Information for Health Care Providers
BY ENCOURAGING
PATIENTS TO GET
TESTED FOR HIV,
YOU PLAY
A CRUCIAL ROLE
IN FIGHTING THIS
EPIDEMIC.
HIV Testing. Linkage to Care. The Time Is Now.
More than 1.1 million people in the United States are living
with HIV infection, and nearly 1 in 5 (18.1%) are unaware of
their infection.1 Of those diagnosed, Black/African Americans
and Hispanics/Latinos continue to have the highest rates of
HIV.
The Centers for Disease Control and Prevention (CDC)
recommends routine HIV testing as part of standard primary
care. Primary care providers have a unique opportunity to
screen all of their patients for HIV and to help lessen HIV’s
disproportionate and growing burden on Black/African
Americans and Hispanics/Latinos by
•
Routinely screening for HIV as the standard of
medical care.
•
Linking patients who test positive for HIV to medical
treatment and services.
By encouraging patients to get tested for HIV, health care
providers can play a crucial role in fighting this epidemic.
1
CDC Surveillance Shows Black/African American and Hispanic/Latino
Populations Disproportionately Affected by HIV Epidemic
By race, Blacks/African Americans face the most severe
burden of HIV.
•
In 2011, Blacks represented approximately 12% of the U.S. population, but
accounted for 47% of diagnoses.2
•
Unless the course of the epidemic changes, an estimated 1 in 16 Black
men and 1 in 32 Black women will be diagnosed with HIV infection in
their lifetime.3
•
In 2011, Black/African American men who have sex with men (MSM)
accounted for approximately 38% of adult and adolescent MSM who were
diagnosed with HIV infection. Of all MSM aged 13 to 24 years diagnosed
with HIV infection in 2011, an estimated 58% were Black/African American,
followed by Hispanic/Latinos (20%) and White(18%).4
Hispanic/Latinos are also disproportionately affected by HIV.
•
In 2011, Hispanic/Latinos accounted for 16% of the U.S. population but 21%
of HIV diagnoses.5
•
At some point in life, 1 in 36 Latino men will be diagnosed with HIV, as will
1 in 106 Latinas.6
•
Unless the course of the epidemic changes, an estimated 1 in 50 Hispanic/
Latinos will be diagnosed with HIV infection at some point in their lifetime.7
•
From 2008 through 2011, the estimated percentage of Hispanic/Latino MSM
diagnosed with HIV infection increased from 22% to 24%, while
the percentage of White MSM diagnosed with HIV infection decreased from
36% to 34%.8
Disparities persist in the rates of HIV Infection
diagnosis.
In assessing the estimated rate of diagnoses of HIV
infection (per 100,000 population)9:
•
Black/African American males were nearly 8 times as
high as the rate for white males (112.8 versus 14.5).
•
Black/African American females were 20 times as
high as the rate for white females (40.0 versus 2.0).
•
Hispanic/Latino males were almost 3 times as high
as that for white males (43.4 versus 14.5).
•
Latinas were almost 4 times as high as that for white
females (7.9 versus 2.0).
Rates of Diagnosis of HIV among Adults and Adolescents,
by Sex and Race/Ethnicity, 2011 – United States
120
Diagnoses Rate
(per 100,000 population)
100
80
60
40
20
0
Male
Total rate 30.8
Female
Total rate 7.7
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino*
Native Hawaiian/other Pacific Island
White
Multiple races
Data include persons with a diagnoses of HIV regardless of stage of disease at diagnosis. All
displayed data have been statistically adjusted to account for reporting delays, but not for
incomplete reporting. Rates are per 100,000.
* Hispanics/Latinos can be of any race.
3
Missed Opportunities
Despite CDC HIV testing recommendations, opportunities to identify HIVpositive patients are routinely missed. Many patients avoid testing or treatment
until late in the course of infection because of fear of the disease, discrimination,
stigma, or because their providers never recommended it.
•
In a 2009 survey of experiences with HIV testing, many respondents
noted that one of the reasons for not testing is that “their doctor never
recommended it.” (See graphic for details and additional responses.)
