HIV management and clinical care continue to evolve rapidly, and this information may become outdated. The information contained herein is not intended to constitute or substitute for medical advice from a licensed health care professional.

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Welcome!Welcome!

Please sign in Please complete:

1. Participant Information Form & Pre-Test

(“bubble form”) NOW

2. Program Evaluation & Post-Test Later Please silence cell phones and pagers

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Learning ObjectivesLearning Objectives

At the end of this session you will be able to: Explain rationale for revised HIV screening

recommendations Clarify definitions of “HIV testing” Review CDC routine HIV testing recommendations Discuss HIV testing modalities Apply routine HIV screening recommendations in

clinical practice

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HIV Testing:HIV Testing:

James Curran, dean of public health at Emory University and director of the university's Center for AIDS Research,

was head of the Centers for Disease Control task force as the HIV epidemic unfolded in the early 1980s.

19851985

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HIV Testing: 2008HIV Testing: 2008

A 38 year-old man presents to urgent care with complaints of burning while urinating for the past 2 days. He denies fevers, flank pain, or penile discharge. He is sexually active with both men and women and uses condoms sporadically.

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Would you include an HIV test as Would you include an HIV test as part of his visit?part of his visit?

1. Yes

2. No

3. Maybe/Depends

4. I have no idea

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HIV Testing: 2008HIV Testing: 2008

A 38 year-old man presents to clinic to establish care. His only complaint is of a sore ankle for the past week after an injury while playing soccer. He states he is otherwise healthy.

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Would you include an HIV test as Would you include an HIV test as part of his visit?part of his visit?

1. Yes

2. No

3. Maybe/Depends

4. I have no idea

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Case DiscussionsCase Discussions

Answer for both case scenarios: YES!!YES!!

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According to the CDC, what According to the CDC, what percentage of people infected percentage of people infected with HIV in the U.S. do not know with HIV in the U.S. do not know they are infected?they are infected?

About 25%About 25%

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The CDC has estimated that The CDC has estimated that approximately how many approximately how many persons in the U.S. become persons in the U.S. become infected with HIV each year?infected with HIV each year?

Approximately 56,000 per yearApproximately 56,000 per year

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HIV Incidence in the U.S.HIV Incidence in the U.S.180

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HIV Incidence in the U.S.HIV Incidence in the U.S.

Transmission is higher among people unaware of infection

Risk behavior is reduced with awareness of HIV+ status:

68% reduction in unprotected sex

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What we’ve learned so far . . . What we’ve learned so far . . .

Individuals remain untested Routine HIV testing reduces stigma Routine HIV screening is highly

effective: Perinatal transmission reduced from

25-30% to <2% w/ interventions

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CDC Recommendations: CDC Recommendations: ObjectivesObjectives

Increase HIV screening Detect disease earlier ID & counsel HIV+ patients Link patients to services Further reduce perinatal

transmission

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CDC Recommendations: CDC Recommendations: Routine Testing for HIVRoutine Testing for HIV

Routine, voluntary testing for all patients ages 13-64

“Opt-out” testing; no separate consent for HIV

Pretest counseling not required

Repeat testing at provider’s discretion

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DefinitionsDefinitionsThe “Old”

Opt-in screening: performing an HIV test after assessing patient’s risk, obtaining informed consent, and conducting pre-/post-test counseling

The “New”

Opt-out screening: performing an HIV test after notifying patient that the test will be done; consent is inferred unless patient declines

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DefinitionsDefinitions

Routine testing: performing an HIV test for all persons in a defined population

Diagnostic testing: performing an HIV test for persons with clinical signs or symptoms of HIV infection

Targeted testing: performing an HIV test for subpopulations of persons at higher risk based on behavioral, clinical or demographic characteristics

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So, Who Should Be Tested?So, Who Should Be Tested?

Everyone ages 13-64 in all healthcare settings

Everyone beginning treatment for TB Everyone seeking treatment for STDs All pregnant women For all: no separate consent or required

prevention counseling (“opt-out”)

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Who Needs Repeat Testing?Who Needs Repeat Testing?

High-risk patients: Who is included? How frequently?

