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Rapid HIV Testing & Scaling Up Testing


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Phillip Keen (NAPWA) provides an update on the state of rapid testing in Australia in the context of the UNPD targets. This presentation was given at the AFAO/NAPWA Gay Men's HIV Health Promotion …

Phillip Keen (NAPWA) provides an update on the state of rapid testing in Australia in the context of the UNPD targets. This presentation was given at the AFAO/NAPWA Gay Men's HIV Health Promotion Conference in May 2012.

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  • 1. Rapid HIV Testing & Scaling Up TestingPhillip 2012
  • 2. Overview• Why rapid HIV testing?• Where to now on rapid HIV testing• National HIV Testing Policy Review• Scaling up testing
  • 3. UNPD Targets• Need to scale up testing coverage and frequency:  New technologies (eg. rapid HIV testing)  Reorienting existing testing services  New models for marketing & providing testing Community/peer-based Outreach (Home?)
  • 4. Testing Coverage among MSM• There is still scope for benefit from increased testing coverage and frequency o Testing coverage low in broad-based MSM samples: • e-Male Survey (2008) – 23.8% never tested – Among men who had tested, 31% had not tested in previous year • PASH Survey (2009) – 15.2% never tested • Adam (2012), NCHSR
  • 5. Testing Frequency• Real testing frequency v’s self-report data o Guy et al (2010): • Less than 40% of MSM retested after I year • Less than 20% of highly sexually active men retested after six months• Late HIV diagnoses o Approximately 14% of diagnoses among MSM are late diagnoses • Most have never previously tested, others have not tested for a long time.
  • 6. Rapid HIV Testing in other Settings• Pedrana (2011): Rapid HIV Testing & Community- Based Testing services: o High proportion of never previously tested o High positive yields o High consumer satisfaction with rapid HIV testing o High workforce satisfaction with rapid HIV testing o Staffing models incorporating non-clinical staff in community based testing services
  • 7. Rapid Testing at NZAF
  • 8. HIV Testing Policy Review•Support for rapid HIV testing for use at point of care: • Limited to use as screening tests • Confirmatory testing required for reactive rapid test results • May be considered for: • High risk populations (eg. gay men) • Hard to reach populations and individuals (who are resistant to conventional testing) and
  • 9. False Positives to True Positives Test Specificity Positive Yield 99.5% 99.8% 1.5% 1:3 1:7.5 (MSM in VPCNSS) (5 FP per 1000 tests) (2 FP per 1000 tests) 1.0% (Males @MSHC, 2009) 1:2 1:5 0.1% (Females @MSHC, 2009) 5:1 2:1 0.025%(All females tested in Victoria, 20:1 8:1 2004)
  • 10. Community based testing• Scope for non-clinical staff to administer rapid tests: • If State/Territory health department endorses organisation • Staff must attend accredited training and achieve certification • Service must have access to clinical support and venepuncture, and a relationship with a laboratory approved by the National Association of Testing Authorities (NATA)
  • 11. What Now?• Policy support for rapid testing at POC, but:• No TGA licensed tests• No Medicare funding for rapid test kits or procedures
  • 12. Community Organisations• What models for rapid testing make sense locally? • Establish a new community based testing service? • What planning needed? • Partner with other services to offer rapid testing? • Incorporate peer-based workers to some parts of testing services?• Identify services well-placed to introduce rapid HIV testing and start talking to them• Liaison with funders and other stakeholders to plan for the
  • 13. HIV Educators & Counsellors• Peer Educators & TreatAware Officers:• Community Awareness about rapid HIV testing • Limitations and benefits of rapid testing• Participate in rapid testing service delivery • Very different role for most • What selection & training?• Counsellors:• Different issues in context of rapid HIV testing – e.g. anxiety while
  • 14. Reorienting Services• Opening hours• Location• One-stop testing  Providing results by phone/email
  • 15. Marketing• Increasing HIV testing rates will be needed to reach new HIV Prevention and Targets• Introducing rapid HIV testing represents an opportunity to re-frame HIV testing
  • 16. Home Testing• Home testing was not supported in the recent Australian HIV Testing Policy review• UK: House of Lords Select Committee on HIV in the UK recommendations: o Legalise home testing o Establish a quality control system o THT supports the above
  • 17. Home Testing• USA:  Orasure application to FDA for home sales  Study of home users found 93% sensitivity vs 99.3% when used by trained testers  Expert panel unanimously supported approving home sales  FDA decision expected soon
  • 18. Outreach Testing• Was not considered in detail in policy review• Outreach testing trial may start soon in Sydney• Community HIV sector doesnt have a well- developed position on outreach testing.
