Embed Size (px)
Citation preview
Expanding HIV Screening in the Veterans Administration
Matthew B. Goetz, MD
Chief, Infectious Diseases, VA Greater Los Angeles HCS
Clinical Coordinator, QUERI-HIV/HCV
Professor of Clinical Medicine, David Geffen School of
Medicine at UCLA
What should be done for this patient?
54 yo male new dx HCV+; abnormal LFTs and chronic pruritis
PMH: Depression, viral pericarditis, GSW to thorax 1977
SHx: denies tobacco and ETOH, admits MJ; denies IDU
PE: Folliculitis 2 to pruritis, otherwise unremarkable
Lab: Hg 15.4 WBC 3.8 (47 P, 32 L, 12 M, 9 E), Platelets 105K,
ALT 59, AST 91, Alk P 55, bili 1.1, HCV Ab+, HCV VL 6,030,000
What should be done for this patient?
54 yo male new diagnosis HCV+; abnormal LFTs and chronic pruritis
PMH: Depression, viral pericarditis, GSW to thorax 1977
SHx: denies tobacco and ETOH, admits MJ; denies IDU
PE: Folliculitis 2 to pruritis, otherwise unremarkable
Lab: Hg 15.4 WBC 3.8 (47 P, 32 L, 12 M, 9 E), Platelets 105K
ALT 59, AST 91, Alk P 55, T bili 1.1, HCV Ab+, HCV VL 6,030,000
One month later: Admitted with 2 weeks SOB, cough
ABG: pH 7.48, PCO2 28, pO2 58;
CXR: diffuse reticulonodular opacities
HIV+, CD4 74, VL 37,000. Bronchoscopy PCP.
Despite Rx, died of progressive respiratory failure
Audit of 397 death in UK 2005: Scenario leading to AIDS-related deaths
% of AIDS
deaths
Diagnosed too late for effective Rx 40%
Under care with untreatable complication 29%
Treatment ineffective due to poor adherence 12%
Chose not to receive treatment 8%
Known positive, not under regular care 6%
MDR HIV, ran out of options 5%
BHIVA Audit – Johnson et al 2006
Benefit of HIV Therapy vs Diagnostic Delay
Antiretroviral therapy reduces HIV-related morbidity
and mortality, and reduces perinatal transmission,
but 21% of US HIV+ persons do not know their status
50% of newly diagnosed patients have < 200 CD4 cells
• High risk of AIDS-related complications
• Many patients have multiple, missed opportunities for early
testing
MMWR: Vol 57(39), 2008. Campsmith ML et al. JAIDS. 2010; 5:619-624.
Epidemiology
1.2 million HIV cases in US• Heterosexual transmission increasing most rapidly
• Women and minorities are disproportionately affected
MMWR: Vol 57(39), 2008. Campsmith ML et al. JAIDS. 2010; 5:619-624. CDC HIV Surveillance Reports.
Africa
n Am
eric
an
Hispan
ic
Multi
ple ra
ces
Nativ
e Haw
aiia
n
Cauca
sian
Amer
India
n Ala
ska
Nat
Asian
0400800
HIV Cases per 100,000 People
2005 2006 2007 2008 2009
Equal Case rate in AI/NA & Caucasians
American Indian
CDC and ACP Guidelines for HIV Testing
Early diagnosis of HIV reduces morbidity and mortality
HIV screening should not be contingent on an assessment of
patients' behavioral risk
Opt-out HIV screening recommended for all patients
• CDC recommends age range from 13 – 64; ACP has no upper bound
• Exception if HIV prevalence known to be < 0.1% of patients screened
At least yearly testing for people at high risk for infection
MMWR. 2006; 55(RR-14). Qaseem A, et al. Ann Intern Med. 2009; 150:125-131.
Screening and Testing for HIV is Cost Effective
QALY with consideration of HIV transmission
Testing in VA is cost effectiveeven at very low HIV prevalence
CDC recommends routine offer of HIV testing if prevalence of undiagnosed infection is > 0.1%
$50,000/QALY0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
0 0.2 0.4 0.6 0.8 1
Prevalence (%)
Incr
emen
tal C
ost
Eff
ecti
ven
ess
($/Q
ALY
) QALY without consideration of HIV transmission
Sanders GD, et al. NEJM. 2005; 352:570.
