Improving HIV Testing and Prevention
in New York City
Sekai Chideya, MD, MPH
Bureau of HIV/AIDS Prevention and Control
NYC Department of Health and Mental Hygiene
Overview
• Epidemiology of HIV – U.S. and NYC
• HIV Testing
– Recommendations and laws
– Why ‘opt-out’ testing?
• Assessing and reducing risk
• Testing Patients
– Who and how
• The HIV-Positive Patient
The HIV Epidemic Today
United States1
• Total # HIV-Infected = 1.1 million
• >56,000 new HIV infections per year
• >44,000 new diagnoses in U.S. in 2007
– 1 in 5 HIV-positive individuals unaware of
infection
NYC2
• Total # HIV-Infected = 102,000 (1.3% population)
• ~3,800 new diagnoses in 2007
• >2,000 deaths in 2007 (5 people every day)
1.
Hall et al. JAMA. 2008;300:520-529
2.
New York City HIV/AIDS Annual Surveillance Statistics
Who is Being Diagnosed in NYC?
• 80% Blacks and Latinos
– Blacks have higher rates of testing*
• 73% Men
– 80% Men who have Sex with Men (MSM)
• 30% 13-29 years old
• 27% Women
• 17% ≥50 years old
…Basically, everyone!
* Anderson, et al. Natl Ctr Health Statistics; 2005
You are
here!
HIV Testing Recommendations
and Laws
CDC Recommendations
2001 Guidelines recommend:
• Offer testing in all health-care settings
• Notify patients that HIV testing will be
performed unless they decline (“opt-out”)
• Obtain written consent
– Include with general medical consent
• Streamline pre-test counseling
• Post-test counseling optional if negative test
• Test high-risk people at least annually
New York State Laws
• Agrees with most, but not all, CDC
recommendations
– HIV testing be voluntary
– Pre-test counseling streamlined
– Patient signature required
• Separate, written informed consent still
required (not “opt-out”)
• Post-test counseling still required if
negative test
NYC Department of Health
• Follows NY State Law
• Supports CDC’s Recommendations
– Testing remain voluntary
– Informed consent with general consent
• Opt-out model
• Deemphasize pre-test counseling
– Provide in-person or via videos, pamphlets
• Brief post-test counseling
NYC DOH Testing Campaigns
DOH HIV prevention campaigns
Opt-Out HIV Testing
Opt-Out Testing: Rationale
1.
2.
3.
4.
5.
6.
Effective treatment is available
Late diagnoses are common
Patients don’t think they’re at risk
Many doctors don’t offer testing
Some patients think they’ve been tested
People who know their status change
their behavior
7. Most patients want routinized HIV testing
1. Effective Treatment is Available
• Testing guidelines and laws drafted
when no treatment existed
• HIV is now a chronic disease
– >20 FDA-approved antiretrovirals (ARVs)
– 20-year-old HIV+ person starting ARVs
today expected to live to age 69*
* The Antiretroviral Therapy Cohort Collaboration. Lancet 2008; 372
2. Late Diagnoses are Common
Late Diagnosis = concurrent HIV and AIDS
diagnosis or AIDS diagnosis within 3 years
• 45% of newly-diagnosed people in the U.S.
had an AIDS diagnosis within 3 years*
– NYC: ¼ of all new diagnoses also have AIDS
• Late diagnoses result in
– Prolonged transmission
– ↑ morbidity and mortality
– ↑ health care costs
*CDC, MMWR 2009;58(24):661–665
Reasons for Testing: Late vs. Early Testers
Supplement to HIV/AIDS Surveillance, 2000–2003
100%
Late (Tested < 1 yr before AIDS dx)
80%
Early (Tested >5 yrs before AIDS dx)
60%
40%
20%
0%
Illness
Self/partner
at risk
Wanted to
know
Routine
check up
Required
Other
3. Patients Don’t Think They’re at Risk
• Kaiser Foundation poll1: 69% people thought they
were not at risk
• GYN patients2: only 2% considered themselves
high-risk but nearly half reported unprotected sex
with more than one partner
• Why?
–
–
–
–
–
“It’s a gay disease”
“I don’t use drugs”
“I’m monogamous”
“I’m too old”
“I feel fine”
1. Kaiser Family Foundation Survey of Americans on HIV/AIDS 2009
2. VH Coleman et al. Matern Child Health J, 2009
3. Patients Don’t Think They’re at Risk
• Kaiser Foundation poll1: 69% people believed
they were not at risk
• Gynecology patients2: only 2% considered
themselves high-risk but nearly half reported
unprotected sex with more than one partner
• Why?
–
–
–
–
–
1.
2.