Anyone engaging in a new relationship Occupational exposure to blood or bloody

fluid which can contain HIV Pregnant women in 3rd trimester in high HIV

prevalence areas

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Law??Law??

Recommendation??Recommendation??

State HIV Testing Laws Compendium

http://www.ucsf.edu/hivcntr

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CA HIV/AIDS Testing BillCA HIV/AIDS Testing Bill

AB 682: Effective January 1, 2008 Paves the way for HIV screening to be a

routine part of medical care Repeals written informed consent for HIV

testing Patient can decline test and if so, should be

noted in chart

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Necessary DocumentationNecessary Documentation

Accepts test:

(Nothing!)

Declines test:

“Patient declines HIV test”

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Group DiscussionGroup Discussion

1. “What SHOULD BE” Advantages and disadvantages of routine HIV testing

2. “What IS” Misconceptions about HIV testing Barriers to implementation

3. “What COULD BE” Changes needed to implement HIV testing as part of

routine medical care

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HIV Testing . . . ???HIV Testing . . . ???

Rapid?

ELISA?Western Blot?

Blood test?

Oral test?

UniGold?

OraQuick?

IFA?

Confirmatory?

False positive?

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How is HIV Diagnostic Testing How is HIV Diagnostic Testing Done?Done?“Gold Standard:”

ELISA followed by Western Blot confirmatory test or immunofluorescence assay (IFA)

Detects antibody to HIV virus Usually takes a few days for results May not be positive during window period Indeterminate result possible

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Window PeriodWindow Period

Virus in Blood

Antibodies Detected

Window PeriodWindow Period

Infection

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The Indeterminate TestThe Indeterminate TestWestern Blot: looks for antibodies to specific HIV proteins

and demonstrates presence by a change in color. Indeterminate Result: Some, but not all, bands are present. Causes: recent infection; advanced HIV; certain strains of HIV; cross reaction to other antibodies; HIV vaccine; lab error

Next Steps: Retest in >6 weeks. Risk counseling if

indicated.

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The Indeterminate TestThe Indeterminate Test

Column 1: Positive Control

Column 2: Negative Control

Column A: Negative Test

Column B: Indeterminate Test

Column C: Positive Test

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ELISA: ~25% do not return for test results of standard test

RAPID TESTS: Only ~2% leave before results of rapid HIV test

The ELISA HIV Test: The ELISA HIV Test: Perils of WaitingPerils of Waiting

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Rapid HIV TestsRapid HIV Tests

Uni-Gold Recombigen

Reveal G2

Multispot HIV-1/HIV-2

OraQuick Advance

Stat Pak

Complete

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A patient has a rapid HIV test performed A patient has a rapid HIV test performed and it is positive. What does this and it is positive. What does this mean?mean?

A. Patient has HIV.

B. Patient most likely has HIV: repeat rapid test now.

C. Patient most likely has HIV: order a Western Blot or IFA.

D. Unclear if the patient has HIV: do another rapid test after window period.

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Rapid HIV TestsRapid HIV Tests

Results available in < 1 hour Most easy to perform High specificity: negative means negative

except during window period! High sensitivity: positive means likely

positive BUT…

Important! Positive rapid test results must be confirmed for HIV diagnosis!

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Group DiscussionGroup Discussion

1. What are the advantages and disadvantages to using the rapid HIV test?

2. What changes would need to occur in your healthcare setting to implement use of the rapid HIV test?

3. What would you tell patients before and after running a rapid test?

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SummarySummary

All persons ages 13-64 should be screened for HIV

No need for written informed consent or counseling

High risk patients should be screened more frequently

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ResourcesResources http://www.hivtest.org/

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ResourcesResourcesAETC National Resource Centerhttp://www.aids-etc.org/

AIDSinfoDHHS Treatment Guidelineshttp://aidsinfo.nih.gov/

Centers for Disease Control & Prevention (CDC)http://www.cdc.gov/hiv/default.htm

HIV InSitehttp://hivinsite.ucsf.edu/InSite

National HIV/AIDS Clinicians’ Consultation CenterWarmline, PEPline, Perinatal HIV Hotlinehttp://www.ucsf.edu/hivcntr/

Pacific AETChttp://www.ucsf.edu/paetc