•
In a 2011 National Medical Association survey of its members, Black/African
American family practice, general practice/internal medicine, and emergency
room/urgent care specialists reported infrequent testing of Black/African
American patients, a group that is disportionately affected by HIV.10
•
In the same survey, health care providers cited fear of appearing judgmental
of the patient’s behavior as a significant impediment to testing.11
Millions of Americans have never been tested for HIV.12
These are some of the reasons why:
You don’t think you’re at risk
69%
56%
49%
73%
Your doctor never recommended it
27%
24%
27%
28%
Your don’t like needles or giving blood
Your don’t know where to go to get tested
8%
9%
13%
8%
6%
9%
15%
4%
Total
African American
Latino
White
Source: Kaiser Family Foundation Survey of Americans on HIV/AIDS (conducted Jan. 26 - March 8, 2009)
4
Making HIV Screening the Standard of Care
This brochure offers health care providers tailored information and tools for
incorporating HIV testing into primary care settings as a routine part of care.
To encourage primary care providers to include routine HIV testing during patient
visits, CDC developed recommendations for HIV screening that call for HIV testing
as part of routine health care for all patients and annual rescreening for those at high
risk. Patients diagnosed through routine HIV screening can benefit from early HIV
medical treatment, which reduces illness and premature death. Treatment also helps
to prevent transmission of HIV to partners by lowering viral load.13,14
HIV Screening Recommendations
In 2006, CDC released “Revised Recommendations for HIV Testing of Adults, Adolescents,
and Pregnant Women in Health-Care Settings.”
•
HIV screening for all patients ages 13 to 64 as part of routine health care. The
patient is informed that testing will be done unless the patient declines, a process
known as “opt out” screening.
•
Annual rescreening (at a minimum) for patients at high risk for HIV infection.
These include injection drug users and their sex partners, people who exchange sex for
money or drugs, sex partners of HIV-infected people, and anyone who has had or whose
sex partners have had more than one sex partner since their most recent HIV test. For
people with these risk factors, CDC’s sexually transmitted disease treatment guidelines
recommend screening every 3 to 6 months for HIV.15
•
HIV screening as part of routine prenatal screening tests for all pregnant women.
The patient is informed that testing will be done unless she declines.
In 2013, the U.S. Preventive Services Task Force (USPSTF) issued a final recommendation
statement on screening for HIV:16
•
Everyone aged 15 to 65 should be screened for HIV infection. Teens younger than 15
and adults older than 65 also should be screened if they are at increased risk for HIV
infection.
•
All pregnant women, including women in labor who do not know their HIV status, should
be screened for HIV infection.
5
Routine Testing Works17
•
Routine screening allows many people with undiagnosed HIV infection to be
identified who may have been missed by risk-based testing.
•
HIV infection meets all the criteria that justify other screening programs for
chronic diseases:
•
•
•
HIV is a serious health disorder that can be diagnosed before
symptoms develop.
HIV can be detected by reliable, inexpensive, noninvasive screening tests.
HIV-infected patients have years of life to gain if antiretroviral therapy
is started early.
Test, Diagnose, and Link to Care:
The Sooner the Better
HIV testing technologies have progressed, and clinical trials have demonstrated
that antiretroviral therapy and suppressed viral loads improve health and reduce
HIV transmission. Routine screening can identify HIV-positive patients early,
allowing for faster linkage to care and treatment.
•
Including HIV screening alongside routine tests (blood pressure and
cholesterol screenings, for example) allows for earlier identification while
helping to reduce the stigma associated with HIV.
•
Patients with newly diagnosed HIV infection should be linked to HIV care
and treatment as quickly as possible to improve health outcomes.
•
Linkage to care and treatment can reduce sexual and perinatal transmission
of HIV.
•
There is evidence that people who test HIV-positive take steps to keep from
exposing others to the virus.18,19
Testing your patients helps them to reduce risky behavior that can transmit HIV.
I include HIV testing as part of a
holistic approach to make sure my
patients stay as well as possible
irrespective of their age—whether
they are 80 or 30.
~ Celia Maxwell, M.D., FAACP
Howard University Women’s
Health Institute, Washington, DC
6
TESTING YOUR
PATIENTS
HELPS THEM
TO REDUCE
RISKY BEHAVIOR
THAT CAN
TRANSMIT HIV.
HIV—Implications on Other Clinical Conditions
In addition to benefiting the patient, early knowledge of HIV infection provides
clinicians with important information for managing other health conditions.
Uncontrolled HIV infection may cause inflammation and other complications
such as cardiovascular disease, hepatic disease, renal disease, and non-AIDS
cancers (cancers that include those other than Kaposi sarcoma, non-Hodgkin’s
lymphoma, and cancers of the lung, mouth, cervix, and digestive system).
