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Universal HIV Screening: Putting Policy into Practice in Hard-to-Reach Populations: American Indians/Alaska Natives (AI/AN). IOM Workshop HIV Access and Testing April 15, 2010 RADM Scott Giberson, RPh, PhC, M.P.H. IHS National HIV/AIDS Program Rockville, MD. AI/AN HIV Epidemiology*.

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Universal HIV Screening: Putting Policy into Practice in Hard-to-Reach Populations: American Indians/Alaska Natives (AI/AN)

IOM Workshop

HIV Access and Testing

April 15, 2010

RADM Scott Giberson, RPh, PhC, M.P.H.

IHS National HIV/AIDS Program

Rockville, MD

ai an hiv epidemiology
AI/AN HIV Epidemiology*

Incidence rates, 2007: AI-AN = 14.6/100K (Rank 3rd )

Est. # living with HIV/AIDS roughly 3,500+.

Rate of HIV Dx for AI/AN men (17.7per 100K) and for females roughly 4.6/100K.

Similar time from HIV to AIDS of all races/ethnicities

Shortest time (with African American) from AIDS diagnosis to death. *

Most MSM/IDU combo of any ethnicity *

AI/AN youth at higher risk (YBRS, BIA/CDC 2002)

* CDC HIV/AIDS Surveillance Report 2006, Released Feb 2009:

rates of hiv aids 100k
Rates of HIV/AIDS / 100K*


* 33-state HIV/AIDSSurveillance Data through 2006; 34-states in 2007

solutions ihs hiv aids program goals 3 year expansion
Solutions: IHS HIV/AIDS Program Goals3-Year Expansion

Assist AI/A N individuals in becoming aware of HIV serostatus - Support CDC revised HIV testing recommendations.

Decrease risk through education, open communication, and the reduction of stigma

Ensure access to quality health services, including people living with HIV/AIDS

Form sustainable collaborations with Tribes, community stakeholders, states, federal agencies and other HIV partners

Be transparent, culturally fluent and accountable

success in i t u expanded hiv testing
Success in I/T/U Expanded HIV Testing
  • Data may suggest successful methodology or implementation model
  • HIV-adapted ecological model of public health
  • Prenatal HIV screening rate from 54% to 82%. (4 yrs)
  • Expanded HIV testing to over 50,000 tests per year. 4-fold increase since 2001.
  • Champion efforts at multiple levels of influence.
  • Implemented Policy reform and partnered with Tribes
  • Over 39 IHS/Tribal/Urban sites now implementing universal HIV testing including policy change.




Tx &



and Evaluation



Research / Epidemiology

Integrate Intervention Model into Priority Areas

intervention model
Intervention Model

Broad sociocultural / traditionalism/ spiritual

Constructed Environment


Clinical / Facility


ihs prenatal hiv screening rates 2005 2009
IHS Prenatal HIV Screening Rates2005-2009










% Prenatal












Impact: Prenatal HIV Screening

Source: GPRA Data 2005-2009

impact expanded universal hiv screening
Impact:Expanded/Universal HIV Screening

Data from latest ‘patch’ into our operating RPMS system. Aggregate, non-identifiable numbers:

Number of HIV screens performed:GRPA YearNumber

2001 12,042

2007 46,679

2008 51,052

federal state local barriers to testing
Federal/State/Local Barriers to Testing
  • State policies/resources (Ryan White, ADAP, etc) located in areas where hard-to-reach populations cannot access
  • Anecdotally, state restrictions on comprehensive health or sexual health education, many AI/AN are unaware of the risks
  • Variation in state laws: (qualifications of those allowed to perform an HIV test, consent regulations, provider education)
  • Federal resources specific for HIV in AI/AN are very limited. Capacity to build partnerships with states/local are limited
  • Concern of Insurance companies’ use of information and data
  • Federal funding fiscal year restriction. Service delivery in AI/AN (especially rural areas) is largely through IHS/Tribal sites and can’t be programmed throughout the year when funding is fiscally tied. This is a barrier to testing programs if non-appropriated funding streams are utilized (i.e. MAI)
available ai an data re implementation of hiv testing
Available AI/AN Data Re: Implementation of HIV Testing
  • IHS HIV GPRA data available now (ongoing):
      • Prenatal HIV Testing
      • Universal HIV Testing
      • Bundled HIV Testing (STI/HIV)
  • Physician and Nurse Perspectives on Implementation of Universal Adult HIV Screening Guidelines in IHS. Randomized Respondent-Driven Survey and Respondent Driven Site Survey
  • Case Study: Syphilis Outbreak and HIV Testing
  • Case Study: Universal HIV Testing Sites
  • Case Study: Urban Expanded Testing
  • Ongoing data being collected from over 39 I/T/U sites
1 ihs physician and nurse perspectives n 205
1. IHS Physician and Nurse Perspectives n=205
  • 70% supported routine, rather than risk-based testing
  • 51% stated HIV screening would be realistic in their facility.
  • 43% felt community HIV prevalence was below the 0.1% threshold
  • 49% felt they needed special qualification to offer HIV Test.
  • 49.2% stated that separate written consent was necessary.

