Routine HIV Testing in the Community Health Center

Routine HIV Screening in the Primary Care Setting Michigan Primary Care Association Annual Meeting September 28, 2009 Grand Rapids, MI

Why Are We Doing This?
Among 4,127 persons with AIDS*, 45% were first diagnosed HIV-positive within 12 months of AIDS diagnosis (“late testers”)
Late testers, compared to those tested early (>5 yrs before AIDS diagnosis) were more likely to be:
Younger (18-29 yrs)
Heterosexual
Less educated
African American or Hispanic
MMWR June 27, 2003 *16 states

Awareness of Serostatus Among People with HIV and Estimates of Transmission ~75% Aware of Infection ~ 25% Unaware of Infection ~54% of New Infections ~46% of New Infections People Living with HIV/AIDS New Sexual Infections Each Year Marks G, et al AIDS 2006; 20:1447-1450. Accounting for:

Revised CDC Recommendations Adults and Adolescents - I
Routine, voluntary HIV screening for all persons 13-64 in health care settings, not based on risk
All patients with TB or seeking treatment for STDs should be screened for HIV
Repeat HIV screening of persons with known risk at least annually

Revised Recommendations Adults and Adolescents - II
When acute retroviral infection is a possibility, use an RNA test in conjunction with an HIV antibody test
Settings with low or unknown prevalence:
Initiate screening
If yield from screening is less than 1 per 1000, continued screening is not warranted

Revised Recommendations Adults and Adolescents - III
Opt-out HIV screening with the opportunity to ask questions and the option to decline testing
Separate signed informed consent should not be required
Prevention counseling in conjunction with HIV screening in health care settings should not be required

Revised Recommendations Adults and Adolescents - IV
Screening is voluntary
Inform patients orally or in writing that HIV testing will be performed unless they decline.
Arrange access to care, prevention, and support services for patients with positive HIV test results

Approaches to HIV Testing
Diagnostic testing: performing an HIV test based on clinical signs or symptoms
Targeted testing: performing an HIV test on subpopulations of persons at higher risk based on behavioral, clinical or demographic characteristics
Screening: performing an HIV test for all persons in a defined population

Approaches to HIV Testing
Opt-out screening: performing an HIV test after notifying the patient that the test will be done; consent is inferred unless the patient declines
Anonymous testing : patient-initiated, usually through the Board of Health or in a public clinic
Outreach testing : performing tests at events and non-medical locations, usually for education and prevention

What makes Routine Screening a good idea?
Serious health disorder that can be detected before symptoms develop
Treatment is more beneficial when begun before symptoms develop
Reliable, inexpensive, acceptable screening test
Cost of screening are reasonable in relation to anticipated benefits
Treatment must be accessible
Principles and Practice of Screening for Disease
-WHO Public Health Paper, 1968

Health Center Routine HIV Screening Model Developed by NACHC
Mississippi
North Carolina
South Carolina
Pilot States Objective: To develop a model for the integration of HIV testing into routine primary care at Non-Ryan White funded health centers along with a model for post test counseling and referral to specialty care

Guiding Principles
Unit of analysis is the Patient
HIV is a chronic disease
Routine testing across organization same day
Apply redesign and Collaborative learning models, change theories, and lessons learned
Build on existing infrastructure
Leverage Community and State Partnerships
Intense coaching to create momentum, trust, support, and quality outcomes

Redesign Principles
Don't Move the Patient . This principle focuses on the importance of organizing the work of a patient visit around the patient rather than organizing the patient around the work. For instance, this means that a center should avoid moving patients from place to place to place during a single visit (e.g., check in area to a vitals room then on to the exam room). Rather, the goal is to deliver routine services to patients in the exam room.
Increase Clinician Support . This principle assumes clinicians can be optimally productive only with optimum support. This requires that practices ensure the proper ratio of nursing or other support staff to clinicians as well as being sure clinicians are focused on clinical work, not other supportive services that can be delivered by other members of the care team.