Implications of Uncontrolled HIV
Replication on Other Clinical Conditions
Cardiovascular disease
Increased risk of myocardial infarction20 and early carotid atherosclerosis.21
Hepatic disease
Faster progression of fibrosis and increased risk of cirrhosis, end-stage liver disease, and
hepatocellular cancer in patient with hepatitis B or C coinfection.14
Renal disease
Increased risk of HIV-associated nephropathy, especially among Black/African Americans
and older patients and those with diabetes, hypertension, or a low CD4 count.14
Non-AIDS cancer
Possible role in non-AIDS cancers. The direct inflammatory effects of HIV infection can
also raise the risk of some non-AIDS cancers.22
Streamlining Routine HIV
Screening in Your Practice
I think the simplest mechanism is
to include the HIV antibody test
on the standard lab panel used for
general screening of patients.
~Derrick Butler
M.D., M.P.H., T.H.E. Clinic, Los Angeles, CA
Talking About Testing23,24
Before administering an HIV test during a patient visit,
you and your staff can explain that
•
Anyone can be infected and not know it.
•
CDC recommends HIV screening as part of routine
care for all patients ages 13 to 64, similar to other
screening tests such as cholesterol and blood glucose.
•
Informed consent for HIV testing is covered by
general consent for medical care.
•
Early detection allows patients to stay healthy by
starting effective HIV treatment right away and to
prevent transmission to others.
It is important to listen and respond to a patient’s
questions and concerns, understanding that
confidentiality may be an issue for patients in consenting
to HIV testing. You and your staff must assure patients
that their health information is confidential and that it
will not be disclosed, except to public tracking entities,
without their approval. You are encouraged to familiarize
yourself with state laws or regulations about HIV testing.
For more information, see the section “Knowing Your
State HIV Testing Policies and Laws.”
9
IT’S IMPORTANT
THAT PATIENTS
BE LINKED
TO HIV CARE
BEFORE THEY
LEAVE THE
OFFICE.
HIV tests, along with cholesterol and blood
pressure, are just a few of the standard tests
included in a prevention visit that will help keep
my patients well. When I explain that HIV tests
are not just for people at highest risk, my patients
are fine with me running the test and more likely
to wait for [rapid testing] or come back for their
results because they don’t feel scared.
~ Ligia Peralta,
M.D., FAAP, FSAHM, AAHIVM
Delivering HIV Test Results
For Positive Results
Patients’ responses to a positive HIV test can vary greatly. To help patients
understand and process test results, please consider the following:
• Hold the session in a private area.
• Communicate the test result in a direct, neutral tone.
• Patients may have questions about
• HIV infection and transmission.
• How they can reduce the risk of transmission to their partners.
• HIV disclosure to partners (and how the health departments partner
services can help notify their partners).
It’s important that patients be linked to HIV care before they leave the office.
•
•
•
Provide a referral, including the name and contact information of a
physician or clinic.
Ensure that a follow-up appointment is set up before they leave the office.
Encourage the patient to contact you with any questions.
These steps are critical, as this is often the time when patients
drop out of care.
For Negative Results
For patients who have likely not been exposed and do not require a confirmatory
test, delivery of a negative result means that they should take steps to stay
negative. These steps include
• Practicing mutual monogamy with a partner known to be HIV-negative.
• Using condoms every time they have sex, especially for anal or vaginal sex.
• Not sharing needles and other drug use equipment.
11
Resources for Linking Patients to Care
Connecting patients diagnosed with HIV to medical care, including antiretroviral
therapy and other services, is essential. HIV screening without linkage to care
provides little to no benefit to the patient. The resources below can be used to find
an HIV care provider when referral is needed:
The American Academy of HIV Medicine
An independent organization of HIV specialists dedicated to promoting excellence
in HIV/AIDS care; offers online searching for HIV care providers by location,
language, services provided, and types of insurance accepted.
http://www.aahivm.org
202−659−0699
The HIV Medicine Association
(part of the Infectious Diseases Society of America)
Organization of medical professionals who practice HIV medicine; online
searching for HIV care providers by location, language, services provided, and
types of insurance accepted.
http://www.hivma.org/Home.aspx
703−299−1215
The Ryan White HIV/AIDS Program
Helps people living with HIV/AIDS access the medical care they need but can’t
afford.
http://findhivcare.hrsa.gov/Search_HAB.aspx
877−464−4772
AIDS.gov
A comprehensive website that offers HIV treatment guidelines, testing
recommendations, and a search tool that finds testing clinics, health centers,
housing, and other service providers by ZIP code.
http://www.aids.gov
[The law that requires] the offer of an HIV
test … eliminates longstanding barriers
to testing and ensures that more people,
especially Black/African Americans and
other communities of color, will know their
status and gain access to early treatment
and care if needed.
