Routine HIV Screening in Health Care Settings
Background and Definitions
David Spach, MD
Clinical Director
Northwest AIDS Education and Training Center
Professor of Medicine, Division of Infectious Diseases
University of Washington Seattle
This project was funded under cooperative agreement number U65/PS000821 from the Centers for Disease Control and Prevention (CDC).
Routine HIV Screening in Health Care Settings
Slide Set Topics
• Background & Definitions
• HIV Epidemiology Update
• Rationale for Routine HIV Screening
• 2006 CDC HIV Screening Recommendations
• Overcoming Barriers to Routine HIV Screening
• Diagnostic Tests
• Counseling and Linking to Care
Routine HIV Screening in Health Care Settings
Master Slide Set Topics
• Background & Definitions
• HIV Epidemiology Update
• Rationale for Routine HIV Screening
• 2006 CDC HIV Screening Recommendations
• Overcoming Barriers to Routine HIV Screening
• Diagnostic Tests
• Counseling and Linking to Care
Source: CDC. MMWR 2006;55(no. RR-14):1-17.
Goal of Routine HIV Screening
Medical
Care
HIV
Screening
HIV
Diagnosis
Link to Care
Prevention
Services
Desired Outcome of Routine HIV Screening
Improve Survival
&
Quality of Life
HIV
Screening
HIV
Diagnosis
Link to Care
Prevent New HIV
Infections
Routine HIV Testing in Health Care Settings
Definitions
•
Diagnostic testing. Performing an HIV test for persons with clinical signs or symptoms
consistent with HIV infection.
•
Screening. Performing an HIV test for all persons in a defined population.
•
Targeted Testing. Performing an HIV test for subpopulations of persons at higher risk,
typically defined on the basis of behavior, clinical, or demographic characteristics.
•
Informed Consent. A process of communication between patient and provider through
which an informed patient can choose whether to undergo HIV testing or decline to do so.
•
Opt-out Screening. Performing HIV screening after notifying the patient that 1) the test will
be performed and 2) the patient may elect to decline or defer testing. Assent is inferred
unless the patient declines testing.
•
HIV-Prevention Counseling. An interactive process of assessing risk, recognizing specific
behaviors that increase the risk for acquiring or transmitting HIV, and developing a plan to
take specific steps to reduce risks.
Source: CDC. MMWR 2006;55(no. RR-14):1-17.
Missed Opportunities for Earlier HIV Diagnosis
Study Background
- Data analyzed for HIV cases in SC from 2001-2005
- HIV cases cross-linked to all health care visits
- 4,315 cases of HIV in South Carolina
Source: Centers for Disease Control. MMWR. 2006;55:1269-72.
Missed Opportunities for Earlier HIV Diagnosis
Other
58.7%
Late Tester
41.3%
Late Tester = AIDS Diagnosed within 1 Year of HIV Diagnosis
Source: Centers for Disease Control. MMWR. 2006;55:1269-72.
Missed Opportunities for Earlier HIV Diagnosis
Other
58.7%
Late Tester
41.3%
Among All Late Testers
73% with Prior Visit to
Health Care Facility
Late Tester = AIDS Diagnosed within 1 Year of HIV Diagnosis
Source: Centers for Disease Control. MMWR. 2006;55:1269-72.
CDC Analysis of HIV Reporting Data, 1996-2005
Study Background
- Data analyzed from HIV reporting 1996-2005
- 34 US states
- N = 281,421 persons receiving diagnosis of HIV
Source: Centers for Disease Control. MMWR. 2009;58:661-5.
CDC Analysis of HIV Reporting Data, 1996-2005
Late Tester
38.3%
Other
61.7%
HV Testing in Relation to AIDS Diagnosis
Late Tester = AIDS diagnosis < 1 year of HIV diagnosis
Source: Centers for Disease Control. MMWR. 2009;58:661-5.
CD4 Cell Count at Time of HIV Diagnosis
HIV Infection
36% with CD4 < 200 cells/mm3
Study Background
- N = 2223 HIV-infected persons
- Community clinics in larger urban areas
- Evaluated CD4 count at time of HIV diagnosis
Source: Dybul M, et al. J Infect Dis. 2002;185:1818-21.
CD4 Cell Count at Time of HIV Diagnosis
HIV Infection
34% with CD4 < 200 cells/mm3
Study Background
- N = 759 HIV-infected persons
- Analysis of statewide data in South Carolina (2004-5)
- Evaluated CD4 count at time of HIV diagnosis
Source: Ogbuanu ID, et al. Am J Pub Health. 2009;Suppl1:111-17.
Acute HIV: Clinical Manifestations
Signs and Symptoms of 160 Patients with Acute HIV
Source: Vanhems P, et al. AIDS. 2000;14:375-81.
Laboratory Studies with Initial HIV Infection
High Level Viremia Precedes Detectable Antibodies
HIV RNA
Antibody Titer
Detectable Antibody
Infection
Laboratory Studies with Initial HIV Infection
“Window Period”
Window Period
Laboratory Studies with Acute HIV
• Positive HIV-1 RNA Assay and Negative HIV Antibody Test
Acute HIV
HIV RNA
Antibody Titer
Detectable Antibody
Infection
Testing for HIV
• Recommended in Patients with Clinical Manifestations of HIV/AIDS
Oral Candidiasis
Kaposi’s Sarcoma
Oral Hairy Leukoplakia
Pneumocystis pneumonia
Images Source: HIV Web Study (www.HIVwebstudy.org)
Mortality and HAART Use Over Time
HIV Out-Patient Study, CDC, 1994-2003
Source: Centers for Disease Control and Prevention.
Per Person Survival Gains with Various Interventions
for Chronic Diseases in US
Source: Walensky RP, et al. J Infect Dis. 2006;194:11-19.
Figure Reproduced with permission from University of Chicago Press
Correlation of Baseline CD4 Cell Count and Outcome
after Staring Antiretroviral Therapy
Study Background
- N = 12,574 HIV-infected adults starting antiretroviral therapy
Source: Egger M, et al. Lancet. 2002;360:119-29.
Acknowledgement
This project was funded under cooperative
agreement number U65/PS000821 from the
Centers for Disease Control and Prevention
(CDC).