Universal HIV Screening: Putting Policy into Practice in Hard-to-Reach Populations:

American Indians/Alaska Natives (AI/AN)

IOM WorkshopHIV Access and Testing

April 15, 2010

RADM Scott Giberson, RPh, PhC, M.P.H.IHS National HIV/AIDS Program

Rockville, MD

AI/AN HIV Epidemiology*

• Incidence rates, 2007: AI-AN = 14.6/100K (Rank 3rd )

• Est. # living with HIV/AIDS roughly 3,500+. • Rate of HIV Dx for AI/AN men (17.7per 100K) and for females

roughly 4.6/100K. • Similar time from HIV to AIDS of all races/ethnicities • Shortest time (with African American) from AIDS diagnosis

to death. *• Most MSM/IDU combo of any ethnicity *• AI/AN youth at higher risk (YBRS, BIA/CDC 2002)

* CDC HIV/AIDS Surveillance Report 2006, Released Feb 2009:

http://www.cdc.gov/hiv/topics/surveillance/united_states.htm

Rates of HIV/AIDS / 100K*

9.5

11.110.1

11.1 10.6

8.8

12.8

8.7 8.8 8.5 9 98.2

9.2

0

2

4

6

8

10

12

14

2001 2002 2003 2004 2005 2006 2007

AI/AN

Caucasion

* 33-state HIV/AIDS Surveillance Data through 2006; 34-states in 2007

(Adults/Adolescents/Children)

Solutions: IHS HIV/AIDS Program Goals 3-Year Expansion

• Assist AI/A N individuals in becoming aware of HIV serostatus - Support CDC revised HIV testing recommendations.

• Decrease risk through education, open communication, and the reduction of stigma

• Ensure access to quality health services, including people living with HIV/AIDS

• Form sustainable collaborations with Tribes, community stakeholders, states, federal agencies and other HIV partners

• Be transparent, culturally fluent and accountable

Success in I/T/U Expanded HIV Testing

• Data may suggest successful methodology or implementation model

• HIV-adapted ecological model of public health

• Prenatal HIV screening rate from 54% to 82%. (4 yrs)

• Expanded HIV testing to over 50,000 tests per year. 4-fold increase since 2001.

• Champion efforts at multiple levels of influence.

• Implemented Policy reform and partnered with Tribes

• Over 39 IHS/Tribal/Urban sites now implementing universal HIV testing including policy change.

Integrate Intervention Model into Priority Areas

Integrate Intervention Model into Priority Areas

PolicyPolicyCapacity BuildingCapacity Building

Preven-tion

Preven-tion

Tx & CareTx & Care

AdvocacyAdvocacy

Research / Epidemiology

Research / Epidemiology

Monitoring and Evaluation

Monitoring and Evaluation

Intervention Model

Broad sociocultural / traditionalism/ spiritual

Constructed Environment

Community

Individual

Clinical / Facility

IHS Prenatal HIV Screening Rates2005-2009

Impact: Prenatal HIV ScreeningImpact: Prenatal HIV Screening

Source: GPRA Data 2005-2009

Perc

ent

Year

54

65

7479 82

0

20

40

60

80

100

2005 2006 2007 2008 2009

% PrenatalScreeningRate

Impact:Expanded/Universal HIV Screening

• Data from latest ‘patch’ into our operating RPMS system. Aggregate, non-identifiable numbers:

Number of HIV screens performed:GRPA Year Number

2001 12,0422007 46,6792008 51,052

Federal/State/Local Barriers to Testing

• State policies/resources (Ryan White, ADAP, etc) located in areas where hard-to-reach populations cannot access

• Anecdotally, state restrictions on comprehensive health or sexual health education, many AI/AN are unaware of the risks

• Variation in state laws: (qualifications of those allowed to perform an HIV test, consent regulations, provider education)

• Federal resources specific for HIV in AI/AN are very limited. Capacity to build partnerships with states/local are limited

• Concern of Insurance companies’ use of information and data• Federal funding fiscal year restriction. Service delivery in AI/AN

(especially rural areas) is largely through IHS/Tribal sites and can’t be programmed throughout the year when funding is fiscally tied. This is a barrier to testing programs if non-appropriated funding streams are utilized (i.e. MAI)

Available AI/AN Data Re: Implementation of HIV Testing

1. IHS HIV GPRA data available now (ongoing):• Prenatal HIV Testing • Universal HIV Testing• Bundled HIV Testing (STI/HIV)

2. Physician and Nurse Perspectives on Implementation of Universal Adult HIV Screening Guidelines in IHS. Randomized Respondent-Driven Survey and Respondent Driven Site Survey

3. Case Study: Syphilis Outbreak and HIV Testing

4. Case Study: Universal HIV Testing Sites

5. Case Study: Urban Expanded Testing

6. Ongoing data being collected from over 39 I/T/U sites

1. IHS Physician and Nurse Perspectives n=205

• 70% supported routine, rather than risk-based testing

• 51% stated HIV screening would be realistic in their facility.

