HIV Testing Update
Best Practices in TB Control - August 28, 2012
HIV Screening for Patients 13-64 years:
A Guide for TB Clinic Providers
Philip J. Peters, MD
Medical Officer
Division of HIV/AIDS Prevention
Centers for Disease Control and Prevention
Atlanta, GA
1
Disclosures
• Conflicts of Interest: None
• Disclaimer: The findings and conclusions in this
presentation are those of the author and do not
necessarily represent the views of the Centers
for Disease Control and Prevention
.
1
HIV Testing Update
Question
What is responsible for the greater than
95% decline in perinatally acquired
AIDS in the US?
1. Widespread HIV screening of all pregnant women
2. Antiretroviral use during the antenatal, perinatal,
and newborn periods
3. Reduction in number of pregnant women with
HIV infection
4. 1 & 2
3
2006 Revised Recommendations
Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.
4
.
2
HIV Testing Update
CDC’s Recommendations
• HIV screening for all patients aged 13 to 64 years
– Opt-out screening: patients should be told screening
will be performed but may decline testing
– Prevalence of undiagnosed HIV infection > 0.1%
• Written consent and prevention counseling not
required
• Annual HIV screening for those at high risk for HIV
• Prompt clinical care for HIV-infected persons
Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.
5
Learning Objectives
• Analyze the rationale for HIV screening
recommendations
• Assess clinical benefits of routine HIV screening
• Formulate approaches to simplify routine HIV
screening in practice
• Update on selecting HIV tests
6
.
3
HIV Testing Update
Estimated HIV Prevalence in the
United States, 2008
1,178,350 persons living with HIV infection
Prevalence = 448 per 100,000 population
0.4% of population living with HIV infection
20% unaware of their diagnosis
Campsmith ML, et al. CDC. Morb Mortal Wkly Rep. (MMWR). 2008;57(39):1073-1076.
Campsmith ML, et al. J Acquir Immune Defic Syndr. 2010 Apr;53(5):619-24.
CDC. HIV surveillance—United States, 1981-2008. MMWR 2011;60: 689-693.
7
Geographic Comparison of Rates of AIDS Diagnoses
and Tuberculosis Cases in the United States
Rate of AIDS Diagnoses by
MSA* of Residence - United
States and Puerto Rico, 2008
Rate of Tuberculosis Cases
per 100,000 Population –
United States, 2011
* MSA = Metropolitan Statistical Area
Centers for Disease Control and Prevention. Rates of AIDS Diagnoses by Metropolitan Statistical Area
(MSA) of Residence, 2008 - United States and Puerto Rico. Areas. Slide set.
http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm. Accessed May 27,2011.
.
Centers for Disease Control and Prevention. Trends in Tuberculosis - United States, 2011.
MMWR Morb Mortal Wkly Rep. 2012 Mar 23;61(11):181-5.
8
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm. Accessed August 1, 2012.
4
HIV Testing Update
Why Routine Screening?
• Patients do not always disclose or may not
be aware of their risk1
– 39% of men who had sex with a man within
the past year did not disclose to their health
care provider2
– 51% of rapid test positive patients identified
in Emergency Department (ED) screening had
no identified risk3
1. Chou R, et al. Ann Intern Med. 2005;143:55-73.
2. Bernstein KT, et al. Arch Intern Med. 2008;168(13):1458-1464.
3. Lyss SB, et al. J Acquir Immune Defic Syndr. 2007;44(4): 435-442.
9
Risk-Based HIV Testing Has
Become Less Effective
• Patients with HIV infection often have
multiple health-care visits before diagnosis
– median of 7 visits over 5 years in one study1
• Risk-based testing frequently misses2,3:
– Young people (< 24 years)
– Women and heterosexual men
– Members of racial and ethnic minorities
– People residing outside of urban areas
1. Klein D, et al. J Acquir Immune Defic Syndr. 2003; 32(2): 143-152.
2. Institute of Medicine. Washington, DC: National Academy Press; 2001.
3. CDC. HIV surveillance—United States, 1981-2008. MMWR 2011;60: 689-693.
10
.
5
HIV Testing Update
Late Diagnosis of HIV Infection
Percentage of Patients Diagnosed with HIV
Late in the Course of Infection 2009, US*
Late Diagnosis:
AIDS Diagnosed within a
year of receiving HIV
diagnosis
32%
68%
Early Diagnosis
* 46 states with confidential name-based HIV infection reporting (n= 45,336)
Centers for Disease Control and Prevention. HIV Surveillance Report, 2010; vol. 22.
11
Probability Curve of Mortality According
Death
to Baseline CD4 Cell Count
CD4 cell count (cells/µL)
0.20
0.15
0-24
25-49
0.10
9
50-99
100-199
200-249
0.05
9
>=350
0.00
4
5
0
1
2
3
4
5
Years from starting antiretroviral therapy (ART)
May M, et al. AIDS. 2007;21;1185 ART-CC.
])
0.20
Viral Load (log10[copies/mL])
12
0.15
0.10
.
>=5
6
HIV Testing Update
Tuberculosis and HIV