  • 19. Thanks
  • 20. Clinical Staff• Should rapid testing be introduced?• New procedures• Training & staffing – clinicians or nurses?• Relationship with NATA-approved laboratory
  • 21. Policymakers• Planning • How and where should rapid testing be introduced to complement existing testing services? • NSW Health Model - Point of Care Testing Working Group: • ASHM • Clinical & social research • Community orgs • Sexual health clinic director • Counsellor
  • 22. Policymakers II• Funding• Public sexual health clinics and specialist community based testing services may be best placed to offer rapid HIV testing - but State/Territory funding covers most costs of public sexual health clinics and would need to for new community based testing services• Cost barriers to introducing rapid testing in all settings until there is Medicare funding • Public clinics: Currently some HIV testing costs recouped from Medicare
  • 23. Policymakers III• Funding support for trials of rapid HIV testing• Trials are underway in public sexual health settings • Test performance (sensitivity, specificity, NPV & PPV) • Acceptability to clients • Feasibility issues in clinics • Any impact on testing frequency?
  • 24. Researchers• Tracking changes in testing patterns in the context of rapid testing• Understanding the impact of rapid HIV testing on gay men’s sexual cultures
  • 25. CD4 at start of cART (closest CD4 with 6 months prior) Prior to 1 Jan 2006 1 Jan 2006 onwards Overall Total 1882 427 2309 Mean 327.9 324.0 327.1 SD 242.4 193.5 234.1 Median 288.5 294 290 25th 150 200 160 75th 450 422 445 n (%) n (%) n (%) 250-349 347 (18.4) 101 (23.6) 448 (19.4) <250 787 (41.8) 161 (37.7) 948 (41.1) >=350 748 (39.7) 165 (38.6) 913 (39.5)
  • 26. CD4 Decline Following Seroconversion• CASCADE Study (Europe n. = 18,495) CD4 Level Median time following Seroconversion 500 1.19 years 350 4.19 years 200 7.93 years
  • 27. Treatments Uptake Needed• Rapid increases in treatments uptake occurred 1996-1998 (20% > 70%) Year Estimated Proportion Population Additional Population on ARVs not on ARVs needed if 90% 2010 21,391 70% 6,417 4,278 2011 22,391 70% 6,717 4,478
  • 28. Challenges• Costs of access• Costs of multiple medications / management interventions• Complexity of access to prescriber / dispensing arrangements• Dr concerns re adherence• Dr concerns re lifelong treatment commitments• Concern re impact of side effects• Other Patient barriers
  • 29. Increased cost sharing• 1. Lower rates of drug treatment / selective Rx• 2. Diminished adherence among existing pts• 3. More frequent discontinuation of therapy• 4. Affect likelihood of pt to seek care• Summary point• For each 10% increase in cost sharing, prescription drug spending decreases
  • 30. Issues – Pt involvement• 35% started treatment within a year of diagnosis• Majority waiting more than a year btwn diagnosis and initiating• Reasons• 47% - Dr’s decision to wait*• 27% - Pt Unsure about starting• *Age split: Under 50 – 52% / Over 50 - 18%
  • 31. Issues - Access• Access has costs• PBS drugs have pt contributions $35.40 / $5.80 per script• Safety net $1281.30 / $324.00• Pt experience survey – PCR (ABS) 2009• 9.7 % delay or reject filling a script (general pop)
  • 32. HIV population• 30% live below poverty line• 40% rely on a govt benefit• Chronic disease management increasingly complex within the ageing population• Medicare not covering cost of most non medical treatments, or increasingly newer procedures
  • 33. Issues - Access• Chronic Illness• - regardless of income levels spending up to 30% of household income on medications• Plhiv (Futures 6) (n = 1100)• - 42% report major source of income as Govt support• 31% report living below poverty line levels
  • 34. Issues - Access• BGF Survey (2010)• PLHIV respondents struggling to access treatment• 46% - HIV medications• 60% - Other prescribed medications• Hardship requires people to make decisions between care and basic living expenses