• 43% felt community HIV prevalence was below the 0.1% threshold

• 49% felt they needed special qualification to offer HIV Test.

• 49.2% stated that separate written consent was necessary.

Conclusions: Majority of IHS physicians and nurses support the 2006 Revised CDC HIV Testing guidelines. Providers need more information and training on HIV Testing guidelines, implementation strategies, and state HIV regulations.

2. Case Study: STI OutbreakLessons Observed

• Streamlining - New testing policy created in conjunction with Tribal health authorities. Bundle STD/HIV screening

• Education- Intense community outreach with local media• Transparency - Patients aware of new testing policy• Stigma - Testing all patients decreased stigma• Acceptance - Costs billable to state/federal programs.

Time streamlined with clear division of labor reduced time (Nurse, Doctor, Lab). Verbal consent only, flexible counseling decisions

• Interviews with health care workers: • 88% said patient acceptance high or very high• 61% said new testing policy added negligible time

to consults• 93% said wider testing policy should continue

Perceived or Credible Barriers

• State law (consent, minors)• Patient acceptance

– Confidentiality– Stigma

• Provider acceptance– 30% familiarity with CDC Revised Guidelines– Cost– Counseling/time– Relevancy (low HIV prevalence)

Actions Taken

• Attitudes toward universal HIV screening indicate opportunity and barriers

• New testing policy created in conjunction with Tribal health authorities

• Integrate STDs and HIV testing• Tailor testing age range to correspond with

epidemic• Intense community education with local media

and organizations

Outcomes: Acceptance

• Patient acceptance– Testing all patients decreased stigma– Patients aware of new testing policy– Confidentiality with tx by both MDs, PHNs

• Provider acceptance / importance– Costs billable to state and federal programs– Time streamlined with clear division of labor

reduced time (Nurse, Doctor, Lab)– Verbal consent only, flexible counseling decisions

Survey of Direct IHS sites (Federally owned/operated- 15 respondent sites)

• 77% worked with AETC• 62% changed HIV policy in writing• 69% bundle HIV as STD panel• Wide range of costs for tests ($5-$75)• Long range to referral sites (Average distance

over 100 miles with minimum near 50 miles)

3. Case Study: Pilot Universal Testing Site Lessons Observed

• Ongoing initiative with FY08 funding• 4 Aberdeen Area sites implementing expanded

screening• Implementation across multiple levels of influence

(facility, tribal, Area-level, IHS)• Focus on sustainability

– Policy changes– Provider support– Tribal Support through resolution

• Anecdotal increase in patient acceptance• Begin to reduce stigma: outreach efforts• Success story

4. Case Study: Urban Universal TestingLessons Observed

• Minority AIDS Initiative Funding: 2007-2009• Now 15 of 21 “capable” Urban clinics (75%)

implemented expanded HIV testing• Urban Provider Survey conducted• Successful implementation

– Acceptance of additional responsibility– Assurance of confidentiality– Policy and procedures change to streamline and

sustain– Patient acceptance

Gaps in Knowledge

• Prior HIV Testing overwhelmingly limited to women. • Use of IT system to monitor rates of bundled

screenings (STIs/HIV). Clinical and Surveillance tool.• Sustainability concern - exhaustion of external funding • Client perspectives need to be flushed out more • Testing leads to increase in PLWH/A. Need for

additional innovate linkages to care and continuity of care for harder-to-serve populations.

• More evidence on routinization of testing as a stigma reduction methodology.

• Require more data collection on implementation models.

Key Discussion Points

• Gender disparity in testing needs to be corrected - follow epidemiology.

• Women must continue to be universally tested. Prenatal to continue. Set goal of 100%

• Stigma, complacency, and support for HIV preventive services needs focused attention

• Competing Priorities + Lower Perceived Risk + Resource Constraints = Reactive Paradigm. This needs to change.

• Need improved models to link to care and provide care.• Implementation of HIV testing within AI/AN through

ecological model has been observed to improve partnerships, HIV services, and Native HIV network.

Key Discussion Points• Rapid HIV tests not widely utilized in IHS. Conventional

testing has been instrumental to develop routinization in expansion to universal screening.

• Broad support has been observed from IHS providers for testing. Providers need more information on HIV testing guidelines, implementation, and state regulations.

• Anecdotally, clients have been receptive to expanded HIV Testing, however dependent on ‘how’ test is offered

• Education – how can we be more effective to change risk behavior and/or risk-perception?

• Create ‘One-message’ to improve trust/transparency for hard-to-reach populations

Overall Lessons ObservedTo date, anecdotal and objective data indicate:

• Policy needs to change early in the process• Need to collaborate with Tribes for improved

transparency and trust in system. • Education of Providers and nurses: ensure HCWs

aware of new testing policy and its rationale• Have clear protocol for patient follow up, including

linkages to care and social services as needed• Have partners to demonstrate successful

implementation• Integrate HIV and STD testing• “Seed money” and local champion drive local success