Slide 1: HIV Screening in TB Clinics: A Practical Approach
Slide 2: TB-HIV

This slide shows two images of TB-HIV co-infection
Slide 3: Syndemic

The convergence of two or more diseases that act synergistically to magnify the burden of disease.

The intersection and syndemic interaction between the human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics have had deadly consequences around the world. Without adequate control of the TB-HIV syndemic, the long-term TB elimination target set for 2050 will not be reached.
Slide 4: Objectives
Upon completion of this seminar, participants will be able to:

Describe the current CDC recommendations for HIV screening of TB patients

List the barriers TB programs face in providing HIV screening to TB patients

Outline effective strategies to increase HIV screening in TB programs

Explain how TB and HIV programs can collaborate to improve prevention and treatment services for patients
Slide 5: Faculty (1)

Bill L. Bower, MPH
 Director of Education and Training, Charles P. Felton National TB Center at Harlem
Hospital
 Assistant Clinical Professor, Heilbrunn Department of Population & Family Health,
Mailman School of Public Health, Columbia University

Philip Peters, MD

Medical Officer, HIV Clinical Epidemiology Team

The Centers for Disease Control and Prevention, Atlanta, GA
Slide 6: Faculty (2)

Adrian Gardner, MD, MPH

Assistant Professor

Service Organization Warren Alpert Medical School at Brown University

Providence, RI

Mark Hodge, MS, BSN, RN

Nurse Administrator

Montgomery County Health Department, MD

Susan Nutini, RN
 Clinical Nurse
 The Miriam Hospital RISE Clinic, Providence, RI
Slide 7: Polling Question

Approximately how many contacts to TB cases do you manage to screen for HIV?
 0-25%
 26-50%
 51-75%
 76-100%
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Slide 8: HIV Screening for Patients 13-64 years: A Guide for TB Clinic Providers
Phillip Peters, MD
The Centers for Disease Control and Prevention
August 28, 2012
Slide 9: 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
Slide 10: Question

What is responsible for the greater than 95% decline in perinatally acquired AIDS in the US?
 Widespread HIV screening of all pregnant women
 Antiretroviral use during the antenatal, perinatal, and newborn periods
 Reduction in number of pregnant women with HIV infection
 1 & 2
Slide 11: 2006 Revised Recommendations

This image shows the Revised Recommendations document.
Slide 12:
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
Slide 13: 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
Slide 14: Estimated HIV Prevalence in the United States, 2008

This image shows a map of the US with the estimated HIV prevalence
Slide 15: Geographic Comparison of Rates of AIDS Diagnoses and Tuberculosis Cases in the United States

These two figures show the rates of AIDS diagnoses by Metropolitan Statistical Area and the rate of TB cases by state.
Slide 16: Why Routine Screening?

Patients do not always disclose or may not be aware of their risk
 39% of men who had sex with a man within the past year did not disclose to their health care provider
 51% of rapid test positive patients identified in Emergency Department (ED) screening had no identified risk
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Slide 17: 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 study

Risk-based testing frequently misses
 Young people (< 24 years)
 Women and heterosexual men
 Members of racial and ethnic minorities
 People residing outside of urban areas
Slide 18: Late Diagnosis of HIV Infection

This chart shows the percentage of patients diagnosed with HIV late in the course of infection.
Slide 19: Probability Curve of Mortality According to Baseline CD4 Cell Count

This chart shows the prognosis over 5 years of HIV-infected, treatment-naive patients who are starting antiretroviral therapy.
Slide 20: Tuberculosis and HIV

A high proportion (7.9%) of people with tuberculosis disease in the US are HIV infected

Compared with HIV-negative patients, HIV-infected patients with Mycobacterium tuberculosis infection are markedly (21 – 34 times) more likely to develop active tuberculosis disease
Slide 21: Antiretroviral Therapy Reduces Rates of Sexual Transmission of HIV

This graph shows antiretroviral therapy reduces heterosexual HIV transmission by 96% in discordant couples
Slide 22: Desired Outcome of Routine HIV Screening

This image show a chain of events that HIV screening leads to new, early HIV diagnoses which leads to clinical care

This chain of events results in two outcomes: first it improves the quality of life and survival of patients who have HIV infection and second it decreases the risk of transmission of HIV infection to others.
Slide 23: 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
 Include testing reminders in patient’s electronic medical record

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
Slide 24: Implementing HIV Screening (cont’d)

