HIV testing in North
Carolina- A pathway to
Universal Access
Peter A. Leone, MD
Professor of Medicine
University of North Carolina
Medical Director
NC HIV/STD Prevention and
Care NCDHHS
Stemming the Tide of HIV
Transmission in the United States
• Number Infected
• 1,039,000-1,185,000
• Number unaware of their
HIV infection
• 220,000-250,000
(~21%)
• Estimated new infections
annually
• 56,000
• Those with unrecognized
infection account for ~51%
of new infections
• ~29,000
• Onset of symptoms or illness acts as a cue for testing
42% of HIV positive in U.S. tested due to illness (MMWR
2003)
Glynn M, Rhodes P. 2005 HIV Prevention Conference
HIV incidence
Hall et al, JAMA 2008
HIV Diagnosis in Men
Hall et al. JAIDS 2009
Estimates of New Infections, 2006, By Race/Ethnicity, Risk Group,
and Gender,
for the Most Affected U.S. Subpopulations*
Impact of HIV/STD on MSM
• HIV: 53% all new infections
• Syphilis: 65% all P&S infections
• Evidence of growing role in other STD
– GC (20+% of cases in GISP)
– Prevalence of GC, CT underestimated due to
limited rectal, pharyngeal screening
– Outbreaks of LGV
• High rates of HIV co-infection (syphilis 40-60%,
GC 5-10%)
HIV/STD disparities among
African-Americans in the U.S.
Est. annual
incidence
HIV
GC
CT
P&S syphilis
Trichomoniasis
HSV-2
56,000
718,000
2.8 m
11,500
7.4 m
1.6 m
Based on:
HIV estimated incidence (JAMA 2008)
STD Surveillance 2007
NHANES assessments of HSV-2 and Trichomoniasis
Weinstock Persp Sex Rep Health 2004
B:W Incidence /
Prevalence Ratio
7:1
18:1
8:1
6:1
10:1
3:1
% all cases
in blacks
45%
70%
48%
46%
59%
30%
HIV Incidence is High Among
African American MSM
• HIV incidence among African American men
aged 15-22
4%
• HIV incidence among African American men
aged 23-29
15%
MMWR, HIV incidence among young MSM – 7 US Cities, 1994-2000, June 01,
2001
African American MSM have very high
HIV prevalence rates and unrecognized
infection
HIV infection and Unrecognized Infection
among MSM, 5 US Cities, aged >18:
Black, Non-Hispanic
46%
(67%)
White, Non-Hispanic
21%
(18%)
Multiracial
19%
(50%)
Hispanic
17%
(48%)
Other
13%
(50%)
MMWR, HIV Prevalence, unrecognized infection and HIV Testing among MSM
– 5 US Cities, June 2005, April, 2005, June 24, 2005.
HIV Prevalence: General US
Population
Add Health1:
Young adults
(%, 95% CI)
NHANES2:
Aged 18 to 39
(%, 95% CI)
NHANES2:
Aged 40 to 49
(%, 95% CI)
Whites
0.022 (0, 0.64)
0.26 (0.05, 1.24)
0 (0, 0.45)
Blacks
.492 (0.18, 0.87)
1.42 (0.71, 2.84)
3.58 (1.88, 6.71)
White men
n/a
0.52 (0.11, 2.45)
0 (0, 0.89)
White women
n/a
0 (0, 0.31)
0 (0, 0.92)
Black men
n/a
1.93 (0.77, 4.72)
4.54 (2.24, 8.97)
Black women
n/a
1.01 (0.36, 2.84)
2.78 (1.00, 7.45)
n/a, not available.
1. Morris M et al. Am J Public Health. 2006;96(6):1091-1097.
2. McQuillan GM et al. J Acquir Immune Defic Syndr. 2006;41(5):651-656.
2005 HIV PREVALENCE REPORTED IN
UNAIDS 2006 REPORT ON THE GLOBAL AIDS
EPIDEMIC
Burkina Faso
Cameroon
Ghana
Rwanda
Senegal
Uganda
Cambodia
India
Haiti
PREVALENCE (%)
2.0
5.4
2.3
3.1
0.9
6.7
1.6
0.9
3.8
UNAIDS. 2007 AIDS Epidemic Update
HIV 2006 (incidence estimates)
22 States Participating
NC ranked 4th (FL, NY, LA)

NC



2,356 persons
(32.2/100,000) - 40%
higher than the US
NC





Males represented 72%
Blacks represented 67%
Black rate was 9 times the
rate for whites
US
56,300 persons
(22.8/100,000)
US



