Welcome to CDC course: “Fundamentals of Waived Rapid HIV Testing and Prevention Counseling”

1. Welcome to CDC course:“Fundamentals of Waived Rapid HIV Testing and Prevention Counseling” Sponsored by the Northwest AIDS Education and Training Center and the Idaho Family Planning, STD and HIV Program Your Trainers Today: Judy Thorne, MPA HIV Education Coordinator, Master of Public Health Program, Idaho State University/Boise and Jan Nissl, RN Healtwise, Inc. and St. Luke’s Regional Medical Center

2. Thank you for having us!Goals for today… • Reminder: completion of forms (PIF’s, evaluations) Learning Objectives: • Identify at least 2 benefits to waived testing • Understand the testing/counseling process • Role play the client-centered approach • Problem solve potential rapid test scenarios • Develop local referrals/resources

4. What are the current stats for HIV and AIDS?

5. Australia & New Zealand 15,000 Adults and Children Living with HIV/AIDS Eastern Europe 1 million Western Europe 550,000 N. America 1.2 million Asia & Pacific 6.6 million North Africa 500,000 Caribbean 420,000 Sub-Saharan Africa 28.5 million Latin America 1.5 million Total: 40+ million Data from UNAIDS

6. Idaho’s numbers?

7. HIV in Idaho – Prevalence **Idaho diagnoses only, with additional 20-25% undiagnosed HIV AIDS • District 1 57 73 • District 2 29 30 • District 3 63 77 • District 4 248 199 • District 5 51 54 • District 6 48 43 • District 7 37 34 • Total 533 511 1,044 (As of Sept. 2008)

8. True/False: The 40-49 yr old age group is most affected by HIV in Idaho

9. Idaho HIV positive by age at diagnosis

11. Older Adults 11-15% of U.S. AIDS cases in over 50 group Challenges: access to health care, income, social support minority and ethnic groups age stigma barriers: misdiagnosed OIs

12. 2006 CDC Guidelines • Routine voluntary screening for all persons aged 13-64 (normalize testing) • Opt-out testing and counseling not required • Repeat HIV screening yearly for those with known risk • Routine screening for all pregnant women -repeat screening in 3rd trimester in areas with high HIV rates

13. Rapid HIV Testing • Provides same-day results. • Detects HIV antibodies (exposure) not virus • Offsets no-return rate (2.1 million tests yearly) • 31% of positives do not return for results. • 39% of negatives do not return for results. • Increases ability to reduce new HIV infections (CDC). • Allows people to know their status (21% are unaware of their HIV infection).

14. What are some advantages for rapid testing?

15. Advantages of Rapid Test • Know HIV status (KYS) • Earlier access to care for all clients • Decreased transmission • Effective treatment available • Healthcare workers • Cost effective • Success stories – pregnancy (decline in neonatal transmission to <1%)

16. What symptoms might a person present with?

17. Fever Lymphadenopathy Pharyngitis Rash Myalgia/arthralgia Diarrhea Headache Nausea/Vomiting Hepatosplenomegaly Weight loss Thrush Neurologic symptoms 96% 74% 70% 70% 54% 32% 32% 27% 14% 13% 12% 12% Acute Retroviral Syndrome  CDC. Guidelines for using antiretroviral agents…MMWR 2002;51(RR-7)

18. Opportunistic Infections

19. What populations of people may not actively seek testing and why?

20. Missed Opportunities for Testing • Pregnant women: • Who do not receive regular if any prenatal care • Who are not offered testing • Immigrant populations • Injection drug users • Homeless individuals • Historically; lesbian, gay, bisexual, transgender, questioning (LGBTQ) individuals do not seek care • Those not considered at risk (i.e. older adults)

21. Why advocate for rapid HIV testing?

23. 2007 Updated HIV Treatment Guidelines • Antiretroviral therapy should be initiated in patients with history of an AIDS defining illness or with a CD4 T-cell count <350 cells/mm3 • Treatment for the following groups regardless of CD4 T-cell count: • pregnant patients • patients with HIV-associated nephropathy • patients co-infected with hepatitis B when treatment for hepatitis B virus is indicated *Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents December 1, 2007

24. What is HIV

25. Life Cycle of HIV-1

26. Penetration Uncoating Reverse Transcription Integration Transcription Translation Processing Assembly Release Antiretroviral Strategies Fusion Inhibitors Entry Inhibitors CD4 Analogues NRTI’s NNRT’s Integrase Inhibitors TAT Inhibitors Protease Inhibitors Interferons Maturation Inhibitor

27. Resources for Consultation • Local experts identified for PEP (ID consultant, hospital epidemiologist) • National Clinicians’ Postexposure Prophylaxis Hotline (PEPline), telephone 888-448-4911.