State Laws Regarding HIV Testing
 Requirements to obtain written consent are being phased out.
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 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/
Slide 25: Communicating Positive HIV Test Result

Provide result by direct personal contact

Provide result confidentially

Ensure patient understands test result

Connect to services
Slide 26: Rapid HIV Tests

These images show different rapid HIV tests
Slide 27: 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
Slide 28: Time to detection of HIV RNA, p24 antigen, and antibody during early HIV infection

This graph shows another problem with rapid testing and HIV testing in general; we have not been able to detect the earliest phase of HIV infection called acute HIV infection because there is an antibody window period
Slide 29: Time to detection of HIV RNA, p24 antigen, and antibody during early HIV infection

This graph shows the HIV infection window period
Slide 30: 4 th Generation Combo Ag/Ab Assay

Detects p24 antigen and HIV antibody

Time to result: 29 minutes

100 results/hour

FDA-approved June 22, 2010
Slide 31: 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
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Slide 32: Opt-Out HIV Testing in U.S. Tuberculosis Clinics: A Survey of Current Practice and Perceived Barriers

Adrian Gardner MD, MPH
 Assistant Professor of Clinical Medicine, Infectious Diseases, Indiana University School of Medicine
 Assistant Professor of Clinical Medicine (Adjunct), Alpert School of Medicine at Brown
University
 Visiting Lecturer, Moi University School of Medicine, Eldoret, Kenya
Slide 33: Disclosures

No relevant conflicts of interest

Survey conducted and analyzed by Caitlin Naureckas as part of her senior undergraduate thesis work (Brown University)

Presented at the 16 th Conference of The Union North American Region (2012) in San
Antonio, TX

Manuscript is in progress
Slide 34: Methods
 Online Survey Monkey® survey designed to assess the extent of opt-out HIV testing as well as TB providers’ knowledge and perceptions of the current CDC guidelines

No comprehensive list of TB providers in US

Survey was sent to 2011 National TB Conference attendees, National TB Nurse Controllers, and the CDC’s TB-educate mailing list
Slide 35: Results and Limitations

158/2522 (6.3%) responded
 Self-selected group (? bias)
 Limited generalizability of conclusions
Slide 36: Results: Demographic characteristics of respondents

Occupation
 91 (59.5%) nurses
 30 (19.6%) physicians
 19 (12.4%) public health practitioners
 13 (8.5%) other

Geography
 39 states were represented

Experience
 104 (66%) reported >5 years in TB care
Slide 37: Results: How important is HIV Testing?

This graph shows the respondents thought HIV testing was more important in those with active TB or those suspect active TB compared with those who are contacts or those with latent TB infections.
Slide 38: Results: Current Practice

This graph shows 92% of people reported that the patients with TB disease were always or almost always HIV tested
Slide 39: Results: Barriers
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
This graph shows some of the barriers to incorporating routine opt-out HIV testing for all patients
Slide 40: Results: Informed Consent for Testing

59 (38.6%) respondents reported their state required written consent for HIV testing

12 of those (7.8% of total respondents) are from states that actually required written consent at the time of survey distribution

One (0.7%) respondent from a state with laws requiring written consent stated it was not compulsory

7 (4.6%) reported they did not know whether written consent was required
Slide 41: Results: Perceived Feasibility

This graph shows despite the barriers that are identified, a majority of respondent are either already doing this or believe it to be feasible and acceptable in their clinical setting.
Slide 42: Conclusions

Significant work must be done to promote the integration of opt-out HIV testing into routine care of all patients affected by TB —by either infection or disease
 Fewer than half of respondents’ care settings have an opt-out HIV testing policy for LTBI patients, indicating a true missed opportunity

Although providers tend to report acceptance of the need for universal testing of TB affected patients, they cite a long list of barriers, some of which are no longer valid (i.e. HIV consent procedures by state)
 This represents a teachable moment as well a potential funding partnership for TB care
Slide 43: Contact Information

Caitlin Naureckas MD (2016) ( Caitlin_Naureckas@brown.edu
)

Adrian Gardner MD, MPH ( adriangardner1@gmail.com
)

E. Jane Carter MD ( E_Jane_Carter@brown.edu
)
Slide 44: TB and HIV: Working Together

Mark Hodge
 Nurse Administrator
 Montgomery County DHHS
 TB Control and Prevention
Slide 45: Where’s Montgomery County?