Males represented 73%
Blacks represented 45%
Black rate was 7 times the
rate for whites
Communicable Disease Surveillance Unit
AHI in North Carolina
• AHI were more likely to be adolescents (≤21 years
old) and less likely to be women vs. prevalent
infection
• 28% of AHI (N=35) were adolescents of whom
51% (N=18) were identified from 2007-2008
(versus 2002-2006, p=0.03).
• Adolescent AHI were predominately MSM of
color (74%), compared to only 23% of adult
acutes (p< 0.0001).
Kuruc et al. IAS 2009
N.C. Population and new HIV
Disease Reports, 2007
22%
Black,
non-Hispanic
62%
68%
White,
non-Hispanic
28%
Asian/PI, 2%
AI/AN, 1%
7%
Population
Hispanic
8%
HIV Disease
Communicable Disease Surveillance Unit
Asian/PI, <1%
AI/AN, 1%
NC adult/adolescent HIV disease
2007
IDU
5%
Males
MSM/IDU
3%
Hetero
sexual
19%
Females
Other
5%
Other
1%
MSM
72%
Heterosexual
86%
IDU
9%
Communicable Disease Surveillance Unit
Disparities for Males 2007 HIV Disease
15.7/100,000 White males
 85.2/100,000 Black or African American males
(more than 5 times that of Whites)
 38.0/100,000 Hispanic males
(more than 2 times that of Whites )

Communicable Disease Surveillance Unit
Disparities for Females 2007 HIV Disease



2.8/100,000 White females
42.9/100,000 Black or African American
females (more than 15 times that of Whites)
12.2/100,000 Hispanic females
(more than 4 times that of Whites)
Communicable Disease Surveillance Unit
Late HIV Diagnosis in North Carolina
• ~35,000 living with HIV
• Each year ~ 25 - 30 percent of new HIV
disease cases in North Carolina represent
persons diagnosed concurrently with both HIV
infection and AIDS.
19
8
19 7
8
19 8
8
19 9
9
19 0
9
19 1
9
19 2
9
19 3
9
19 4
9
19 5
9
19 6
9
19 7
9
19 8
9
20 9
0
20 0
0
20 1
0
20 2
0
20 3
0
20 4
0
20 5
06
Rate (per 100,000) .
AIDS Rates 1987-2006:
U.S. and N.C.
45
40
35
NC
Year of Report
US
30
25
20
15
13.9
10
12.7
5
0
Missed opportunities for HIV
diagnosis in the South
• In a South Carolina there were 4315 cases of HIV
reported between 2001-2005)*
– 41% had AIDS diagnosis within 1 year of AIDS diagnosis
– 16.5 had AIDS diagnosis within 30 days
– Of 1748 late testers, 1303 (~75%) had a health care
visit(s) from 1997-2005.
•
•
•
Number of health care visits with no HIV test: 7988 (average 4
per person
Visits with diagnosis that should trigger HIV testing: 1711
No risk at visit: 6277
* CDC MMWR Weekly Report Dec. 1, 2006
Identification of HIV Status to
Reduce Transmission
• Goal of new CDC recommendations to increase
number who know HIV+ status
• People do not perceive risk
• Clinicians do not offer test
• Stigma more with “identified” risk and infection
less so with testing itself
• Knowing HIV+ status can reduce transmission by:
- Behavior change
- Addressing Co-morbidity
- HAART reducing viral load
MMWR 55:1-7, 2006
Inungu J. AIDS atient Care STDs 16:293, 2002
New CDC Recommendations
In health care settings:
· HIV screening is recommended in all health care settings,
after notifying the patient that testing will be done unless
the patient declines (opt-out screening)
· Persons at high risk for HIV infection should be screened
for HIV at least annually
· Separate written consent for HIV testing is not required.
General consent for medical care is sufficient to
encompass consent for HIV testing
· Prevention counseling need not be conducted in conjunction
with HIV testing
Knowledge of HIV Infection and
Behavior
Reduction in unprotected anal or vaginal intercourse with HIV
Negative partners - HIV positive aware vs HIV positive unaware:
68% (95% CI: 59%–76%)
Source: Marks G, et al. Meta-analysis of high risk sexual behavior, aware vs unaware. JAIDS. 2005
Forth coming CDC Recommendations for
HIV testing in non-health care settings
• Single positive EIA is adequate for referral
• Ryan White Funds can be used for initial
evaluation and confirmation
• Strong component for linkage and retention
to care – 50% by 3 months; 75% by 6 mo.
• Further define frequency of testing for high
risk individuals
North Carolina Rules and
Statutes
Branch Strategies for HIV