“It’s a gay disease” – 40% cases heterosexual
“I don’t use drugs” – Sex is #1 transmission risk
“I’m monogamous” – But is their partner?
“I’m too old” – 1in 6 new cases is ≥50 yrs
“I feel fine” – Most people do until they develop AIDS
Kaiser Family Foundation Survey of Americans on HIV/AIDS 2009
VH Coleman et al. Matern Child Health J, 2009
3. Patients Don’t Think They’re at Risk
Reasons for not being tested*among those never tested
You don't think you're
at risk
69%
Your doctor never
recommended it
You don't like needles
or giving blood
You don't know where
to go to get tested
You worry about
confidentiality
You're afraid you'll test
positive
0%
27%
8%
6%
5%
2%
10%
20%
30%
40%
50%
60%
Source: Kaiser Family Foundation Survey of Americans on HIV/AIDS (conducted Jan. 26–March 8, 2009)
*Interviewee may choose more than one reason, so total exceeds 100%
70%
80%
4. Doctors Aren’t Offering Testing
Reasons for not being tested*among those never tested
You don't think you're
at risk
69%
Your doctor never
recommended it
You don't like needles
or giving blood
You don't know where
to go to get tested
You worry about
confidentiality
You're afraid you'll test
positive
0%
27%
8%
6%
5%
2%
10%
20%
30%
40%
50%
60%
Source: Kaiser Family Foundation Survey of Americans on HIV/AIDS (conducted Jan. 26–March 8, 2009)
*Interviewee may choose more than one reason, so total exceeds 100%
70%
80%
Why Aren’t Doctors Offering Testing?
• Don’t have time
– “Burdensome consent process” top reason*
• “Patient looks like my mom, brother, etc.”
• Counter-transference
– Patient is difficult, non-adherent
• Patient might be offended
• Discomfort discussing it
*Burke, et al., AIDS 2007, 21
5. Some Patients Think They’ve
Already Been Tested
Many patients assume they were tested as
part of routine workup
• Healthcare providers often say they’ve
checked for “everything”
– What does “everything” mean?
• 23% of hospitalized patients incorrectly
assumed that HIV was included among
their blood tests*
* McAdam, et al. International J of STD & AIDS 1997; 8
6. People Who Know They Have HIV
Change Their Behavior
~1/4
Unaware of
Infection
Account for:
~2/3 of New
Infections
~3/4
Aware of
Infection
~1/3 of New
Infections
People Living with HIV/AIDS:
1,039,000-1,185000
Marks et al., AIDS, 2006
New Sexual Infections Each Year:
~32,000
7. Most Patients Want HIV
Testing to be Routine
Removing Separate Consent
Increases Testing
Mean Rate of HIV Tests, San Francisco Dept. Health
Zetola, N. M. et al. JAMA 2007
Your Role as a Doctor
Until opt-out HIV testing adopted:
•
•
•
•
Assess risks – “every patient, every time”
Counsel on risk reduction
Offer testing
Facilitate Prevention with Positives
Patients Don’t Self-Disclose Risks
The ideal patient encounter…
“Hi Doctor. Just to let you know, I inject
drugs, had three STIs last year, and my
partner is sleeping with other people.”
This NEVER happens!
Assess, Don’t Assume
You can’t treat a problem if you don’t know it exists
Only 35% of primary care physicians routinely ask
patients about sexual behaviors*
Tips for taking a sexual history:
• Develop a routine
– Utilize with all patients
• Avoid moral or religious judgments
• Clarify misinformation, dispel myths, and provide
factual information
* McCance, et al. Am J Prev Med 1991;7
Assessing Sexual Behavior:
Sample Questions*
• Are you currently sexually
active? Have you ever been?
• Are your partners men,
women, or both?
• How many partners have
you had in the past 6
months?
• What method of
contraception do you use?
• Do you or your partner(s)
use any particular devices or
substances (e.g., crystal
meth) during sex?
Nusbaum. Am Fam Physician 2002; 66
• Do you have, or have you
ever had, any risk factors for
HIV? (List them out loud)
• Have you ever had any STIs?
• Have you ever been tested for
HIV? Would you like to be?
• What do you do to protect
yourself from getting HIV?
Risk Reduction Counseling
You know they’re at risk…now what?
• Behavior change is a gradual process, not
“all or nothing”
– Ex., few smokers quit “cold turkey” – have to
decrease # cigarettes, use NRT, etc.
• Emphasize that your primary concern is
their health and that they are in control
• Clearly outline what is putting them at
risk, then ask if they are willing to make
some changes to be safer
– Don’t pressure them if not ready/willing
Risk Reduction Counseling (2)
For willing patients:
• Be nonjudgmental but avoid downplaying risks
• Brainstorm with patient about acceptable
alternatives
– “What if you always carried a condom?”