This image shows a map of Montgomery County in Maryland
Slide 46: Montgomery County TB

In 2011 MC had 73 active TB cases, 7.6 cases/100,000; double the U.S. case rate

Montgomery County sees one-third of all active TB cases in the State of Maryland

Non-Hispanic blacks and African Americans represented 33% of active TB cases in 2011

In recent years, 5-8% of persons with active TB are co-infected with HIV
Slide 47: Montgomery County HIV

In 2008 (most recent numbers available) MC had 3008 cases of HIV/AIDS, 316 cases/100,000; double the U.S. case rate

NonHispanic blacks or African Americans represent 16% of the county’s population and
71% of the HIV cases diagnosed in 2008
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Slide 48: Working Together

HIV and TB are located in the same building at 2000 Dennis Ave, Silver Spring, MD

Also co-located with STD, Disease Control, Immunization and Refugee Health programs

All program managers in the building meet monthly

Summer picnic and December holiday party for all staff in the building
Slide 49:

This slide shows an image of the TB clinic in Montgomery County
Slide 50: HIV Testing

HIV testing is provided as a service of the Montgomery County STD clinic to all county residents

All clients with active TB are offered an HIV test by TB Nurses when all other labs are drawn
– it is included in the consent and discussion of care from the beginning

Very rare to have someone refuse HIV testing since we are already sticking them for other tests

Known HIV status 69% in 2007, 84% in 2011
Slide 51: Treatment for Active and Latent TB in HIV+ Clients

Patients are co-managed

All treatment for active and latent TB is done in the TB clinic; HIV care provided in the HIV clinic

One nurse case manager in TB Control and one nurse case manager in HIV are responsible for all co-infected patients
Slide 52: Barriers no more?

Language
 Staff interpreting
 Language Line

Cultural beliefs around HIV and TB
 Cultural Competency Training
 Experience with different populations

Documentation in 2 different charts
 Electronic Medical Records –coming soon!

Small numbers sometimes means skewed data
Slide 53: TB Program

This image shows the interior of the TB building in Montgomery County
Slide 54: Successes

Communication
 HIV Clinic and TB Clinic work very closely together to share results and treatment responsibilities
 RN to RN contact
Slide 55: Successes

Collaboration
 HIV Clinic has a grant to increase numbers of blacks and African Americans tested for
HIV. Since the TB Clinic does approximately 30 QFTs every Tuesday, this was a great
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opportunity for the HIV clinic to put a staff member in the TB Clinic to offer HIV testing since the clients were already getting stuck
Slide 56: Contact Information
Mark Hodge, M.S., B.S.N., R.N.
2000 Dennis Ave, Suite 150
Silver Spring, MD 20902
240-777-1574 (office)
240-777-4899 (fax)
Mark.Hodge@montgomerycountymd.gov
Slide 57: Implementing HIV Testing in the Rhode Island TB Clinic

Susan Nutini, RN
 RISE TB Clinic
 The Miriam Hospital
 Providence, RI
Slide 58: Rhode Island

These images show a map of Rhode Island and a photo of the RISE TB Clinic
Slide 59: Rhode Island

Rhode Island ~ 1 million people

Capital city: Providence ~ 180,000 people
 Large immigrant population (29.2% foreign born)

Single TB clinic based at The Miriam Hospital
 25-50 cases of active TB annually
 ~1000 cases of LTBI annually

Estimate 4000-4500 prevalent HIV cases
 1400 patients in care at The Miriam Hospital HIV clinic
Slide 60: Demographic Characteristics of RI HIV Cases, Jan 1, 2006 to Dec 31, 2010

This table shows a broad overview of HIV cases in Rhode Island. As you can see, the predominant risk factor – is men-having-sex-with-men. And the greatest population of HIV positive is in the Providence area.
Slide 61: Case History

33 year old woman was referred to TB clinic for evaluation of TST (22x22mm) noted during pre-natal care

She had been part of a contact investigation 14 years earlier, was found to be TST + and had initiated but not completed INH treatment

At her TB clinic visit during pregnancy, she had no symptoms and a normal chest radiograph.

