HIV Testing Just Got A Lot Easier:
Putting ACTS into Action
AETC NRC Training Exchange
May 23, 2006
Donna Futterman, MD
Stephen Stafford
Today’s Agenda
 The Tipping Point for Routine HIV Testing
 The Evolution / Intelligent Design of HIV C&T
 Results from ACTS in Action
 A User’s Guide to the ACTS Approach & Tools
 ACTS Role Play
 Questions & Discussion
2
Unfinished Business

HIV is the worst epidemic in history

40,000 new cases each year; 25-50% among youth

1 in 4 (300,000) HIV+ Americans don’t know
they’re infected

80% of young HIV+ gay and bisexual men didn’t
know their status

41% of those diagnosed HIV+ were diagnosed with
AIDS within one year of their positive HIV test
3
Taking Care of Business
 Case finding hasn’t kept up with treatment
advances
 Patients overwhelmingly accept HIV testing
when a provider recommends it
 The mobilization for prenatal testing
missed a golden opportunity to routinize
screening for all, but it remains a successful
model for how to proceed
4
Routine Testing: The Benefits
REDUCES HIV TRANSMISSION
 HIV+ people who know their status reduce
high-risk sex by about 50%
 Lower viral loads from ARVs also reduce Tx
PROLONGS LIFE
 HIV treatment can increase survival by many
years and improve quality of life
5
Routine Testing: Best Practice
 2003, CDC issues “Advancing HIV Prevention:
New Strategies for a Changing Epidemic” calling
for routine testing in communities with ≥ 1% HIV
prevalence
 2005, routing testing found cost/care effective in
settings with ≥ .05% HIV prevalence
 CDC, HRSA & DOHs working toward routine
testing by streamlining counseling & consent
 ACTS makes provider-delivered routine testing
feasible in various care settings
6
Keeping Up with the Times
1986
2006
Environment
 No effective treatment
 Discrimination against
those infected: MSM, IDU,
immigrants & sex workers
Environment
 Many effective treatments
 HIV discrimination
reduced & at-risk
populations have changed
Policy
 C&T regulations often
written to limit testing:
Policy
 C&T regulations remain
largely unchanged:
 mandated counseling
 written consent
 separates C&T from
routine medical care
 prevention value of pretest counseling minimal
7
Why Don’t Providers
Routinely Test?
 2001 qualitative research investigated HCP
motivators and barriers impacting HIV
testing of adolescents
 Commissioned by AAP, conducted by
professional qualitative research firm
 Interviewed 55 Bronx-based providers and
administrators in public and private settings
 Key findings informed ACTS initiative
8
“Not Enough Time,
Not Enough Experience,
Not Aware of Risk”
 Found that conventional HIV testing is:
 time-intensive
 specialized
 stigmatized
 separated from routine care
9
It’s Time for a
Paradigm Shift!
HIV testing has become such a huge obstacle that
many providers and patients prefer to sail around it.
1
The Provider Imperative:
Less Referring, More Screening
 YOU can help solve the solvable problem of
finding the ±300K unidentified HIV+ patients
 YOU can provide links to effective prevention
counseling
 YOU can engage HIV+ patients into early care
 YOU are an essential player in the team that
will meet public health HIV/AIDS goals
11
Fast Facts on ACTS
ACTS is a concise, comprehensive system that
makes provider-delivered HIV testing feasible
in clinical care settings
 Provides instruction & tools for making
operational and clinical practice changes
 Meets CDC and DOH testing requirements
 Condenses 45-minute process to 5-10 minutes
 Allows for better allocation of counseling
resources
12
ACTS in ACTION
Results from a Randomized Control Trial

