Kristina Cesa, MPH

ORISE fellow, Division of HIV/AIDS Prevention

Office of the Director

CDC’s Expanded HIV Testing Program: Successes, Best Practices and Lessons

Learned

1

National HIV Prevention Conference

Atlanta, GA

August 14-17th, 2011

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Division of HIV/AIDS Prevention

Advancing HIV Prevention: New Strategies for a Changing Epidemic, 2003

� Strategy 1

• Make HIV testing a routine part of medical care

� Strategy 2

• Implement new models for diagnosing HIV infections outside medical settings

� Strategy 3

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� Strategy 3

• Prevent new infections by working with persons diagnosed with HIV and their partners

� Strategy 4

• Further decrease perinatal HIV transmission

MMWR 2003;52:329-32

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in

Health-Care Settings

� HIV screening in all health-care settings for adults ages 13-64 years

• Opt-out testing strategy

� Persons at high risk for HIV infection should be screened annually

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annually

� General consent for medical care should encompass consent for HIV testing

� Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings

� HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women

MMWR 2006;55 (No.RR-14)

PS07-768: Expanded and Integrated Human

Immunodeficiency Virus (HIV) Testing for Populations

Disproportionately Affected by HIV, Primarily African

Americans

� Purpose:

1. Increase testing opportunities for populations disproportionately affected by HIV, primarily African Americans

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affected by HIV, primarily African Americans

2. Increase the proportion of HIV-infected persons in these populations who are aware of their infection and are linked to medical care

PS07-768: Expanded HIV Testing Program

� Annual Goals:

1. Test 1.5 million persons

2. Identify 20,000 previously undiagnosed HIV infections

� Project length: 3 years (Oct 2007 – Sept 2010)

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� Total Funding: $111,211,614

� Venues: Clinical settings (at least 80%)Non-clinical settings (no more than 20%)

MA

NYC

NJ

ChicagoWA

OR

ID

MT

WY

ND

SD

MN

WINY

ME

MI

NH

VT

PA

RI

CT

PS07-768: Funded Jurisdictions¹

Eligibility: At least 140 AIDS cases (estimated) among African Americans in 2005

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Washington, D.C.

1Represents 95% of AIDS cases among African Americans in the United States in 2005

Los Angeles County CA

NV

WY

UT

AZNM

CO

NE

KS

OK

TX

IA

MO

AR

LA

MS AL GA

FL

ILIN

KY

TNSC

NC

VAWV

PADE

MD

Houston

CT

OH

Funded in Years 1-3

Funded in Years 2-3

Philadelphia.

Number of HIV Tests, Positive Tests, and Positive Test Rates

October 2007 – September 2010

Total Clinical Settings Non-Clinical Settings

Tests Done 2,786,739 2,519,917 (90%) 266,822 (10%)

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Confirmed HIV+ 29,503 23,546 (80%) 5,957 (20%)

New HIV+ 18,432 15,478 (84%) 2,954 (16%)

Previous HIV+ 11,071 8,068 (73%) 3,003 (27%)

New HIV+ Rate 0.7 0.6 1.1

Data Source: APR Year 1–3

Number of HIV Tests, New Positive Tests and New Positive Rate in Years 1 – 3

Year 1 Year 2 Year 3

HIV Tests 458,014 1,021,181 1,307,544

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New Positive Tests 4,029 6,821 7,582

New Positive Rate 0.9% 0.7% 0.6%

Data Source: APR Year 1–3

Proportion of HIV Tests and New HIV Positives by Race/Ethnicity

October 2007 – September 2010

60%

70%

60%

80% HIV TestsNew HIV PositivesNew Positive Rate, %

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18% 16%

5%

14% 12%

5%

0%

20%

40%

Black/AA White Hispanic Other/Unknown*

Race/Ethnicity

Perc

en

t

0.8 0.5 0.5

* Includes American Indian/ Alaskan Native, Asian, Native Hawaiian/ Pacific Islanders, multiple race and unknown

Proportion of HIV Tests and New HIV Positives by Gender

October 2007 – September 2010

55%

45%

72%

60%

80%

HIV TestsNew HIV PositivesNew Positive Rate, %

10

45%

<1%

27%

1%0%

20%

40%

Male Female Other*

Perc

en

t

Gender

New Positive Rate, %

0.9 0.4

* Includes transgender and unknown categories

Venues Funded Under PS07-768Year 3 (October 2009 – September 2010)*

20%

30%

281

183

270

315

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* (n=1,331)

0%

10%

Emergency Departments

STD Clinics Correctional Health

Facilities

Substance Abuse

Treatment Centers

Community Health

Centers

Community Based

Organizations

Other**

108

7698

** Includes Inpatient Medical Units, Urgent Care Clinics, Substance Abuse Treatment Centers, TB Clinics, and miscellaneous