Conclusions: Majority of IHS physicians and nurses support the 2006 Revised CDC HIV Testing guidelines. Providers need more information and training on HIV Testing guidelines, implementation strategies, and state HIV regulations.

2 case study sti outbreak lessons observed
2. Case Study: STI OutbreakLessons Observed
  • Streamlining - New testing policy created in conjunction with Tribal health authorities. Bundle STD/HIV screening
  • Education- Intense community outreach with local media
  • Transparency - Patients aware of new testing policy
  • Stigma - Testing all patients decreased stigma
  • Acceptance - Costs billable to state/federal programs. Time streamlined with clear division of labor reduced time (Nurse, Doctor, Lab). Verbal consent only, flexible counseling decisions
    • Interviews with health care workers:
      • 88% said patient acceptance high or very high
      • 61% said new testing policy added negligible time to consults
      • 93% said wider testing policy should continue
perceived or credible barriers
Perceived or Credible Barriers
  • State law (consent, minors)
  • Patient acceptance
    • Confidentiality
    • Stigma
  • Provider acceptance
    • 30% familiarity with CDC Revised Guidelines
    • Cost
    • Counseling/time
    • Relevancy (low HIV prevalence)
actions taken
Actions Taken
  • Attitudes toward universal HIV screening indicate opportunity and barriers
  • New testing policy created in conjunction with Tribal health authorities
  • Integrate STDs and HIV testing
  • Tailor testing age range to correspond with epidemic
  • Intense community education with local media and organizations
outcomes acceptance
Outcomes: Acceptance
  • Patient acceptance
    • Testing all patients decreased stigma
    • Patients aware of new testing policy
    • Confidentiality with tx by both MDs, PHNs
  • Provider acceptance / importance
    • Costs billable to state and federal programs
    • Time streamlined with clear division of labor reduced time (Nurse, Doctor, Lab)
    • Verbal consent only, flexible counseling decisions
survey of direct ihs sites federally owned operated 15 respondent sites
Survey of Direct IHS sites (Federally owned/operated- 15 respondent sites)

77% worked with AETC

62% changed HIV policy in writing

69% bundle HIV as STD panel

Wide range of costs for tests ($5-$75)

Long range to referral sites (Average distance over 100 miles with minimum near 50 miles)

3 case study pilot universal testing site lessons observed
3. Case Study: Pilot Universal Testing Site Lessons Observed
  • Ongoing initiative with FY08 funding
  • 4 Aberdeen Area sites implementing expanded screening
  • Implementation across multiple levels of influence (facility, tribal, Area-level, IHS)
  • Focus on sustainability
    • Policy changes
    • Provider support
    • Tribal Support through resolution
  • Anecdotal increase in patient acceptance
  • Begin to reduce stigma: outreach efforts
  • Success story
4 case study urban universal testing lessons observed
4. Case Study: Urban Universal TestingLessons Observed
  • Minority AIDS Initiative Funding: 2007-2009
  • Now 15 of 21 “capable” Urban clinics (75%) implemented expanded HIV testing
  • Urban Provider Survey conducted
  • Successful implementation
    • Acceptance of additional responsibility
    • Assurance of confidentiality
    • Policy and procedures change to streamline and sustain
    • Patient acceptance
gaps in knowledge
Gaps in Knowledge
  • Prior HIV Testing overwhelmingly limited to women.
  • Use of IT system to monitor rates of bundled screenings (STIs/HIV). Clinical and Surveillance tool.
  • Sustainability concern - exhaustion of external funding
  • Client perspectives need to be flushed out more
  • Testing leads to increase in PLWH/A. Need for additional innovate linkages to care and continuity of care for harder-to-serve populations.
  • More evidence on routinization of testing as a stigma reduction methodology.
  • Require more data collection on implementation models.
key discussion points
Key Discussion Points
  • Gender disparity in testing needs to be corrected - follow epidemiology.
  • Women must continue to be universally tested. Prenatal to continue. Set goal of 100%
  • Stigma, complacency, and support for HIV preventive services needs focused attention
  • Competing Priorities + Lower Perceived Risk + Resource Constraints = Reactive Paradigm. This needs to change.
  • Need improved models to link to care and provide care.
  • Implementation of HIV testing within AI/AN through ecological model has been observed to improve partnerships, HIV services, and Native HIV network.
key discussion points22
Key Discussion Points
  • Rapid HIV tests not widely utilized in IHS. Conventional testing has been instrumental to develop routinization in expansion to universal screening.
  • Broad support has been observed from IHS providers for testing. Providers need more information on HIV testing guidelines, implementation, and state regulations.
  • Anecdotally, clients have been receptive to expanded HIV Testing, however dependent on ‘how’ test is offered
  • Education – how can we be more effective to change risk behavior and/or risk-perception?
  • Create ‘One-message’ to improve trust/transparency for hard-to-reach populations
overall lessons observed
Overall Lessons Observed

To date, anecdotal and objective data indicate:

  • Policy needs to change early in the process
  • Need to collaborate with Tribes for improved transparency and trust in system.
  • Education of Providers and nurses: ensure HCWs aware of new testing policy and its rationale
  • Have clear protocol for patient follow up, including linkages to care and social services as needed
  • Have partners to demonstrate successful implementation
  • Integrate HIV and STD testing
  • “Seed money” and local champion drive local success