Expand and make HIV testing routine

Continue NC STAT program

Get newly diagnosed persons into care

CD4 and Vl on all newly Dx individuals

Keep persons diagnosed with HIV in care
Communicable Disease Surveillance Unit
Changes to NC Administrative Code
Nov. 1, 2007
• Opt-out HIV screening in medical settings and for
prenatal and STD visits
• Pretest counseling not required
• Post-test counseling required only for positives
• HIV tests at first prenatal visit and 3rd trimester
• Mandatory HIV test at L&D for all women for
whom HIV status is unknown and in infant if test
not obtained from mother
Further Modification to “Routinize”
HIV testing in Medical Care Settings
"Testing for HIV may be offered as part of
routine laboratory testing panels using a
general consent which is obtained from the
patient for treatment and routine laboratory
testing,so long as the patient is notified that
they are being tested for HIV and given the
opportunity to refuse testing."
Web site addresses
• For CDC testing guidelines, go to
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
• For the changes to North Carolina testing rules, go to
http://www.epi.state.nc.us/epi/hiv/regulations.html
• For epidemiological data in North Carolina, go to
http://www.epi.state.nc.us/epi/hiv/stats.html
North Carolina HIV Testing
Initiatives
•
•
•
•
•
•
•
DOC opt-out screening
Jail Screening 28 county sites
ED screening/testing- 3 EDs in Triangle
Rapid HIV testing in 25 counties
Community Health Centers screening
GRGT
Free Neonatal testing (2010)
HIV Tests North Carolina DHHS
Laboratory
300000
250000
200000
150000
100000
50000
0
2001
2002
2003
2004
2005
2006
2007
2008
2009
Communicable Disease Surveillance Unit
North Carolina HIV Disease Reports
3000
2650
2237
2044
2000
1702
1551
2053
1822
1594
1800
1500
1000
500
Communicable Disease Surveillance Unit
20
09
20
07
20
05
20
03
20
01
19
99
19
97
19
95
19
93
19
91
19
89
19
87
19
85
0
19
83
# of reports .
2500
NC ED in Syphilis HMA
Missed opportunities
142,470 visits to the ED during the study period
420 (0.3%) patients had an HIV test 6% positive (25/420)
554 (0.4%) patients had an RPR test 5.8% positive
(32/554)
Agreement between RPR and HIV test orders was low
(kappa = 0.35, 95% CI: 0.30, 0.40).
Only 31% (173/554) of patients receiving an RPR test also
had an HIV test performed. Of these, 8 (4.6%) tested
positive for HIV and 15 (8.7%) tested positive for syphilis;
4 (2.3%) were co-infected with both HIV and syphilis
Klein et al CDC STD Prevention Conference 2010
North Carolina AHI Initial Presentation to
Care
50%
n=128
45%
40%
36%
35%
30%
25%
20%
15%
10%
5%
21%
17%
11%
5%
2%
5%
1%
1%
1%
0%
Communicable Disease Surveillance Unit
McKellar et al. North Carolina Acute HIV Infection Research Consortium 2009
1%
Number of healthcare visits
prior to diagnosis of AHI
•
•
•
•
Diagnosed at first contact
51 (40%)
1 visit before HIV diagnosis 41 (32%)
> 2 visits before HIV diagnosis 25 (20%)
Previous data suggested 52% of AHI seen >3x
before diagnosed with AHI
Weintrob 2001
McKellar et al. North Carolina Acute HIV Infection Research
Consortium 2009
Geography Aint enough:
Still Not Getting to the
Infected Population
RIOT Forsyth
603 Screened for Syphilis and HIV
3 new syphilis cases
4 new HIV Identified
GRGT at Winston Salem State:
158 tested for HIV
157 tested for syphilis
No new positives for HIV or syphilis
One recent AHI : 11 HIV+ , 10 new syphilis dx,
7 co-infected (N=16)
Planned vs. Actual HIV Testing
<25% of individuals reporting medium or high risks
reported an HIV test in the previous year.
Those with a medium or high self-perceived HIV risk, and
with heavier alcohol consumption did not match intent to
test with actual testing
The difference between intent and actual testing higherrisk > lower-risk groups regardless of whether tests
obtained for any reason or only voluntary
Ostermann et al. Arch Intern Med 2007
NC Delay to HIV Testing
• Over one-quarter of patients reported
delayed seeking an HIV test for over 4
years.
• Patients who reported HIV infection in