  • 35. Patient Concerns• Concern about side effects• Lifelong treatment• Lack of readiness• Pt perception ARV are bad for you• Dislike of taking (Reminder)• Commencing Rx means health has declined• Impact on lifestyle
  • 36. Issues – Pt Attitudes• 70%(ATLIS) to 80% (Futures) of treating population believe that ARVs mean better prospects for themselves• 39% (ATLIS) & 30% (Futures)- Negative beliefs such as “harmful” and impacts outweighing benefit to QOL.• Reminder of status / fear of disclosure (includes access issues to care / drugs)
  • 37. Psychological barriers“Commencing was terrifying. I was scared and the night before Istarted I was a mess. Initial physical reaction was minimal so that wasa relief. Changing meds is also a scary thought which I am trying toavoid” (ARCSHS Tracking Changes, 2011)“I had thought it would be difficult for me to commence meds since thiswould be an acknowledgment of the progression of my HIV. Howeversince starting my meds I have found that a lot of small irritatingconditions have cleared up and my overall health is significantlyimproved. Im just grateful every day that the meds exist!” (ARCSHSTracking Changes, 2011)
  • 38. What are the outcomes• Therapeutic Treatment coverage and maintenance will improve individual health• Secondary prevention impacts will follow• Dynamics across other Strategies and within the BBVSS framework benefits shared• As fast as knowledge is acquired it must be applied (NHMRC Research Translation goal)
  • 39. ROI• Base policy options on evidence base of current data + the value of treatments to community• Environment of community acceptability with drive to resolve barriers or disincentives for individuals• National Strategy could be adapted to this expansive vision
  • 40. Economic analysis• NSW – 50% Gay + men initiated Treatment at diagnosis then minimum 10 % - up to 22% of new infections would be averted• $14,000 annually on HIV therapy• One infection over a lifetime costs Govt $700,000• Data build to show nationally if a program targets people who would otherwise have not received therapy, it would be cost effective,
  • 41. Success of Test and Treat in San Francisco? Reduced Time to Virologic Suppression, Decreased Community Viral Load, and Fewer New HIV Infections, 2004-2009 M Das, P Chu, G-M Santos, S Scheer, W McFarland, E Vittinghoff, G Colfax Minimum, Most Recent, Maximum CVL and Newly Diagnosed and Reported HIV cases
  • 42. Where can we do more? Testing Treatments uptake Community Mobilisation PrEP + PEP Targeting Primary Infection Targeting Late HIV Diagnoses Specific actions to reduce heterosexual transmissions
  • 43. HIV diagnoses, 2006 --2010, by HIV exposure category Source: State and Territory health authorities
  • 44. Newly diagnosed HIV among men who report an exposure other than sex with men, 2001 – 2010, by year and HIV exposure category 80 60 Num be r 40 20 0 Y ear Source: State and Territory health authorities
  • 45. Newly diagnosed HIV among women, 2001 – 2010, by year and HIV exposure category Source: State and Territory health authorities
  • 46. Reducing Heterosexual Transmissions• Diagnosing o Expand ASHM mentoring project o Clinical markers (eg oral candidiasis) o Populations focus – people from high prevalence countries & partners o Clusters (swingers)• Serodiscordant couples
  • 47. Peer base• Community information• Informed by community• Drivers / influence• Nuances• Sophisticated (Persistence/ Resilience)• Strength of peer ownership / partnership• Acceptability / thresholds of tolerance &
  • 48. Community Mobilisation• Gay community o High profile social marketing initiatives to suggest a period of concerted community action o Seek support from gay community leadership• Disproportionate contributions to new diagnoses from: o Men in serodicordant relationships o Sexually adventurous men
  • 49. Targeting Late HIV Diagnoses• NAPWA believes there is scope to reduce late HIV diagnoses among MSM, heterosexuals and CALD.