0.1
Survival Gains of ART Compared With Other Disease Interventions
Walensky R et al. JID 2006;194:11-19
020406080
100120140160180200
Node + Node – 2 vessel 3 vessel BMT OI Proph ART
Chemo/breastcancer
CABG/PTCA Lymph-oma
AIDS Care
Su
rviv
al G
ain
s (m
on
ths)
Frequency and Delayed HIV Diagnosis& Types of Missed Opportunites
USA (VA) (2007)
UK & Ireland (2005)
USA (2004)
Scotland (2004)
Canada (2004)
Italy (2004)
USA (2003)
USA (1998)
0% 20% 40% 60%
HIV Diagnosis with < 200 CD4 Cells (%)
Public facility: 1994 – 2001• 6 visits before HIV diagnosis
• 40% of visits were to either the
ED or to an urgent care clinic
VA data: 1998 – 2002 • 6 visits before HIV diagnosis
• Visits prior to diagnosis
- Primary care clinic: 56%
- Subspecialty clinic: 50%
- Psychiatry clinic 31%
- Substance abuse clinic: 16%
Girardi DE et al. (J Acquir Immune Defic Syndr 2007; 46: S3–S8. Gandhi NR et al. Med Care. 2007; 45:1105-1109. Samet J et al. Arch Intern Med. 1998; 158:734. Liddicoat R, et al. J Gen Intern Med. 2004; 19:349.
2005: Status of HIV Testing in the VA
No HIV testing in 50 – 70% of patients with known
risk factors
50% of newly diagnosed patients had < 200 CD4 cells
How were these problems addressed?
Identified Impediments to HIV Testing
Organizational barriers• Written informed consent & pre-test counseling requirements
• Constraints on provider time
• Uncertain capacity to manage newly diagnosed patients
Provider behaviors• Lack of recognition of HIV risk factors
• Discomfort with HIV counseling and discussion of risky behaviors
• Lack of prioritization of HIV testing
Patient behaviors• Fear of stigma
Interventions
Organizational changes• Streamlined, scripted & nurse-based consent process; verbal consent
• Telephonic notification of negative test results
• Assure assistance in counseling & HIV clinic f/u for new HIV+ pts
Provider behavior• Education through academic detailing & social marketing
• Regular clinic level feedback regarding HIV testing rates
• Electronic clinical reminder to identify previously untested patients
Patient fear of stigma
• Substitution of routine, non-risk based testing
How did the Electronic Medical Record (EMR) help the HIV testing program?
100% access to records
Able to identify patients not previously tested and
avoid repeatedly offering tests the previously tested
Able to identify patients at higher risk of disease
through lab results and ICD-9 codes
Able to use data to create reports, provide feedback
Decision support tools at point of care including
clinical reminders to providers
What does the VA Computerized Patient Record System (CPRS) look
like?
Cover Sheet
Problem List
Medications
Laboratory Results
Reports tab – imaging report
Progress Note Tab
Using CPRS-Based Decision Support (Clinical Reminders)
Used for a wide variety of purposes in the VA• Screening for depression, traumatic brain injury• Screening for Tobacco & alcohol use• Hypertension identification and management• Diabetes monitoring• Vaccination rates• Etc.
Contribute to attainment of performance standards HIV testing Clinical Reminder is among the simplest
and best accepted
Electronic prompt for identification and testing of patients at-risk for HIV infection
Implementation PlanIn-Person Launch Meeting
Met with facility leadership, e.g., COS and leadership of
nursing, laboratory, ambulatory care and primary care
Promoted program at primary care team meetings
• Consent process
• Emphasize that HIV testing is not a performance measure
• Tips for proposing HIV testing
Provide educational materials
Emphasized use of site-wide rather than provider-
specific feedback
Handout package
Pocket card
Overview Sheet Poster & Pamphlet
Tips for Proposing HIV Testing
Would you like a free HIV test? As a veteran, you’re entitled to an HIV test. In addition to doing some tests to check for
cholesterol, diabetes, etc., we’re now offering HIV
testing. Would you like us to check for HIV
infection?
Quarterly feedback• HIV testing rate• Rate of clinical
reminder resolution
VISN 22: Pre- vs Post Incident HIV Testing RateVA facilities in Southern California & Nevada
2 – 3 fold Increased Testing Rate, which is Sustainable
Intervention YearControl
Site A Site B Site C Site D Site E
0%
10%
20%
30%
40%
50%
60%
70%
80%
-1 1 2 -1 1 2 -1 1 -1 1 2 -1 1
Rem
ind
er R
eso
luti
on
(%
) HIV testing HIV evaluation without testing
Post vs Pre Odds Ratio of HIV Testing Analysis of Patient Level Factors
0 1 2 3 4
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
OtherMarried
SingleMissing
OtherHispanic
African AmericanCaucasian
HighLow
> 64 years51-64 years31-50 years
18 – 30 years
Post vs Pre Odds Ratio
Age
Income
Ethnicity
Marital status
Homeless
HCV Risk Fx
HCV Infection
HBV InfectionPrior STD
Illicit Drug Use
Goetz MB et al. J Gen Intern Med. 2008; 23:1200-1207.
