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HIV Screening and Testing

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  1. HIV Screening and Testing San Francisco AreaAIDS Education and Training Center University of California, San Francisco at San Francisco General Hospital

  2. About this Presentation • These slides were developed by the UCSF San Francisco Area AIDS Education and Center as a component of the SFAETC HIV Screening and Testing Training Curriculum Guide. The intended audience is experienced AETC trainers, clinical faculty, and training participants. • Users are cautioned that concepts of HIV management and clinical care continue to evolve rapidly, and this information may become outdated. The information contained herein is not intended to constitute or substitute for medical advice from a licensed health care professional.

  3. Welcome! • Please sign in • Please complete: • Participant Information Form & Pre-Test (“bubble form”) NOW • Program Evaluation & Post-Test Later • Please silence cell phones and pagers

  4. Learning Objectives • At the end of this session you will be able to: • Explain rationale for revised HIV screening recommendations • Clarify definitions of “HIV testing” • Review CDC routine HIV testing recommendations • Discuss HIV testing modalities • Apply routine HIV screening recommendations in clinical practice

  5. HIV Testing: 1985 James Curran, dean of public health at Emory University and director of the university's Center for AIDS Research, was head of the Centers for Disease Control task force as the HIV epidemic unfolded in the early 1980s.

  6. HIV Testing: 2008 • A 38 year-old man presents to urgent care with complaints of burning while urinating for the past 2 days. He denies fevers, flank pain, or penile discharge. He is sexually active with both men and women and uses condoms sporadically.

  7. Would you include an HIV test as part of his visit? • Yes • No • Maybe/Depends • I have no idea

  8. HIV Testing: 2008 • A 38 year-old man presents to clinic to establish care. His only complaint is of a sore ankle for the past week after an injury while playing soccer. He states he is otherwise healthy.

  9. Would you include an HIV test as part of his visit? • Yes • No • Maybe/Depends • I have no idea

  10. Case Discussions Answer for both case scenarios: YES!!

  11. According to the CDC, what percentage of people infected with HIV in the U.S. do not know they are infected? • About 25%

  12. The CDC has estimated that approximately how many persons in the U.S. become infected with HIV each year? • Approximately 56,000 per year

  13. 180 180 160 160 140 140 120 120 100 100 Estimated Number of Annual Infections (X 1,000) 80 80 60 40 40 20 20 0 0 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 HIV Incidence in the U.S.

  14. HIV Incidence in the U.S. • Transmission is higher among people unaware of infection • Risk behavior is reduced with awareness of HIV+ status: • 68% reduction in unprotected sex

  15. What we’ve learned so far . . . • Individuals remain untested • Routine HIV testing reduces stigma • Routine HIV screening is highly effective: • Perinatal transmission reduced from 25-30% to <2% w/ interventions

  16. CDC Recommendations: Objectives • Increase HIV screening • Detect disease earlier • ID & counsel HIV+ patients • Link patients to services • Further reduce perinatal transmission

  17. CDC Recommendations: Routine Testing for HIV • Routine, voluntary testing for all patients ages 13-64 • “Opt-out” testing; no separate consent for HIV • Pretest counseling not required • Repeat testing at provider’s discretion

  18. Definitions • The “Old” • Opt-in screening: performing an HIV test after assessing patient’s risk, obtaining informed consent, and conducting pre-/post-test counseling • The “New” • Opt-out screening: performing an HIV test after notifying patient that the test will be done; consent is inferred unless patient declines

  19. Definitions • Routine testing: performing an HIV test for all persons in a defined population • Diagnostic testing: performing an HIV test for persons with clinical signs or symptoms of HIV infection • Targeted testing: performing an HIV test for subpopulations of persons at higher risk based on behavioral, clinical or demographic characteristics

  20. So, Who Should Be Tested? • Everyone ages 13-64 in all healthcare settings • Everyone beginning treatment for TB • Everyone seeking treatment for STDs • All pregnant women • For all: no separate consent or required prevention counseling (“opt-out”)

  21. Who Needs Repeat Testing? • High-risk patients: • Who is included? How frequently? • Anyone engaging in a new relationship • Occupational exposure to blood or bloody fluid which can contain HIV • Pregnant women in 3rd trimester in high HIV prevalence areas

  22. Recommendation?? Law?? State HIV Testing Laws Compendium http://www.ucsf.edu/hivcntr

  23. CA HIV/AIDS Testing Bill • AB 682: Effective January 1, 2008 • Paves the way for HIV screening to be a routine part of medical care • Repeals written informed consent for HIV testing • Patient can decline test and if so, should be noted in chart

  24. Accepts test: (Nothing!) Declines test: “Patient declines HIV test” Necessary Documentation

  25. Group Discussion • “What SHOULD BE” • Advantages and disadvantages of routine HIV testing • “What IS” • Misconceptions about HIV testing • Barriers to implementation • “What COULD BE” • Changes needed to implement HIV testing as part of routine medical care

  26. HIV Testing . . . ??? IFA? Oral test? Rapid? UniGold? ELISA? Western Blot? False positive? OraQuick? Blood test? Confirmatory?

  27. How is HIV Diagnostic Testing Done? • “Gold Standard:” • ELISA followed by Western Blot confirmatory test or immunofluorescence assay (IFA) • Detects antibody to HIV virus • Usually takes a few days for results • May not be positive during window period • Indeterminate result possible

  28. Window Period Antibodies Detected Window Period Virus in Blood Infection

  29. The Indeterminate Test • Western Blot: looks for antibodies to specific HIV proteins and demonstrates presence by a change in color. • Indeterminate Result: Some, but not all, bands are present. • Causes: recent infection; advanced HIV; certain strains of HIV; cross reaction to other antibodies; HIV vaccine; lab error • Next Steps: Retest in >6 weeks. Risk counseling if indicated.

  30. The Indeterminate Test • Column 1: Positive Control • Column 2: Negative Control • Column A: Negative Test • Column B: Indeterminate Test • Column C: Positive Test

  31. The ELISA HIV Test: Perils of Waiting • ELISA: ~25% do not return for test results of standard test • RAPID TESTS: Only ~2% leave before results of rapid HIV test

  32. Multispot HIV-1/HIV-2 Uni-Gold Recombigen Stat Pak Reveal G2 OraQuick Advance Complete Rapid HIV Tests

  33. A patient has a rapid HIV test performed and it is positive. What does this mean? • Patient has HIV. • Patient most likely has HIV: repeat rapid test now. • Patient most likely has HIV: order a Western Blot or IFA. • Unclear if the patient has HIV: do another rapid test after window period.

  34. Rapid HIV Tests • Results available in < 1 hour • Most easy to perform • High specificity: negative means negative except during window period! • High sensitivity: positive means likely positive BUT… Important! Positive rapid test results must be confirmed for HIV diagnosis!

  35. Group Discussion • What are the advantages and disadvantages to using the rapid HIV test? • What changes would need to occur in your healthcare setting to implement use of the rapid HIV test? • What would you tell patients before and after running a rapid test?

  36. Summary • All persons ages 13-64 should be screened for HIV • No need for written informed consent or counseling • High risk patients should be screened more frequently

  37. Resources http://www.hivtest.org/

  38. Resources • AETC National Resource Centerhttp://www.aids-etc.org/ • AIDSinfoDHHS Treatment Guidelineshttp://aidsinfo.nih.gov/ • Centers for Disease Control & Prevention (CDC)http://www.cdc.gov/hiv/default.htm • HIV InSitehttp://hivinsite.ucsf.edu/InSite • National HIV/AIDS Clinicians’ Consultation CenterWarmline, PEPline, Perinatal HIV Hotlinehttp://www.ucsf.edu/hivcntr/ • Pacific AETChttp://www.ucsf.edu/paetc