CDC’s Expanded HIV Testing Program: Successes, Best Practices and Lessons Learned
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  • 1. CDC’s Expanded HIV Testing Program:Successes, Best Practices and Lessons Learned Kristina Cesa, MPH ORISE fellow, Division of HIV/AIDS Prevention Office of the Director National HIV Prevention Conference Atlanta, GA August 14-17th, 2011 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention 1
  • 2. Advancing HIV Prevention: New Strategies for a Changing Epidemic, 2003 Strategy 1 • Make HIV testing a routine part of medical care Strategy 2 • Implement new models for diagnosing HIV infections outside medical settings Strategy 3 • Prevent new infections by working with persons diagnosed with HIV and their partners Strategy 4 • Further decrease perinatal HIV transmissionMMWR 2003;52:329-32 2
  • 3. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings HIV screening in all health-care settings for adults ages 13-64 years • Opt-out testing strategy Persons at high risk for HIV infection should be screened annually General consent for medical care should encompass consent for HIV testing Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings HIV screening should be included in the routine panel of prenatal screening tests for all pregnant womenMMWR 2006;55 (No.RR-14) 3
  • 4. PS07-768: Expanded and Integrated HumanImmunodeficiency Virus (HIV) Testing for Populations Disproportionately Affected by HIV, Primarily African Americans Purpose: 1. Increase testing opportunities for populations disproportionately affected by HIV, primarily African Americans 2. Increase the proportion of HIV-infected persons in these populations who are aware of their infection and are linked to medical care 4
  • 5. PS07-768: Expanded HIV Testing ProgramAnnual Goals:1. Test 1.5 million persons2. Identify 20,000 previously undiagnosed HIV infectionsProject length: 3 years (Oct 2007 – Sept 2010)Total Funding: $111,211,614Venues: Clinical settings (at least 80%) Non-clinical settings (no more than 20%) 5
  • 6. PS07-768: Funded Jurisdictions¹Eligibility: At least 140 AIDS cases (estimated) among African Americans in 2005 VT NYC Chicago ME WA NH MT ND MN MA OR NY RI SD WI ID MI NJ WY CT PA Philadelphia. IA DE NE OH MD NV IL IN UT WV VA Washington, D.C. CO KS Los Angeles MO KY County CA NC TN OK SC NM AR Funded in Years 1-3 AZ MS AL GA Funded in Years 2-3 TX LA FL Houston 1Represents 95% of AIDS cases among African Americans in the United States in 2005 6
  • 7. Number of HIV Tests, Positive Tests, and Positive Test Rates October 2007 – September 2010 Total Clinical Settings Non-Clinical SettingsTests Done 2,786,739 2,519,917 (90%) 266,822 (10%)Confirmed HIV+ 29,503 23,546 (80%) 5,957 (20%) New HIV+ 18,432 15,478 (84%) 2,954 (16%) Previous HIV+ 11,071 8,068 (73%) 3,003 (27%)New HIV+ Rate 0.7 0.6 1.1 Data Source: APR Year 1–3 7
  • 8. Number of HIV Tests, New Positive Tests and New Positive Rate in Years 1 – 3 Year 1 Year 2 Year 3HIV Tests 458,014 1,021,181 1,307,544New Positive Tests 4,029 6,821 7,582New Positive Rate 0.9% 0.7% 0.6%Data Source: APR Year 1–3 8
  • 9. Proportion of HIV Tests and New HIV Positives by Race/Ethnicity October 2007 – September 2010 80% HIV Tests 70% New HIV Positives 60% New Positive Rate, % 60% Percent 40% 18% 16% 20% 14% 12% 5% 5% 0.8 0.5 0.5 0% Black/AA White Hispanic Other/Unknown* Race/Ethnicity * Includes American Indian/ Alaskan Native, Asian, Native Hawaiian/ Pacific Islanders, multiple race and unknown 9
  • 10. Proportion of HIV Tests and New HIV Positives by Gender October 2007 – September 2010 80% 72% 60% HIV Tests 55% New HIV Positives New Positive Rate, % 45% Percent 40% 27% 20% 0.9 0.4 <1% 1% 0% Male Female Other* Gender* Includes transgender and unknown categories 10
  • 11. Venues Funded Under PS07-768 Year 3 (October 2009 – September 2010)* 30% 315 281 270 20% 183 10% 108 98 76 0% Emergency STD Clinics Correctional Substance Community Community Other** Departments Health Abuse Health Based Facilities Treatment Centers Organizations Centers * (n=1,331)** Includes Inpatient Medical Units, Urgent Care Clinics, Substance Abuse Treatment Centers, TB Clinics, andmiscellaneous 11
