Routine HIV Screening in Health Care Settings

Background and Definitions

David Spach, MD

Clinical Director

Northwest AIDS Education and Training Center

Professor of Medicine, Division of Infectious Diseases

University of Washington Seattle

This project was funded under cooperative agreement number U65/PS000821 from the Centers for Disease Control and Prevention (CDC). 
Routine HIV Screening in Health Care Settings
Slide Set Topics
• Background & Definitions

• HIV Epidemiology Update

• Rationale for Routine HIV Screening

• 2006 CDC HIV Screening Recommendations

• Overcoming Barriers to Routine HIV Screening

• Diagnostic Tests

• Counseling and Linking to Care

Routine HIV Screening in Health Care Settings
Master Slide Set Topics
• Background & Definitions

• HIV Epidemiology Update

• Rationale for Routine HIV Screening

• 2006 CDC HIV Screening Recommendations

• Overcoming Barriers to Routine HIV Screening

• Diagnostic Tests

• Counseling and Linking to Care

Source: CDC. MMWR 2006;55(no. RR-14):1-17.
 Goal of Routine HIV Screening

Medical
Medical

Care
Care

HIV
HIV HIV
HIV
Link
Link to
to Care
Care
Screening
Screening Diagnosis
Diagnosis

Prevention
Prevention

Services
Services
Desired Outcome of Routine HIV Screening

Improve
Improve Survival
Survival
&
&
Quality
Quality of
of Life
Life

HIV
HIV HIV
HIV
Link
Link to
to Care
Care
Screening
Screening Diagnosis
Diagnosis

Prevent
Prevent New
New HIV
HIV Infections
Infections
 Routine HIV Testing in Health Care Settings
Definitions
• Diagnostic testing. Performing an HIV test for persons with clinical signs or symptoms consistent with HIV infection.

• Screening. Performing an HIV test for all persons in a defined population.

• Targeted Testing. Performing an HIV test for subpopulations of persons at higher risk, typically defined on the basis of behavior, clinical, or demographic

characteristics.

• Informed Consent. A process of communication between patient and provider through which an informed patient can choose whether to undergo HIV testing or

decline to do so.

• Opt-out Screening. Performing HIV screening after notifying the patient that 1) the test will be performed and 2) the patient may elect to decline or defer

testing. Assent is inferred unless the patient declines testing.

• HIV-Prevention Counseling. An interactive process of assessing risk, recognizing specific behaviors that increase the risk for acquiring or transmitting HIV, and

developing a plan to take specific steps to reduce risks.

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

 Missed Opportunities for Earlier HIV Diagnosis

Study
StudyBackground
Background

--Data
Dataanalyzed
analyzedfor
forHIV
HIVcases
casesininSC
SCfrom
from2001-2005
2001-2005

--HIV
HIVcases
casescross-linked
cross-linkedtotoall
allhealth
healthcare
carevisits
visits

--4,315
4,315cases
casesofofHIV
HIVininSouth
SouthCarolina
Carolina

Source: Centers for Disease Control. MMWR. 2006;55:1269-72.

 Missed Opportunities for Earlier HIV Diagnosis

Chart Title

Other Late Tester

58.7% 41.3%

Late
LateTester
Tester==AIDS
AIDSDiagnosed
Diagnosedwithin
within11Year
YearofofHIV
HIVDiagnosis
Diagnosis

Source: Centers for Disease Control. MMWR. 2006;55:1269-72.

 Missed Opportunities for Earlier HIV Diagnosis

Chart Title

Among All Late Testers

Other Late Tester
73% with Prior Visit to
58.7% 41.3%
Health Care Facility

Late
LateTester
Tester==AIDS
AIDSDiagnosed
Diagnosedwithin
within11Year
YearofofHIV
HIVDiagnosis
Diagnosis

Source: Centers for Disease Control. MMWR. 2006;55:1269-72.