Treatment for LTBI was deferred until post-partum
Slide 62: Case History (continued)

Following her TB clinic appointment, she underwent HIV testing during her prenatal care and was found to be HIV +

She was referred to HIV clinic for initiation of ARVs/PMTCT but her HIV status was not communicated to the TB clinic
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
Following delivery, she defaulted from HIV care and did not keep her appointment in TB clinic
Slide 63: Case History (continued)

Three years later, she developed GI symptoms associated with fever and was eventually diagnosed with abdominal TB (retroperitoneal lymph node biopsy smear and culture positive)
Slide 64: HIV testing in TB clinic

Case prompted MDs to consider incorporating routine HIV testing of all new TB and LTBI patients

Pilot trial was started at Tuesday evening clinic sessions
Slide 65: Barriers to starting HIV testing (1)

Reluctance of staff to add one more task in a busy clinic setting

Discomfort of staff members discussing HIV and offering testing

Written consent forms were time consuming and only available in English and Spanish

RI changed law to require verbal consent only

How to get testing kits, who pays?
Slide 66: Barriers to starting HIV testing (2)

Lack of lab space for specimen

Disruption of patient flow in clinic

Would patients be driven away with the mention of HIV testing?

Need for staff to be trained and certified in procedure
Slide 67: Pros for Starting Testing

Important that individuals be screened and referred for HIV treatment if positive
 Important in stratifying patients’ risk of developing active TB

Easy access to HIV care: Hospital immunology clinic right next door

Compliance with CDC guidelines
Slide 68: Overcoming Barriers (1)

Despite staff reluctance (myself included), we gave it a shot

All nurses were trained and certified (1 hour training)

After initially borrowing supplies left over from a research study, funding was built into the grant that supports TB care

With practice, staff became proficient and more comfortable initiating testing

Surprisingly, patients were not upset and were excited to be able to get immediate results
Slide 69: Overcoming Barriers (2)

RI changed consent law and the hospital implemented verbal consent – this was a great help!

Main ob stacle for the staff was that we couldn’t spend 20 min in room waiting for test to run
– disrupted flow
 Working with MDs, we set up a secure site in MD office where specimens could be labeled, test run with timer for each, and MDs or staff could check results when timer went off
9

Slide 70: Overcoming Barriers (3)

Despite all the perceived barriers, we now have a smoothly running system
 Testing initiated by RN
 Post-test counseling done by MDs or RN
 Patients with positive rapid test immediately seen by MD and staff from immunology clinic involved as soon as possible
Slide 71: Results to date

Over 1000 patients tested

Two patients newly diagnosed with HIV
Slide 72: Case 1

Young, foreign-born (Eastern Europe) woman who had PPD done for employment
 TST +, CXR normal
 Single, monogamous with boyfriend of 3 yrs
 HIV result from lab-based testing (not rapid)

Shocked by her HIV diagnosis
– not expected by patient or by staff

Confirmatory testing performed and linked to HIV care (initial CD4 ~ 900)

Successfully completed LTBI treatment

Actively followed in HIV clinic, not yet on ARVs
Slide 73: Case 2

Young woman from West Africa, recently immigrated
 Skin tested to begin work as volunteer nursing assistant
 TST +, CXR normal
 Rapid HIV +

Immediately seen by TB clinic MD, and SW from HIV clinic

Patient initially refused to believe the results

HIV social worker continued engaging re. HIV while we focused only on her LTBI care

Completed confirmatory testing at related hospital, CD4 ~ 300

As of June, 2012, started anti-retroviral therapy

Still receiving treatment for LTBI
Slide 74: Lessons Learned

Universal opt-out HIV testing in the RI TB Clinic is feasible, practical, and well-accepted by staff and patients

Contrary to pre-implementation staff predictions, patient refusal rates were low

Potential barriers can be overcome

HIV testing in this setting may be an effective way of reaching populations that do not otherwise have access to testing
Slide 75: References

Gardner, A, Naureckas,C, Beckwith, C, Martin, C
& Carter, EJ. 2012. “Experiences in implementation of routine human immunodeficiency virus testing in a US tuberculosis clinic.”
Int J Tuberc Lung Dis, 16(9): 1241-1246.
 http://www.ncbi.nlm.nih.gov/pubmed/22793872

Rhode Island Department of Health, Rhode Island STD and HIV Epidemiology Survey.
December 2, 2011.
 http://www.health.ri.gov/publications/epidemiologicalprofiles/2010STDAndHIV.pdf
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Slide 76: Questions and Discussion

If you wish to ask a question or make a comment:
 Un-mute your phone by pressing #6
 After your question, re-mute your phone by pressing *6

Type your questions to host and panelists; priority will be given to verbal questions
Slide 77: Background Documents

These images show two factsheets on TB and HIV
Slide 78: INFORMATION LINE 1*800*4TB*DOCS (482-3627)
Slide 79: Thank you for your participation!!
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