Routine HIV Testing in the Community Health Center
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Routine HIV Testing in the Community Health Center

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Clinical presentation at the 2009 MPCA Annual Conference.

Clinical presentation at the 2009 MPCA Annual Conference.

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  • 1. Routine HIV Screening in the Primary Care Setting Michigan Primary Care Association Annual Meeting September 28, 2009 Grand Rapids, MI
  • 2. 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
  • 3. 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:
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. 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
  • 13.  
  • 14. 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.
  • 15. 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.
  • 16. 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.  
  • 17. 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.
  • 18. 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
  • 19. 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
  • 20. 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.
  • 21. 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
  • 22. 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.
  • 23. For more Information contact
      • LaVerne Wiley
      • Quality Improvement Coordinator
      • Michigan Primary Care Association
      • 513-861-4497
      • [email_address]