28. HIV Services Clinics in Boise, Pocatello, Spokane serving north Idaho (Ryan White Grantees) • Counseling and confidential testing • Comprehensive medical care • Case management • Adherence counseling • Mental health • Support groups • Clinical trials • Education

29. Web Sites to Access the Guidelines • http://www.aidsetc.org • http://aidsinfo.nih.gov • http://www.cdc.gov

30. Guidelines • http://aidsinfo.nih.gov/guidelines/

31. State Laws Applicable to HIV Testing and Counseling Idaho Reportable Diseases (39-602) Confidentiality and Disclosure (39-609) (relates to informed consent) Unlawful to Transmit (39-608) Minors – Consent to Treatment (39-3801) Public Law 104-146 Spousal Notification “good faith effort be made to notify marriage partners”

32. Idaho Code web-site link www. idahohealth.org (click on STD/AIDS information, Idaho Code)

34. Overview Integrating HPC into the Rapid HIV Test Process QA Tasks Throughout the Rapid Test Process: Program Management Training, Documentation and Records Troubleshooting Safe Work Practices • Introduce & orient client to session • (includes obtaining informed consent & assessing readiness) • Identify client’s risk behavior & circumstances • Identify client’s safer goal behavior • Develop action plan • Make referrals & provide support • Summarize & close session HIV Prevention Counseling Steps

35. Integrating HIV Prevention Counseling with Rapid HIV Testing STEP 1 HPC Risk Screening* Provide Information on tests and obtain The Six Steps of informed consent HIV Prevention Counseling Conduct Assess clients’ (HPC) STEPS readiness to take test 4, 5, & 6 of HPC & receive test results 1. Introduce and orient the in the same day client to the session 2. Identify client's risk behavior and circumstances Give test results Facilitate HIV 3. Identify client's safer Explain the meaning testing process: goal behavior and facilitate a QA Testing Universal confirmatory test, if Precautions 4. Develop an action plan preliminary positive 5. Make referrals and provide support Conduct 6. Summarize and close STEPS 2 & 3 of the session HPC (While the Interpret results test is being processed)

36. Why do you need my name?

37. Discuss & Explain Informed Consent Names-reporting State Confidential Testing Age or Parental Consent

38. It’s not about you…

39. It is all about me…(as in your client) • I want to be comfortable. • Is your testing environment appropriate? • I want to leave satisfied. • Are they leaving with what they came in for? • I want to be listened to and heard. • Are you making eye contact? Is your paper away? Are you out from behind that desk? • I would like answers to my questions • The customer is always right

40. HIV and AIDS

41. The Basics • HIV antibody test not AIDS Test • Transmission • Think through a reactive result today. What would comfort them?

42. So what does that mean?

43. The results are in… • Be prepared to explain and speak correctly about the test you have chosen. • Preliminary Positive/Reactive NOT Positive • Manufacture’s Guidelines • Screening vs. Confirmatory • This all can be given to them beforehand

44. Window Period

45. So I had unprotected sex last night… • Three Months (97%) • Many within 25 days • 6 months for those in high risk categories • IDU, Partners of POZ – in some cases HRH, MSM • Or just explain 3% take 6 months and let them decide. ***Remind them their partners have a window period too.

46. Then where can I go?

47. What other tests or referral… • Sexually Transmitted Infections/STD’s • Hepatitis C • Pregnancy • Hepatitis A & B Vaccinations (MSM, ?) • PAP • Birth Control

48. Who am I going to tell?

49. Supports • Does anyone know you are here today? • Is that someone you would call? • How do you think you would respond to a reactive result today? • Now be sure it does not appear that you can see the result, already. Be sure they understand process if result is reactive and how involved you personally or your agency will be.

50. Follow up & Follow Through