~Derrick Butler
M.D., M.P.H., T.H.E. Clinic, Los Angeles, CA
12
CONNECTING
PATIENTS
DIAGNOSED
WITH HIV TO
MEDICAL CARE
After the Appointment
•
•
Document test results in the medical record and include a summary of what
was discussed, an assessment of the patient, and referrals for services.
Submit an appropriate report to the state or local health department for a
positive HIV test.
Knowing Your State HIV Testing Policies and Laws
HIV testing laws vary from state to state. Some state laws require that health
care professionals offer all patients a voluntary HIV test. There are also HIV test
reporting laws and regulations. You can review your state laws by visiting the
Compendium of State HIV Testing Laws.25
Your state may also require partner notification and the duty to warn partners of a
patient’s HIV diagnosis.
•
•
•
•
•
Advise patients that all partners should be informed of possible HIV
infection.
Talk to your patients about partner services and let them know that if they
test positive for a reportable disease such as HIV or a sexually transmitted
disease, they may be contacted by someone from the state or local health
department.
Health departments’ partner services help in identifying and finding sex or
drug-injection partners to inform them of their HIV risk and to provide
testing, counseling, and referrals for other services.
Using partner services through the health department helps maintain patient
anonymity and relieves patients of the burden of disclosure.
For the exposed partner, partner services notification facilitates quick access
to testing and linkage to care if the partner tests positive for HIV.
Approximately 20% of partners tested by partner services test positive for HIV
and were previously undiagnosed. For more details on state laws, visit
http://www.nccc.ucsf.edu/consultation_library/state_hiv_testing_laws.
Additional Free Resources for Providers
and Patients
The National HIV/AIDS Clinicians’ Consultation Center
htt://www.nccc.ucsf.edu/
Warmline: 800−933−3413 (M−F, 6 a.m. to 5 p.m. Pacific time)
Offers health care providers up-to-the minute HIV clinical information and
individualized expert case consultation.
HIV Testing e-Inquiry Service: hivtesting@nccc.ucsf.edu
Provides expert email consultation for health care providers on HIV testing and
linkage-to-care questions. (Please do not include any patient-identifying information.)
14
CDC-INFO
1−800−232−4636; TTY: 888−232−6348 English, en Español
To find an HIV testing site, text ZIP code to KNOWIT (566948)
•
Toll-free, confidential HIV/AIDS information for the public—8 a.m. to 8 p.m.
Eastern time, Monday through Friday.
•
Sensitive and compassionate service via multiple channels (e.g., phone calls, email,
mail, and fax materials).
•
Customer service representatives offer referrals to appropriate services, including
clinics, hospitals, local hotlines, counseling, and legal services.
Footnotes
1 CDC. HIV in the United States: At A Glance (CDC Fact Sheet) [Internet]. 2013 Feb. Available from: http://www.cdc.gov/hiv/resources/factsheets/us.htm.
2 CDC. HIV Surveillance Report [Internet]. 2011; vol. 23. Available from: http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm. Published February
2013.
3 CDC. HIV in the United States: At A Glance (CDC Fact Sheet) [Internet]. 2013 Feb. Available from: http://www.cdc.gov/hiv/resources/factsheets/us.htm.
4 CDC. HIV Surveillance Report [Internet]. 2011; vol. 23. Available from: http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm. Published February
2013.
5 CDC. HIV Surveillance Report [Internet]. 2011; vol. 23. Available from: http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm. Published February
2013.
6 CDC. HIV among Latinos [Internet]. 2013 April. Available from: http://www.cdc.gov/hiv/risk/racialethnic/hispaniclatinos/facts/index.html.
7 CDC. HIV and AIDS among Latinos (CDC Fact Sheet) [Internet]. 2012 Oct. Available from: http://www.cdc.gov/nchhstp/newsroom/docs/2012/CDC-Latinos-1012-508.pdf.