– “On the first of the month, buy syringes from
Duane Reade instead of sharing used ones”
• Refer, refer, refer: case management,
psychiatry, etc. Don’t go it alone
• Draft an informal contract on a Rx pad
**Even if patients don’t want to discuss their
sexual history, offer them HIV testing
Offering HIV Testing
Offering HIV Testing: Who
• Everyone establishing care
• Everyone getting a physical
• High-risk patients (based on assessment)
–
–
–
–
–
–
Unprotected sex
Anyone wanting a STI or pregnancy test
Drug or alcohol dependent
“Frequent flyers” with recurrent illnesses
Mental health issues, if competent
Symptoms consistent with AIDS
Offering HIV Testing: How
1. Introduce topic
2. Provide brief pre-test counseling (faceto-face, video, or written)
3. Answer any questions
4. Get consent
5. Provide post-test counseling
Introduce the topic
Reassure patients that you offer it to everyone.
• “I’d like to include an HIV test on your lab panel
because I think it’s important that everyone know
his/her HIV status.”
• “I recommend HIV testing to every (new) patient
getting a physical, no matter his/her age….”
• “HIV is preventable and treatable, just like high
blood pressure or diabetes. So it’s important to
check for it, just like those other diseases.”
Obtaining Consent
1. Answer questions - expertise not needed
2. Obtain consent
•
•
•
•
Minimal Requirements
Present HIV Consent Form Part A to patient
Patient signs Part B
Perform test
Provide “Information on Negative HIV Test
Result” to those who test negative
www.health.state.ny.us/diseases/aids/regulations/2005_guidance/negativetestresults.htm
The HIV-Positive Patient
So, what do you do if patient is positive?
1.
2.
3.
4.
1st, confirm it with Western Blot
Reassure that not a death sentence
Complete Provider Report Form (PRF)
Facilitate:
–
–
–
–
–
Partner Notification (PN)
Counseling on how to stay healthy and safe
Linkage to care
Case management
Pharmacotherapy, if indicated
The HIV-Positive Patient
So, what do you do if patient is positive?
1.
2.
3.
4.
1st, confirm it with Western Blot
Reassure that not a death sentence
Complete Provider Report Form (PRF)
Facilitate:
–
–
“PWP” –
–
–
Partner Notification (PN)
Counseling on how to stay healthy and safe
Linkage to care
Case management
Pharmacotherapy, if indicated
Prevention With Positives (PWP)
• PWP: Any activity that reduces the
likelihood of HIV transmission to others
• PWP aims to prevent the ~1/3 of all new
infections due to transmission from
known HIV-positive people
– NYC: # new cases from 3,800/yr 
2,500/yr
Examples of PWP
•
•
•
•
•
•
•
•
Making people aware of their HIV status
Facilitating partner notification
Keeping viral loads low
Practicing safer sex
Prevention of mother-to-child transmission
Syringe exchange for HIV+ drug users
Housing support
Many other activities…
Making PWP Successful
• Ask, ask, ask: regularly reassess behavior
– Come up with a few responses to convince
people to talk freely
• Frame PWP in a life-affirming way that
emphasizes their safety
– “Using a condom will give you peace of mind
and will also protect you from STIs that could
make your HIV worse.”
– “Not sharing needles makes it less likely you’ll
get Hepatitis C”
• Collaborate with social service providers
PWP at the Facility-Level
• Prioritize cultural competency regarding
ethnicity, language, religion, etc.
– Have low-literacy materials in Spanish, Russian, Creóle,
French, etc. in your waiting rooms and offices
• Put PWP-related questions on intake and
examination forms
• Make PWP a quality improvement (QI)
criteria
You CAN make a difference.
Remember…“Every Client, Every Visit”
Thank you!
Partner Notification Options
1. Provider/DOHMH-assisted
2. Contract notification with patient
3. Anonymous notification
D. Reporting partners to NYC DOHMH:
The Law: Amended PHL Article 21
“Control of Acute Communicable Diseases”
– NYS law: every provider is responsible for
completing a Provider Report Form (PRF) for the
purpose of reporting:
• Each new HIV diagnosis
• All known partners
– At ANY time a partner becomes known
Provider/DOHMH Facilitated PN
• Elicit the names of partners from your
patients
• Conduct a domestic violence (DV) screen
• Report partners to the health department:
– Public Health Law requirement
A. Important partner information
1. Identifying info:
•
First/last name, alias, date of birth, estimated
age, gender, race/ethnicity
2. Locating information:
•
Home address, place of employment, phone #
(home, work, cellular), email
3. Physical description
•
Hair, complexion, other distinguishing
characteristic (piercing, tattoos, etc)
4. Any other information that your patient may
provide
•
HIV status of partner, pregnant, martial status
B. Conduct a DV Screen
• For each partner elicited, providers are
required, by law:
– To complete a domestic violence (DV) screen
– Assess the potential risk of DV to the patient
• If a risk for DV is identified, PN should be deferred
– Refer patient to a DV agency
B. DV Screening questions
• Do you ever feel unsafe at home?