Pre- vs Post-Intervention Risk-Based HIV TestingVA facilities in North-East and South-Central US
1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 30%
5%
10%
15%
20%
25%
30%
35%
Pre-Intervention Post-Intervention
Control Sites Local Implementation National Implementation
HIV
Tes
tin
g R
ate
Control Sites Local CentralNo Implementation Implementation
Implementation
Increase in Testing12% 78% 158%
2009 Changes in VA HIV Testing Policy
VHA Directive – HIV Screening
Current VHA policy: HIV testing is a part of routine
medical care
Providers should routinely provide HIV testing to all
Veterans who give verbal consent
Veterans who test positive for HIV infection are to be
referred for state-of-the-art HIV treatment as soon as
possible after diagnosis
VHA Directive 2009-036, August 17, 2009
2009 Changes in VA HIV Testing Policy
Organizational barriers• Informed consent & pre-test counseling requirements
• Constraints on provider time
• Limited opportunity for timely, in-person post-test notification
• Uncertain capacity to manage newly diagnosed patients
Provider behaviors• Incomplete recognition of HIV risk factors
• Reliance on trained counselors to order HIV tests
• Discomfort with HIV counseling
• Lack of prioritization of HIV testing
Use of verbal consent and routine testing removes only two barriers
Pre- vs Post-Intervention Routine HIV TestingMulti- VISN QI Project
1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 80%
5%
10%
15%
20%
25%
30%
Pre-Intervention Post-Intervention
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH-HHHH
HIV
Tes
tin
g R
ate
Control Sites Local CentralNo Implementation Implementation Implementation
Increase in Testing50% 390% 556%
VETERANS HEALTH ADMINISTRATION
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
Outpatient Visits n= 5,888,599
2010 2011
Outpatient Visits n= 6,114,034
20% Ever Tested n= 1,221,328
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
HIV
Tes
ts (
tho
usa
nd
s)Changes in HIV Testing vs
Use of HIV Testing Clinical Reminder
Sites without Clinical Reminder Sites with Clinical Reminder
2009 2010
VETERANS HEALTH ADMINISTRATION
Percentage of HIV Positive Tests in CY 2011, by VISN
19 23 11 2 17 6 21 18 12 10 20 1 4 15 3 9 7 8 5 16 220.0%
0.1%
0.2%
0.3%
0.4%
0.5%
0.6%
0.7%
% H
IV T
ests
Per
form
ed in
201
0 th
at w
ere
Posi
tive
VISN
Mean: 0.38%Median: 0.35%Range: 0.14-0.64%
*
*CDC Threshold for routine HIV testing
Increased Testing Results in Earlier Diagnosis VA Atlanta & VA Greater Los Angeles
2004
2005
2006
2007
2008
2009
2010
0%
10%
20%
30%
40%
50%
60%
CD4 Count < 200 Cells/µL
Los Angeles Atlanta2004
20052006
20072008
20092010
0
100
200
300
400
500
Mean CD4 Cells/µL
Los Angeles AtlantaGoetz MB, Rimland D. J AIDS. 2011. 57:e23-e25.
Summary of Results
Routine HIV testing is feasible in primary care clinics
Routine testing increased by 390 – 556%
Clinical reminders based technology to promote HIV testing is widely effective and may not require a specialized intervention
Promotion of routine HIV testing in primary care clinics supports the CDC goal that every American aged 13 – 64 know their HIV status
Summary of Justification for Promoting HIV Testing in VHA
HIV care is most effective with early diagnosis
US HIV prevalence generally exceeds CDC testing
threshold
HIV Testing is not cost-free but is an excellent use of
healthcare dollars
ACP recommends offering HIV testing to all adults
Effective interventions have been developed
HIV Consensus
Early diagnosis and treatment improves outcomes
Undiagnosed & infected persons cannot benefit from HAART
Early stage patients are asymptomatic
Antiretroviral therapy decreases risk of disease transmission
Patients who know their status reduce their to others
HIV Testing is cost-effective & allows patients to get treatment
Acknowledgements
VA HSR&D funding: QUERI cord funds, SDP 06-001, SDP 08-002
VA Office of Public Health: moral, financial and logistical support
Local leaders, clinical champions, primary care providers, facility leadership in VISNs 1, 3, 16 and 22
QUERI-HIV/HEP colleagues: Steve Asch, Allen Gifford, Jane Burgess, Tuyen Hoang, Hersch Knapp, Henry Anaya and many, many others
