Karen McCraw
Chief Program Officer
Family First Health
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Goals:
 Reducing New HIV Infections
 Increasing Access to Care and Improving Health
Outcomes for People Living with HIV
 Reducing HIV-Related Health Disparities and Health
Inequities
 Achieving a More Coordinated National Response to
the HIV Epidemic
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The number of patients with a first time
diagnosis of HIV
◦ Rationale: HIV positivity is a HHS data
reporting priority that is not currently in
the UDS.
Quality of Care Measures
◦ Adding a measure for new HIV cases with timely
follow up
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HIV screening must be included as a covered
Preventive Service by private insurance plans
under the Affordable Care Act*
◦ Screening for ages 15-65; other ages at increased
risk
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What does “at increased risk” mean?
No deductible or copayment can be applied
to HIV screening
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In April 2013, the U.S. Preventive Services
Task Force (USPSTF) updated its previous
recommendations for HIV screening as
follows:
◦ The USPSTF recommends that clinicians screen
adolescents and adults aged 15 to 65 years for HIV
infection. Younger adolescents and older adults
who are at increased risk should also be
screened. (Grade A recommendation)
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Early diagnosis of HIV infection leads to
better outcomes
◦ 33% of the newly diagnosed are “late testers” with
an AIDS diagnosis within one year
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People in treatment are less likely to transmit
HIV to others
There are ~50,000 new HIV infections a year;
half of those new infections originate from
the 18-20% of people with HIV who are
unaware of their status
So we know we
need to do it. But
how???????
Plan around your existing
processes
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Management and staff buy-in
The law
Choosing the right HIV test
Developing a framework
Training
Reactive tests
Linkage to care
Financial issues
Record keeping/data management
Ongoing monitoring
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What is the selling point for routine screening
for your audience?
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Public health?
Medical?
Ethical?
Funder expectations?
Insurance regulations?
PI issue?
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PA no longer requires pre- and post-test
counseling
Documentation of informed consent required
Positive results must be reported via NEDSS
as with all other reportable diseases
Cannot use the word “positive” in the absence
of a confirmatory result
Opt-out testing allowed
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One of the most important variables
Considerations:
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Processing time!!
Storage
Ease of use
Reliability
CLIA status
Shelf life
Cost
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Who will obtain consent?
Who will answer patient questions?
Informational handouts
Who will perform tests?
Who will deliver results?
How will a reactive result be handled?
How to keep track of multiple tests
concurrently?
EHR documentation
How to handle minors? Parent in room?
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HIV 101 for support staff
Training on performing test
How to answer patient questions
How to offer a routine HIV test
How to deliver a reactive test result
◦ Reassurance
◦ Confirmatory
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Assessing immediate patient needs
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Develop a protocol in the event of a reactive
test
Forget the conventional wisdom about not
testing on a Friday—”routine” means
whenever you are seeing patients
Consider performing a second rapid test to
rule out a defective test
Always get confirmatory lab work done before
patient leaves
Resources for patient
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People who are engaged in care soon after
diagnosis have a higher rate of remaining
engaged in care
Do you do in-house HIV care?
Are you interested in developing the capacity
to provide HIV care?
Referral agreements with Ryan White-funded
entities
Clarify who is responsible for tracking a
patient once the referral is made
Document linkage to care
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Negotiate lower test cost
Some tests available through 340B pricing
Public grant funding
Uninsured patients and those covered by PPS
rate may be majority of patients
Pharmaceutical company grant funding
Increased reimbursement from private payers
under ACA
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Incorporation into EHR
EHR reporting capacity
What do you want to track?
What would potential funders want to see?
Offered tests/accepted tests/linkage to care
at minimum
Do you need a separate database?
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Just like everything else, routine HIV
screening can fall off the radar
Family First Health has included routine HIV
screening in monthly PI chart audits
Share outcomes to reinvigorate staff
Family First Health includes testing in set of
core competencies for clinical support staff
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Routine HIV screening did not disrupt the
clinic flow
Routine HIV screening is helping reduce
stigma around HIV testing
Routine screening is philosophically provider
driven but operationally support staff driven
Clinical staff buy-in increased dramatically
after the first positive test
The first people newly diagnosed as HIV
positive through this program were existing
health center patients
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We were terrible at assessing “risk”
Patients like the rapid test and the absence of
risk assessment
Staff members were initially upset when tests
were reactive—had to recalibrate their
perspective
There is still a role for testing outside the
primary care setting
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Approximately 82% of HIV positive individuals in
York County have been linked to care
77% of HIV positive clients have been retained in
HIV care
100% of clients retained in care are receiving
Antiretroviral Treatment
Out of the clients who are retained in care and
receiving treatment, 93% have an undetectable viral
load
Across all Caring Together clients, 83% have an
undetectable viral load
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Karen McCraw
Family First Health
(717) 845-7244
kmccraw@familyfirsthealth.org