10 Bronx clinics randomized to receive ACTS
rapid counseling in late 2004



Divided into 5 ACTS Sites & 5 Control Sites
Data collected on HIV testing rates
Eligible patients included those age 15-64,
non-maternity patients
13
ACTS in ACTION
ACTS Sites Double HIV Testing Rates
25%
20%
15%
10%
5%
0%
2003
2004
Control Average
2005
ACTS Average
14
Elements of the ACTS System
 Meeting with the HIV coordinator, clinic
administrator and medical director to develop
implementation plan
 Academic detailing session(s) to train clinic
staff on ACTS
 ACTS manual and toolkit containing
information, materials and resources for
providers, clinic staff and patients
15
Laying the Foundation for
ACTS with Key Staff
Address Philosophical Barriers



Skepticism about patients’ HIV risk
Other health problems viewed as priority
Concerns about loss of prevention
Address Logistical Barriers




Which staff will test
Documentation & consent forms
Patient flow & results follow-up
Billing issues
16
ACTS Site Prep Checklist
17
Training Staff to Utilize ACTS
Academic Detailing



Provider-led training
Catered
Follow-up trainings with new staff
Ongoing Support


Regular meetings with key staff to problemsolve barriers
Ongoing data reporting to all staff via meetings
and newsletters
18
ACTS Materials
19
It’s All in the Manual
Part I – ACTS HIV Counseling and Testing System
ACTS Pocket Card
Talking Points for Translating ACTS into Action
Essential Forms
Patient Education
concise
Part II – ACTS Backgrounders
Chapter 1 – HIV Counseling: Delivering Results
Chapter 2 – HIV Testing Procedures
Chapter 3 – Working with Special Populations
Chapter 4 – Prevention Essentials
Chapter 5 – The ACTS Imperative
comprehensive
Part III - Resources
20
The Pocket Guide to ACTS
21
ACTS Talking Points
22
Forms
23
ACTS Chart Stickers
24
ACTS Update Newsletter
25
Patient HIV Info Brochures
26
The Deal
27
The “A” in ACTS
28
Talking Points
Page 10
ACTS PRE Screen
Page 24
Transmission Basics: The
Risk Continuum Concept
Page 75
Reality-Based
Prevention Counseling
Page 78
Taking a Sexual and
Drug Use History
Page 77
29
The “C” in ACTS
30
The “T” in ACTS
31
The “S” in ACTS
32
Talking Points:
Delivering HIV+ Results
 Give results and allow time to process
• Rapid
• Conventional
 Discuss meaning of results
 Provide support
 Link to care
 Discuss prevention
 Review HIV reporting and partner notification options
 Screen each name for domestic violence risk
33
Putting ACTS into ACTION:
Who Benefits?
Your Patients
Your



Practice
Do what many providers can’t / won’t do
Bill for additional counseling visit
Participate in national pilot intervention
Our Community
 Help us fine-tune ACTS; understand how it works
 Do your part to make ACTS a model for others
 Be on record as having solved this problem!
Public Health
34
ACTS in ACTION
Future Plans for ACTS




Continued regional & national dissemination
Presentation of ACTS at 2006 International
AIDS Conference & Ryan White Clinical Care
Conference in August
Expansion of ACTS to Bronx control sites in
September 2006
Ongoing implementation:
•
•
•
CDC-sponsored South Africa Youth Clinics
Pediatric ER at Montefiore
National Assembly on School-Based Health Care
35
Hearing ACTS in Action
Alex



36 year old white male
Engaged to be married in 6 months
Visiting for routine BP check-up
Keisha



40 year old African American woman
Divorced mother of 3, dating 1 man exclusively
Visiting for a vaginal infection
36
Questions & Discussion
37
Take a few moments to
evaluate this presentation.
Visit
http://www.aidsetc.org/aidsetc?page=cf-acts-eval
to quickly submit your comments
38
Contact Us / Order Materials
Donna Futterman, MD
DFutterman@AdolescentAIDS.org
Stephen Stafford
StephenS@AdolescentAIDS.org
Michelle Lyle, MPH
MLyle@AdolescentAIDS.org
Adolescent AIDS Program
Children’s Hospital at Montefiore
718-882-0232
AdolescentAIDS.org
5.23.06