8 CDC. HIV Surveillance Report [Internet]. 2011; vol. 23. Available from: http://www.cdc.gov/hiv/library/slideSets/index.html Published February 2013.
9 CDC. HIV Surveillance Report [Internet]. 2011; 23. Available at: http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm. Published February 2013.
10 Wong EY, Jordan WC, Malebranche DJ, Delaitsch LL, Abravanel R, Bermudez A, Baugh BP. HIV testing practices among black primary care physicians in the United States.
BMC Public Health. 2013 Feb 2;13:96. doi: 10.1186/1471-2458-13-96.
11 Wong EY, Jordan WC, Malebranche DJ, Delaitsch LL, Abravanel R, Bermudez A, Baugh BP. HIV testing practices among black primary care physicians in the United States.
BMC Public Health. 2013 Feb 2;13:96. doi: 10.1186/1471-2458-13-96.
12 Kaiser Family Foundation. Views and experiences with HIV testing in the U.S. [Kaiser Public Opinion Survey Brief]. 2009 June. Available at: http://www.kff.org/hivaids/7926.
cfm.
13 CDC. HIV screening. [Internet]. [updated 2013 Jan 10; cited 2013 February 2]. Available from: http://www.cdc.gov/actagainstaids/hssc/index.html.
14 Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., . . . Prevention. (2006). Revised recommendations for HIV testing of adults,
adolescents, and pregnant women in health-care settings. MMWR Recommendations Rep, 55(RR-14), 1-17; quiz CE11-14. http://www.cdc.gov/mmwr/preview/mmwrhtml/
rr5514a1.htm.
15 CDC. MMWR Weekly [Internet]. 2011; 60(21); 694-699 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6021a3.htm. Published June 3, 2011
16 Screening for HIV, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm
17 CDC. Questions and answers for professional partners: revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings.
[Internet]. [updated 2009 Jul 24; cited 2013 Feb 2]. Available from: http://www.cdc.gov/hiv/topics/testing/resources/qa/qa_professional.htm#section4.
18 CDC. Questions and answers for professional partners: revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings.
[Internet]. [updated 2009 Jul 24; cited 2013 Feb 2]. Available from: http://www.cdc.gov/hiv/topics/testing/resources/qa/qa_professional.htm#section4.
19 Bisset L, Cone RW, Huber W, et al. Highly active antiretroviral therapy during early HIV infection reverses T-cell activation and maturation abnormalities. AIDS. 1998;12(16):
2115−23.
20 Triant V et al. J Acquir Immune Defic Syndr. 2009;51(3):268−73.
21 Hsue et al. AIDS. 2009;23(9):1059–67.
22 Phillips et al. AIDS. 2008;22(18):2409−18
23 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of HIV/AIDS Prevention. Implementation of routine HIV testing in health care settings: issues
for community health centers. [Internet]. 2011 Jan. Available at: http://www.cdc.gov/hiv/topics/testing/resources/guidelines/pdf/routinehivtesting.pdf.
24 CDC. Questions and answers for professional partners: revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings.
[Internet]. [updated 2009 Jul 24; cited 2013 Feb 2]. Available from: http://www.cdc.gov/hiv/topics/testing/resources/qa/qa_professional.htm#section4.
25 National HIV/AIDS Clinicians’ Consultation Center (NCCC) at San Francisco General Hospital, UCSF. 2012 Compendium of State HIV Testing Laws. http://www.nccc.ucsf.
edu/consultation_library/state_hiv_testing_laws National HIV/AIDS Clinicians’ Consultation Center (NCCC) at San Francisco General Hospital, UCSF. 2012 Compendium of
State HIV Testing Laws. http://www.nccc.ucsf.edu/consultation_library/state_hiv_testing_laws
15
Routinely Test and Link to Care
Testing and Linking African American and Hispanic/Latino
Patients to Care is part of the HIV Screening. Standard Care.™
program of CDC’s “Act Against AIDS” initiative.
Program tools and materials are designed to
• Help increase HIV screening and reduce new HIV infections.
• Help increase access to HIV primary care.
• Help improve HIV outcomes among Black/African American
and Hispanic/Latino patients through routine HIV screening and
linkage to HIV care.
Frontline primary care providers play a vital role – now more than
ever – in implementing routine HIV screening and stemming the tide
of the HIV epidemic.
To order materials, visit:
http://www.cdc.gov/actagainstaids/tlc
Call: 800–232–4636
CS238897-D