more recent calendar years had a shorter
duration of testing delay.
Self-reported HIV testing delay in North Carolina
S Napravnik APHA 2009
Late Entry into Care
UNC HIV Clinic 2000-03
• SE reports greatest proportion of AIDS cases and
deaths1,2
• On presentation, HAART indicated for3:
– 75% of patients based on CD4 count, HIV RNA level,
and an AIDS clinical condition
– 71% solely on CD4 count
– 78%, 57%, and 84% of patients entering HIV care
≤1 year, 1-2 years, and >2 years from HIV diagnosis,
respectively (p=0.02)
1. CDC. First 500,000 AIDS cases–United States, 1995. MMWR Morb Mortal Wkly Rep 1995;44(46):849-53.
2. CDC. Update: AIDS–United States, 2000. MMWR Morb Mortal Wkly Rep 2002;51(27):592-5.
3. Gay CL et al. AIDS. 2006;20(5):775-8.
Why are we not getting to folks
•
•
•
•
•
•
•
•
Stigma of risk
Stigma of HIV Infection
Lack of access to health care or no primary care
Co-morbidities
HIV not perceived as lethal disease
Testing as “risk reduction”
Delay in linkage to care
Sero-sorting
Mental Illness and Substance Abuse
NC HIV Infected Individuals
Whetten et al. Southern Medical Journal 2005
Pence et al. JAIDS 2005
NC HIV Comorbidity
Mental Illness:
- mood disorders (32% past year/21% past month)
- anxiety (21%/17%)
Substance use:
22%/11%
50% with past-year disorders and 40% with past-month disorders met the
criteria for multiple diagnoses
Comorbidity was associated with younger age, White non-Hispanic
race/ethnicity, and greater HIV symptomatology.
Gaynes et al Psychosomatic 2008
A Care Bridge Coordination
Slide 49
Program:
Linking HIV-infected Patients with
Care in North Carolina
Emily S. Brouwer, Leslie Strayhorn, Arlene C. Sena,
Heidi Swygard, Peter A. Leone, Evelyn M. Foust,
Sonia Napravnik, and Joseph J. Eron
University of North Carolina, Departments of Medicine and Epidemiology
North Carolina Department of Health and Human Services
University of North Carolina, Centers for AIDS Research
Care Bridge Coordination
Program
Care Bridge
•Testing sites
•Disease Intervention
Specialists (DIS)
Coordinator
•Clinics
•Care Providers
Slide 50
Slide 51
Activities
 Received referrals beginning April, 2008
 Received194 referrals to date
 52 adults with newly diagnosed HIV
 143 HIV-positive patients lost to follow-up
 Conducted 394 home visits
 Linked 137 patients to initial care or back to
care
 6 Refusals
Care Bridge Coordination
New Client Referral Sites
Other*
31%
Jail
13%
*Includes:
Slide 52
STD
18%
DIS
38%
case managers from other counties, clinical trial sites, self-referral
Slide 53
Patients
 Some patients referred more than once
and re-enrolled if lost-to-care
 178 unique patients
 73% Male, 27% Female
 93% Black, 7% White or Hispanic
 Median age at referral: 41 years
− (Range: 16 years-77 years)
 72 currently active
The next wave is here:
18
NC PSEL Syphilis Rates 1999-2009*
16
15.7
13.6
12
11.5
10
10
8
7.4
4.7
5.6
20
05
20
06
4
5.3
20
04
6
6.8
6.3
5.6
2
* Projected rate
20
08
20
09
*
20
07
20
03
20
02
20
01
20
00
0
19
99
Rate per 100,000
14
PSEL Syphilis Rates by Gender, 2004-2009*
18
16
Male
Rate per 100,000
14
15.9
77%↑
Female
12
10
8
9.9
7.3
9.5
8.1
8.9
6
4
3.4
3.8
3.3
3.2
2
2.5
4.4
76%↑
0
rate ratios
2004
2005
2.1
2.5
* Projected rate
2006
2007
2008
2009*
2.6
3.0
3.6
3.6
% of reports
Comorbidity (syphilis and HIV)
40
35
30
25
20
15
10
5
0
males
females
2004
2005
2006
2007
2008
Distribution Male comorbidity cases
Early Syphilis - HIV
2008 n=133
1999 n=34
25
30
20
25
20
15
15
10
10
5
0
15
-1
20 9
-2
25 4
-2
9
25
-2
30 9
-3
4
40
-4
45 4
-4
9
50
+
%
5
0
1519
2024
2529
2529
3034
4044
4549
50+
We Can Not Test and Treat are way
out of this Epidemic
• Address Contextual/Structural issues
• Health Care/ Public Health reform
• Continue to expand HIV testing but must
strengthen linkage to care
• Sexual Health and not Sexual Disease
• Comprehensive sexual health education
• Rights-based (Support same gender unions, etc)
• Use social network for prevention education and
testing
Communicable Disease Branch Resource List
http://www.epi.state.nc.us/epi/hiv/services.html