Distribution of HIV Tests and New Positive Testsby Venue Type

October 2007 – September 2010*

30%

20%

32%

30%

40%HIV TestsHIV PositivesNew Positive Rate, %

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* (n=2,562,124)

20%

17%15%

6%

11%

20%

12%14%

11% 11%

0%

10%

20%

Emergency Departments

STD Clinics Community Health Centers

Correctional Health Facilities

Community Based Organizations

Other **

0.7 0.6 0.5 0.6 0.6

** Includes Inpatient Medical Units, Urgent Care Clinics, Substance Abuse Treatment Centers, TB Clinics, and miscellaneous

1.2

New HIV-Positives by Selected OutcomeOctober 2007 – September 2010

Total Clinical Settings

Non-Clinical Settings

New HIV-Positives 18,432 15,478 2,954

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New HIV+ Receiving Test Results

91% 93% 84%

New HIV+ Linked to Medical Care

75% 78% 63%

New HIV+ Referred to Partner Services

83% 83% 82%

Data Source: APR Year 1–3

CDC Cost per Test and New HIV DiagnosisOctober 2007 – September 2010

Year 1 Year 2 Year 3

Tests 458,014 1,021,181 1,307,544

Cost/Test $58 $36 $30

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Data Source: APR and grantee financial status reports year 1 – 3

New Positives 4,029 6,821 7,582

Cost/New Positive

$6,634 $5,346 $5,163

PS07-768: Barriers & Challenges

� Start-up delays

� New partnerships

� Provider resistance

� Laws and policies

Operational issues

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� Operational issues

� Technical assistance/training

� Data management

� Reimbursement

PS07-768: Lessons Learned

� Testing Strategy: Opt-out vs. Opt-in

� Difficult to identify a profile to capture all those at risk/unaware of infection

� Opt-out screening reaches clients who otherwise would not have been tested

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tested

� Opt-out HIV screening in high prevalence areas maximizes case finding value

PS07-768: Lessons Learned

� Test Technology: Rapid vs. Conventional

� Rapid Testing Models:

• Increase receipt of preliminary results

• Decrease the number of clients lost to follow up

• More feasible in settings with dedicated testing staff

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� Conventional Testing:

• Reduces disruptions to clinic flow associated with point-of-care testing

• Feasible in clinical settings where routine blood tests are ordered as a standard of care

• Reduces the overall costs of testing

• Using multi-platform analyzers increases the volume of tests and decreases the turn around time for results

PS07-768: Lessons Learned

� Staffing Model: Integrated vs. Parallel

� Parallel Models:

• Minimum effect on the clinic flow

• Better acceptance from staff

• More expensive and require additional space

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� Integrated Models:

• More difficult to initiate due to:

o Perceived burden on clinic flow

o Extensive training requirements

• Requires getting buy-in from staff

• More cost effective and increase sustainability

PS07-768: Lessons Learned

� Sustainability

� Identifying and maximizing all possible sources of funding

� Building community support and cultivating program champions

� Implementing innovative strategies

• Cost effective staffing models

• Low cost testing models

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• Low cost testing models

� Develop a “business case” for routine testing

PS 07-768: Lessons Learned

� Bottom Line:

Routine HIV screening in healthcare settings

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Routine HIV screening in healthcare settings WORKS!

PS10-10138/ PS12-1201: Expanded HIV Testing for Disproportionately Affected Populations

� Purpose:

� To sustain progress made under announcement PS07-768

� To expand routine testing services to new clinical venues to reach a broader array of at-risk populations.

� Target Population:

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� Target Population:

� African American and Hispanic men and women

� MSM and IDUs, regardless of race or ethnicity

� Grantees: � Expanded to 30 state, territorial and local health departments

under PS10-10138

� Eligibility further extended to 36 jurisdictions under PS12-1201

PS10-10138/ PS12-1201: Expanded HIV Testing for Disproportionately Affected Populations

� Objectives: (when fully implemented)

1. Conduct ≥ 1.3 million tests

2. Identify ≥ 6,500 undiagnosed HIV infections

3. Receipt of test results (≥ 85% of positives)

4. Linkage to medical care (≥ 80% of positives)

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4. Linkage to medical care (≥ 80% of positives)

5. Linkage to partner services (≥ 80% of positives)

6. Receipt of prevention counseling and/or referral to prevention services (≥ 80% of positives)

7. Sustainability

8. Service Integration

Acknowledgments:

Co-authors:

� Christopher Brown

� Sam Dooley

� Erica Dunbar

Benny Ferro

Additional Acknowledgments:

Nadia Duffy

Abigail Viall

PS 07-768 Grantees

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� Benny Ferro

� Priya Jakhmola

� Marlene McNeese-Ward

� Kimberly Thomas

� Cathy Yanda

Kristina Cesa404-639-6418

Kcesa@cdc.gov

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For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention