Colorado

1. Colorado HIV Testing Eval Project

2. Background to HIV Testing Eval Project • Worked 10+ years in HIV and STI epidemiology, impact mitigation, policy development and capacity building. Six of those years in sub-Saharan Africa (Lesotho, Zimbabwe, Malawi, South Africa) where TB and HIV are all but endemic. • As we know, HIV and TB have an insidious relationship. TB bacteria can accelerate the progression of HIV to AIDS. • Harder to diagnose TB in HIV+ persons (anergy). • A person who has both HIV infection and active TB disease has an AIDS-defining condition. • This co-morbid relationship is less evident in the U.S. in general and Colorado in particular, but it’s still both a public health and a treatment concern.

3. Timeline of HIV Testing Evaluation • Prior to 2010, Colorado focused on HIV testing TB patients 15 years and older. • 2010 brought new NTIP objectives, and with it, a logic model and evaluation plan were developed in CO to expand testing to all active TB patients regardless of age. • Looking back at previous surveillance and NTIP reports, the same discrepancies were found as in 2009; a handful of active TB cases each year with no HIV status, and often, no HIV test even offered. • Began looking into it; was there a policy on HIV testing of active TB patients in place? If not, why not? The research is clear. If a person is co-infected with TB and HIV, the treatment regimens for both can change or can be delayed depending on viral load, CD4 count and other medical factors. Why would we not confirm all the active TB patients’ HIV status to eliminate the possibility of HIV infection before beginning anti-TB meds?

4. Timeline Part 2 • In the fall of 2010, began looking at the RVCTs of those patients not offered or given an HIV test to see if it was isolated to certain regions or counties. • My assumption was that there were several rural county nurses who were uncomfortable broaching the subject of HIV testing with their active TB patients (the awkwardness of intimating sexual and drug-taking behaviors, perhaps?) so they avoided engaging in a discussion about the need for an HIV test. • Results were surprising to me; while there were a few outlying counties that missed opportunities to HIV test, the majority of missed opportunities came from the larger cities that continue to see the majority of active TB cases and that would seem to have the capacity to offer HIV testing services.

5. Timeline Part 3 • December, 2010 the TB Program began collaborating with the CO’s HIV Prevention Research and Evaluation Unit to develop a knowledge, attitudes and beliefs (KAB) survey meant to identify any barriers that might exist throughout the state specific to HIV testing among PH nurses. Spent a few weeks crafting questions. • A key informant interview questionnaire was design as well to flesh out any clear trends and expand on any barriers found in the KAB survey. • The KAB survey was placed on Zoomerang in early-January 2011 and invitations sent out to all County Public Health nurses on our Listserv throughout the state to take the survey anonymously online. • 41 surveys (92 invites sent out; 45%) were completed by the early-February, 2011 deadline. • Analysis of the results continued through April, 2011. • Final report on the survey results was completed in June, 2011.

7. Known HIV Status • Over the last 10 years (2001-2010), Colorado has seen 117 persons (out of 1075) with active TB disease that were not given, much less offered an HIV test. (A few were dead at TB dx). • Preaching to the choir. Active TB patients not in care for their HIV infection is unacceptable. • We might expect this in the remote mountains of Lesotho, for instance, due to logistic and diagnostic limitations, but not in Colorado with top-notch, well-trained PH staff and world-class TB clinics/hospitals/clinicians. • We should not allow HIV testing decisions to be based on deceptive demographic metrics e.g. She’s only 2 years old or; he’s 85 years old, what are the chances he has HIV? or; patient was born and raised in the U.S., this is a foreign-born issue, etc. Universal HIV testing regardless of age, race, gender, or nativity is the goal in Colorado. • We now know the benefits of getting an HIV positive person immediately into care; all the more so for a person co-infected with TB.

8. Results of the KAB Survey • CDC and CDPHE HIV testing recommendations for persons with active TB disease are/were not well-known among our county HD partners. • Most county HDs do not have an HIV testing policy/algorithm in place specific to persons with active TB disease. • There are a significant number of county HDs that do not offer HIV testing internally. Instead they refer patients to a PCP, family planning clinic or CBO that offers HIV testing services. A few have no HIV testing resource close. • ~10 counties asked for help in developing their own HIV testing policy/procedure/algorithm to clearly direct their respective PH nurses. • Counties that do not see much TB expect clear direction from the TB Program. They are willing to follow our recommendations when given. • There was no evidence of RN discomfort around offering/giving HIV tests. If we remind them, they will either test or refer the active TB patient to a facility that offers HIV testing services once they’ve been deemed non-infectious.

9. The Way Forward • Colorado’s TB Program is working with Colorado’s HIV Prevention Capacity Building Unit to develop and offer HIV rapid testing trainings as needed throughout the state. • State lab is willing to help counties apply for CLIA waivers for rapid testing and to offer use of their courier service to get whole blood to lab in timely manner when a rapid test isn’t an option. • Colorado’s TB Program staff discuss HIV status in weekly case management meetings and are in contact with appropriate HD partners to ensure that HIV tests are offered and given. • If the patient refuses an HIV test, TB Program is encouraging local HD partner staff to clearly explain the health implications of TB/HIV co-infection w/ the patient. • Ultimately, the onus falls to Colorado’s TB Program, as the state’s legislated TB control and oversight body, to keep Known HIV Status an imperative and on everyone’s radar by helping local HDs to remain/become compliant.

10. The Way Forward, Continued • TB registry is working more closely with HIV registry. • HIV testing language has been added to contractual scopes of work as a key local HD deliverable to CDPHE’s TB Program. • TB Program is working with the Curry International TB Center to offer Nurse-to-Nurse training in spring of 2012. 2010 Known HIV Status rate was 95.8%; highest to-date. This is a good sign that the state is making progress toward 100% compliance.

11. Thanks to: • All the public health nurses who participated in this project. • The dedicated, talented PH nurses and ID doctors of Colorado who provide such high-quality care to their TB and HIV patients throughout the state. • My colleagues at the Colorado Department of Public Health and Environment’s TB and HIV Prevention Programs. And thank you for your time

12. Contacts and Resources Pete Dupree, MPH TB Epidemiologist and Assistant TB Program Manager—Colorado peter.dupree@state.co.us 303-692-2677 ------------------------------------------------------------------------------------------------------- Colorado Department of Public Health and Environment’s TB Website: http://www.cdphe.state.co.us/dc/tb/index.html Denver Metro TB Clinic’s Website http://denverhealth.org/Services/PublicHealth/TuberculosisTBClinic.aspx National Jewish Hospital (Denver) TB Program’s Website http://www.nationaljewish.org/programs/directory/tb/