  • 50. CD4+ cell count at HIV diagnosis,2001 – 2010, by year  Click to edit the outline text format  Second Outline Level Third Outline Level  Fourth Outline Level Fifth Outline Level Source: State and Territory health authorities
  • 51. What proportion of ‘late’ HIV diagnoses are MSM?
  • 52. Late HIV Diagnoses Actions• Reduce structural and psychological barriers to testing• Encourage primary health services to offer testing to populations at increased risk. o Low caseload GPs in areas of high HIV prevalence – offer testing to MSM o GPs and community health services working with CALD populations at increased risk
  • 53. Need data for targets• Variable treatment patterns across sub groups• Attitudes and beliefs are wide ranging and complex• Motivations and drivers critical• Campaigns need to be diverse and different mediums – websites, blogs and social media
  • 54. Should we expect an initial increase in HIV Diagnoses? Population Undiagnosed Click to edit the outline  Undiagnosed Size (10%) text format (20%) 22,391 (1) 2,239  Second Outline 4,478 Level Third Outline• Level (1) Estimate of the number of people living with HIV in Australia as at 31/12/2010 plus 1,000 (estimated number of new diagnoses in 2011)  Fourth Outline• Level The estimates of the proportion of the PLHIV population that are undiagnosed are from Mapping HIV Outcomes: Geographical and clinical Fifth forecasts of numbers of people living with HIV in Australia (NCHECR/NAPWA, 2010) Outline• If testing coverage and frequency increase, there may be anLevel initial spike in
  • 55. A package• Targets disease prevention• Targets access inequities• Targets continuity of care
  • 56. Targets are a package• They bring other dynamics and roll on effects• National HIV strategy links• The momentum brings energy and focus• Forward to future yrs and see results• Health and well being of a population is what fosters other secondary benefits, such as prevention and broader BBVSS health maintenance
  • 57. Setting Targets• Set targets based on the number of people it will positively affect.• Planning should be optimistic and lead with positive frameworks for what you can do and what potentials there are to truly transform
  • 58. Targets and Reduced DiagnosesExposure Category 2010 Diagnoses 50% Reduction  Click to edit theReduction 80% outlineMSM + MSM & IDU 621 text format (311) 124 Heterosexual 289 Second Outline  145 IDU 25 Level 13 All Categories 1,043 Third Outline Level • An 80% reduction in MSM diagnoses and a 50% reduction  Fourth Outline in heterosexual, IDU and other categories would result in Level approximately 335 annual diagnoses, which is a 68% reduction overall on the 1,043 diagnoses in 2010. Fifth Outline Level
  • 59. Opportunities• Emerging combination prevention options offer the best chance in thirty years to drive infections down• We have to seize the moment – ‘wait and see’ isn’t an option• Signing up to ambitious (but not unrealistic) 2015 targets will provide the galvanising factor
  • 60. Thanks
  • 61. End here?• End?• Jo, following slides are in case you want to keep them and move them back up into the presentation
  • 62. Implications• Targeted sub groups may require varied interventions• Health maintenance not just understood as clinical benefits• Must be peer driven and focused• Need to measure national against state analysis
  • 63. Treatments Uptake• Reducing barriers to treatment o Dispensing arrangements o Co-payments • Difficulties obtaining medication and co-payments associated with stopping ARVs (ARCSHS Tracking Changes, 2011)• ATRAS and other Medicare Ineligibles• Addressing Psychological barriers to initiating treatment
  • 64. Self reporting• Actual utilisation vs self reported levels• - Both testing – but also treating, and maintenance