A high proportion (7.9%) of people with tuberculosis
disease in the US are HIV infected [1]

Compared with HIV-negative patients, HIV-infected
patients with Mycobacterium tuberculosis infection
are markedly (21 – 34 times) more likely to develop
active tuberculosis disease [2]
1. Centers for Disease Control and Prevention. Trends in Tuberculosis - United States, 2011. MMWR Morb Mortal Wkly Rep.
2012 Mar 23;61(11):181-5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm. Accessed August 1, 2012.
2. World Health Organization. Global Tuberculosis Control. 2011. Available at
http://www.who.int/tb/publications/global_report/2011/en/index.html. Accessed January 31, 2012.
13
Antiretroviral Therapy Reduces Rates of
Sexual Transmission of HIV
HPTN 052:
Antiretroviral
therapy reduced
HIV transmission
by 96% in
discordant couples
Cohen MS, et al. N Engl J Med 2011;365:493-505.
14
.
7
HIV Testing Update
Desired Outcome of Routine HIV
Screening
Improve
Survival
and
Quality of Life
HIV
Screening
HIV
Diagnosis
Link to Care
Prevent New
HIV Infections
15
Implementing HIV Screening
Integrating HIV Screening
into Practice
• Train staff to perform HIV opt-out
screening
• Provide easily understood patient
informational materials
• Be prepared for commonly asked
questions
Address Patients’
Misperceptions
• Many patients believe they were
previously tested for HIV,
particularly if blood was drawn
• Many patients assume an HIV test
was performed and if they didn’t
receive a call from the doctor, that
they do not have HIV
• Include testing reminders in
patient’s electronic medical record
16
.
8
HIV Testing Update
Implementing HIV Screening (cont’d)
State Laws
Regarding HIV Testing
• Requirements to obtain written consent
are being phased out.
• Refer to National HIV/AIDS Clinicians’
Consultation Center’s Compendium of
State HIV Testing Laws for questions
about your state:
http://www.nccc.ucsf.edu/
Compendium of State HIV Testing Laws. National HIV/AIDS Clinicians’ Consultation Center (NCCC) Web site.
http://www.nccc.ucsf.edu/consultation_library/state_hiv_testing_laws/.
17
Communicating
Positive HIV Test Result
• Provide result by direct personal
contact
• Provide result confidentially
+
• Ensure patient understands test result
• Connect to services
Positive
Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.
18
.
9
HIV Testing Update
Rapid HIV Tests
Uni-Gold Recombigen
INSTI
Clearview Complete HIV 1/2
Reveal G3
OraQuick Advance
Clearview HIV 1/2 Stat Pak
19
Rapid HIV Tests
Advantages
 Ensures patient
receives test result
 Option for an oral swab
or finger stick instead
of blood draw
Limitations
 Results are manually
read and charted
 Training and oversight
necessary
 Can overburden nursing
and other staff
 More expensive
20
.
10
HIV Testing Update
Time to detection of HIV RNA, p24 antigen,
and antibody during early HIV infection
HIV RNA (plasma)
HIV Antibody
HIV p24 Antigen
Infection
22
Days
Phase of
Infection
0
10
Eclipse
20
30
40
Acute HIV Infection
Earliest Viral
Detection
50
60
70
80
90
100
Established HIV Infection
Antibody Detection
by Western blot
Reference: Branson BM. JAIDS. 2010; 55(S2): S102-105.
Time to detection of HIV RNA, p24 antigen,
and antibody during early HIV infection
HIV RNA (plasma)
HIV Antibody
HIV p24 Antigen
Infection
22
Days
Phase of
Infection
0
10
Eclipse
20
30
Acute HIV Infection
Earliest Viral
Detection
40
50
60
70
80
90
100
Established HIV Infection
Antibody Detection
by Western blot
Reference: Branson BM. JAIDS. 2010; 55(S2): S102-105.
.
11
HIV Testing Update
4th Generation Combo Ag/Ab Assay

Detects p24 antigen and
HIV antibody

Time to result: 29 minutes

100 results/hour

FDA-approved June 22,
2010
23
HIV Screening. Standard Care.
• Free materials for providers
– Annotated Guide to CDC
Recommendations
– Resource Guide
– AMA/AAHIVM CPT Coding Guide
– ACP Guidance Statements
– National HIV/AIDS Clinicians
Consultation Center Flyer
• Free patient materials
(available in English and Spanish)
– Brochure
– Poster
Download at www.cdc.gov/HIVStandardCare
Order free of charge from screenforHIV@cdc.gov
The findings and conclusions in this presentation are those of the
author and do not necessarily represent the views of the Centers for
Disease Control and Prevention
.
24
12