 CDC Analysis of HIV Reporting Data, 1996-2005

Study
StudyBackground
Background

--Data
Dataanalyzed
analyzedfrom
fromHIV
HIVreporting
reporting1996-2005
1996-2005

--34
34US
USstates
states

--NN==281,421
281,421persons
personsreceiving
receivingdiagnosis
diagnosisofofHIV
HIV

Source: Centers for Disease Control. MMWR. 2009;58:661-5.

 CDC Analysis of HIV Reporting Data, 1996-2005

Chart Title
Late Tester

38.3%

Other

61.7%

HV
HVTesting
TestingininRelation
RelationtotoAIDS
AIDSDiagnosis
Diagnosis

Late
LateTester
Tester==AIDS
AIDSdiagnosis
diagnosis<<11year
yearofofHIV
HIVdiagnosis
diagnosis

Source: Centers for Disease Control. MMWR. 2009;58:661-5.

 CD4 Cell Count at Time of HIV Diagnosis

HIV Infection

3
36% with CD4 < 200 cells/mm

Study
StudyBackground
Background
- -NN==2223
2223HIV-infected
HIV-infectedpersons
persons
- -Community
Communityclinics
clinicsininlarger
largerurban
urbanareas
areas
- -Evaluated
EvaluatedCD4
CD4count
countatattime
timeofofHIV
HIVdiagnosis
diagnosis

Source: Dybul M, et al. J Infect Dis. 2002;185:1818-21.

 CD4 Cell Count at Time of HIV Diagnosis

HIV Infection

3
34% with CD4 < 200 cells/mm

Study
StudyBackground
Background
- -NN==759
759HIV-infected
HIV-infectedpersons
persons
- -Analysis
Analysisofofstatewide
statewidedata
dataininSouth
SouthCarolina
Carolina(2004-5)
(2004-5)
- -Evaluated
EvaluatedCD4
CD4count
countatattime
timeofofHIV
HIVdiagnosis
diagnosis

Source: Ogbuanu ID, et al. Am J Pub Health. 2009;Suppl1:111-17.

 Acute HIV: Clinical Manifestations

Signs and Symptoms of 160 Patients with Acute HIV

Source: Vanhems P, et al. AIDS. 2000;14:375-81.

 Laboratory Studies with Initial HIV Infection
High Level Viremia Precedes Detectable Antibodies

HIV RNA Antibody Titer

Detectable Antibody

Infection
Laboratory Studies with Initial HIV Infection
“Window Period”

Window Period
 Laboratory Studies with Acute HIV

•• Positive
PositiveHIV-1
HIV-1RNA
RNAAssay
Assayand
andNegative
NegativeHIV
HIVAntibody
AntibodyTest
Test

Acute HIV

HIV RNA Antibody Titer

Detectable Antibody

Infection
 Testing for HIV
•• Recommended
RecommendedininPatients
Patientswith
withClinical
ClinicalManifestations
ManifestationsofofHIV/AIDS
HIV/AIDS

Oral Candidiasis Kaposi’s Sarcoma

Oral Hairy Leukoplakia Pneumocystis pneumonia

Images
ImagesSource:
Source:HIV
HIVWeb
WebStudy
Study(www.HIVwebstudy.org)
(www.HIVwebstudy.org)
 Mortality and HAART Use Over Time
HIV Out-Patient Study, CDC, 1994-2003

Source: Centers for Disease Control and Prevention.

 Per Person Survival Gains with Various Interventions
for Chronic Diseases in US

Source: Walensky RP, et al. J Infect Dis. 2006;194:11-19.

Figure Reproduced with permission from University of Chicago Press
 Correlation of Baseline CD4 Cell Count and Outcome
after Staring Antiretroviral Therapy

Study
StudyBackground
Background
- -NN==12,574
12,574HIV-infected
HIV-infectedadults
adultsstarting
startingantiretroviral
antiretroviraltherapy
therapy

Source: Egger M, et al. Lancet. 2002;360:119-29.

Acknowledgement
This project was funded under cooperative agreement
number U65/PS000821 from the Centers for Disease
Control and Prevention (CDC).