• Are you in a relationship in which you have
been physically hurt or felt threatened?
• Have you ever felt afraid of your partner or
ex-partner?
• Has your partner or ex-partner currently or
ever:
– Pushed, grabbed, slapped, choked or kicked you?
– Forced you to have sex or made you do sexual things you
didn't want to?
– Threatened to hurt you, your children or someone close to
you?
– Stalked, followed or monitored you?
Contract PN
C. Physician’s legal status for patients
who refuse partner notification
NYS Public Health Law 63.8
Contact [partner] notification
Provider [physician] can disclose “without
the protected person’s [index] consent to:
- A contact or
- A public health officer
for the purpose of notifying a contact”
C. Partner notification- cont’d
• The following must occur:
– The provider believes the contact is at risk
of infection
– The provider does not believe the patient
will notify the partner
– The provider has informed the patient that
s/he will notify the partner
– DV screen is done and no DV risk identified
• If provider believes risk of transmission
outweighs risk of DV, provider can decide to
proceed but not required
D. Partner Report Form (PRF)
1. Know where the PRFs are located
2. For prevalent cases in which a partner is identified,
• Complete the PRF continuation form
•
Focuses on partner information
Anonymous PN
inSPOT New York City
Assisted Partner Notification via Internet
www.inspot.org
What Does the FSU Do?
• Helps HIV infected patients and their
providers notify sex and needle-sharing
partners of their exposure
• Helps notified partners get tested for HIV,
including through field-testing
• Helps HIV-positive patients and partners
to link and/or return to medical care, if
necessary
Where is FSU based?
• FSU staff are based in 10 major
hospitals/clinics in areas with high HIV
prevalence and mortality
– Bronx: Bronx Lebanon, Lincoln, Montefiore
– Brooklyn: Brookdale, Woodhull, Kings County
Hospital
– Manhattan: Harlem Hospital, NY Presbyterian,
St. Vincent’s, St. Luke’s Roosevelt
– Prison system: Riker’s
Cases reported to FSU staff
• Direct call from hospital staff
– Providers, counselors, nurses, etc
• Montefiore (Weiler, Moses, & Children’s):
– Crystal Moore 646-772-4996
• Weekly report of all western blot positive
from the hospital lab
• Report of all western blot cases from the
HIV/AIDS Registry
Person tests HIV positive
FSU
Workflow
FSU receives referral*:
Clinical staff, onsite lab, or HARS
*Review chart/consult with provider
to ensure post test counseled and
appropriate for initiation.
PHA offers HIV+
face-to-face interview
Case investigation interview
and partner elicitation
Linkage to Care:
Select PCP if needed
Prevention with
Positives
Exposure notification by
FSU or CNAP
Encourage patient to
Attend 1st appointment
Persons with unknown
Status offered testing
Newly diagnosed linked to
medical care and other services
Negatives offered
risk reduction strategies
Persons HIV+ offered
PWP and linkage to care
Which patients do we interview?
1. Newly diagnosed (including AHI)
– Also, FSU assist with returning patients who test
HIV positive but failed to return for their results
2. Patients with unresolved partner issues (no
matter duration of HIV infection) including:
– Perinatally-infected and known to be sexually
active or injecting drugs
– Pregnant
– Newly diagnosed STD
– Past or present sex or needle-sharing partners
who may be unaware of their possible exposure
A. What to emphasize regarding the
confidentiality law?
• It is against the law for the Health Department
to reveal the name of anyone with HIV
infection.
– Personal fines/penalties of up to $5,000 for each
revealed name
– A staff member could lose his or her job
• The NYC Health Department cannot give the
name of an HIV infected person to any local,
state or federal agency, including any
immigration services agency
How can you refer a patient to the FSU?
• Call your FSU PHA:
– Crystal Moore
646-772-4996
• Call the FSU call-line:
– (212) 442-6577
– Representatives are available Monday-Friday,
8:30 a.m.–4:30 p.m.
– At all other times, please leave a message
Previous CDC Recommendations
Adults and Adolescents
• Routinely recommend HIV screening in
acute-care hospital settings with HIV
prevalence >1% (NYC’s = 1.3%)
• Targeted testing based on risk
assessment in clinical settings with lower
HIV prevalence
• Based on previous recommendations,
NYC should already be routinely
screening for HIV in medical settings