  • 12. Distribution of HIV Tests and New Positive Tests by Venue Type October 2007 – September 2010*40% HIV Tests 32% HIV Positives 30% New Positive Rate, %30% 20% 20%20% 17% 15% 14% 12% 11% 11% 11%10% 6% 0.7 0.6 0.5 0.6 1.2 0.6 0% Emergency STD Clinics Community Correctional Community Based Other ** Departments Health Centers Health Facilities Organizations* (n=2,562,124)** Includes Inpatient Medical Units, Urgent Care Clinics, Substance Abuse Treatment Centers,TB Clinics, and miscellaneous 12
  • 13. New HIV-Positives by Selected Outcome October 2007 – September 2010 Total Clinical Non-Clinical Settings SettingsNew HIV-Positives 18,432 15,478 2,954New HIV+ Receiving 91% 93% 84%Test ResultsNew HIV+ Linked to 75% 78% 63%Medical CareNew HIV+ Referred 83% 83% 82%to Partner ServicesData Source: APR Year 1–3 13
  • 14. CDC Cost per Test and New HIV Diagnosis October 2007 – September 2010 Year 1 Year 2 Year 3Tests 458,014 1,021,181 1,307,544Cost/Test $58 $36 $30New Positives 4,029 6,821 7,582Cost/New $6,634 $5,346 $5,163PositiveData Source: APR and grantee financial status reports year 1 – 3 14
  • 15. PS07-768: Barriers & ChallengesStart-up delaysNew partnershipsProvider resistanceLaws and policiesOperational issuesTechnical assistance/trainingData managementReimbursement 15
  • 16. PS07-768: Lessons LearnedTesting Strategy: Opt-out vs. Opt-in Difficult to identify a profile to capture all those at risk/unaware of infection Opt-out screening reaches clients who otherwise would not have been tested Opt-out HIV screening in high prevalence areas maximizes case finding value 16
  • 17. PS07-768: Lessons LearnedTest Technology: Rapid vs. Conventional Rapid Testing Models: • Increase receipt of preliminary results • Decrease the number of clients lost to follow up • More feasible in settings with dedicated testing staff Conventional Testing: • Reduces disruptions to clinic flow associated with point-of-care testing • Feasible in clinical settings where routine blood tests are ordered as a standard of care • Reduces the overall costs of testing • Using multi-platform analyzers increases the volume of tests and decreases the turn around time for results 17
  • 18. PS07-768: Lessons LearnedStaffing Model: Integrated vs. Parallel Parallel Models: • Minimum effect on the clinic flow • Better acceptance from staff • More expensive and require additional space Integrated Models: • More difficult to initiate due to: o Perceived burden on clinic flow o Extensive training requirements • Requires getting buy-in from staff • More cost effective and increase sustainability 18
  • 19. PS07-768: Lessons LearnedSustainability Identifying and maximizing all possible sources of funding Building community support and cultivating program champions Implementing innovative strategies • Cost effective staffing models • Low cost testing models Develop a “business case” for routine testing 19
  • 20. PS 07-768: Lessons LearnedBottom Line:Routine HIV screening in healthcare settings WORKS! 20
  • 21. PS10-10138/ PS12-1201: Expanded HIV Testing for Disproportionately Affected Populations Purpose: To sustain progress made under announcement PS07-768 To expand routine testing services to new clinical venues to reach a broader array of at-risk populations. Target Population: African American and Hispanic men and women MSM and IDUs, regardless of race or ethnicity Grantees: Expanded to 30 state, territorial and local health departments under PS10-10138 Eligibility further extended to 36 jurisdictions under PS12-1201 21
  • 22. PS10-10138/ PS12-1201: Expanded HIV Testing for Disproportionately Affected Populations Objectives: (when fully implemented) 1. Conduct ≥ 1.3 million tests 2. Identify ≥ 6,500 undiagnosed HIV infections 3. Receipt of test results (≥ 85% of positives) 4. Linkage to medical care (≥ 80% of positives) 5. Linkage to partner services (≥ 80% of positives) 6. Receipt of prevention counseling and/or referral to prevention services (≥ 80% of positives) 7. Sustainability 8. Service Integration 22
  • 23. Acknowledgments:Co-authors: Additional Acknowledgments: Christopher Brown Nadia Duffy Sam Dooley Abigail Viall Erica Dunbar PS 07-768 Grantees Benny Ferro Priya Jakhmola Marlene McNeese-Ward Kimberly Thomas Cathy Yanda 23
  • 24. Kristina Cesa 404-639-6418 Kcesa@cdc.govFor more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.govThe findings and conclusions in this report are those of the authors and do not necessarily represent the officialposition of the Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention 24