Redesign Principles
Create Broad Work Roles . This principle emphasizes the importance of cross-training staff to perform multiple roles. For example, nursing support can open the patient visit in the exam room rather than relying solely on front desk staff. Another example, relevant to our current effort, is having nursing staff perform the oral swab rapid HIV tests in the exam room.
Organize Care Teams . This principle speaks to the high quality, integrated care that comes when a patient care team works together day in and day out to meet the needs of a defined patient population. This team learns to work well together, anticipate each others needs, and become more intimately familiar with their patient panel.

Redesign Principles
Communicate Directly . Direct communication in real-time helps insure that patients need are met, and met in a timely manner. Direct communication also helps eliminate errors and misunderstandings that can occur when notes, voice messages or other indirect methods of communication are used.

Start All Visits On Time . This principle speaks to the importance of a health center, and each care team, being prepared for the day that lies ahead and beginning the first patient visit of the day on time.

Health Center Patient Care Model with Integrated Rapid HIV Testing Patient signs in. Encounter form printed and, together with ROUTINE SCREENING FLOW SHEET, placed in bin for pick-up by nurse/MA. If blood work necessary, provider writes an order. Patient directed to laboratory for blood draw. Front Desk
Nurse/MA escorts patient to exam room.
During intake process (which may occur in a “vitals area” in some centers), nurse/MA offers RAPID HIV SCREENING in addition to blood pressure, temperature, etc.
Patient signs consent if accepting HIV test.
If accepted, sample obtained and transported to lab for processing.
Provider performs exam; orders necessary follow-up visits and/or referrals.
Nurse/MA enters results on Routine Screening Form.
Negative results given by nurse/MA
Reactive results given by provider
Waiting Room Exam Room Laboratory Check Out Patient takes encounter form and proceeds to check out area for scheduling of next visit.

Health Center HIV Screening Algorithm Rapid HIV Test Negative Reactive Inform patient Give “Negative” handout, if desired Review risks, if appropriate Discuss “window period” No further testing
Inform pt preliminary results are reactive
Give “Reactive” results handout
Draw confirmatory Western Blot
Schedule follow-up appt in 5 days
Negative Positive Western Blot Patient likely negative unless recent risk Review risks & prevention Schedule 3 mo repeat Western Blot
Counsel patient
Contact DIS and ensure referral to HIV care
Complete “Reactive Tracking Sheet ”
Repeat Western Blot at 5 day follow-up visit Indeterminate

Post Test Counseling & Referral Rapid HIV Test Reactive Negative Positive Western Blot Indeterminate CHC* Notifies DIS of Reactive result *CHC=Community Health Center DIS may come to CHC to counsel pt regarding results, window period, risk reduction; if not CHC does counseling DIS comes to CHC to counsel pt and Western Blot redrawn
CHC informs pt preliminary results reactive
CHC provides written “Reactive” results handout
CHC draws confirmatory Western Blot
CHC schedules follow-up appt in 5 days
DIS performs post-test counseling
DIS completes CDC data form
DIS refers to HIV specialty care and case management
DIS addresses partners notification

Pilot Results
10 health centers ( 26 clinical sites) in four states* have successfully applied this model.
As of March 31, 2008, 16,291 patients were offered testing, with 11,309 (69%) accepting;
17 (.15%) new cases of HIV were identified;
16 of the newly diagnosed cases of HIV were successfully linked to care or in contact with DIS or health center staff regarding decision to refuse care;
Fifty-six percent (56%) of patients tested through this pilot project were tested for the first time.

Results
African Americans and Latinos were significantly more likely to test than were Whites.
Women were more likely to test than were men.
Uninsured patients were more likely to test.
Patients insured under Medicare or Medicaid were less likely to test.
Patient age was not associated

The Initiative is spreading around the country
Ohio presently has four health center organizations who have integrated routine screening using the ‘Health Center Model” with plans to start in 5-7 additional sites.
Illinois has 7 health centers launching the “Health Center Model”
Michigan has one health center who plans to integrate the model soon.

For more Information contact
LaVerne Wiley
Quality Improvement Coordinator
Michigan Primary Care Association
513-861-4497
[email_address]

Routine HIV Testing in the Community Health Center

by MPCA on Sep 30, 2009

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