Hiv Testing VA Goetz

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Hiv Testing VA Goetz

  1. 1. Expanding HIV Screening in the Veterans Administration Matthew B. Goetz, MDChief, Infectious Diseases, VA Greater Los Angeles HCS Clinical Coordinator, QUERI-HIV/HCVProfessor of Clinical Medicine, David Geffen School of Medicine at UCLA
  2. 2. What should be done for this patient?54 yo male new dx HCV+; abnormal LFTs and chronic pruritisPMH: Depression, viral pericarditis, GSW to thorax 1977SHx: denies tobacco and ETOH, admits MJ; denies IDUPE: Folliculitis 2 to pruritis, otherwise unremarkableLab: Hg 15.4 WBC 3.8 (47 P, 32 L, 12 M, 9 E), Platelets 105K,ALT 59, AST 91, Alk P 55, bili 1.1, HCV Ab+, HCV VL 6,030,000
  3. 3. What should be done for this patient?54 yo male new diagnosis HCV+; abnormal LFTs and chronic pruritisPMH: Depression, viral pericarditis, GSW to thorax 1977SHx: denies tobacco and ETOH, admits MJ; denies IDUPE: Folliculitis 2 to pruritis, otherwise unremarkableLab: Hg 15.4 WBC 3.8 (47 P, 32 L, 12 M, 9 E), Platelets 105K ALT 59, AST 91, Alk P 55, T bili 1.1, HCV Ab+, HCV VL 6,030,000One month later: Admitted with 2 weeks  SOB, coughABG: pH 7.48, PCO2 28, pO2 58;CXR: diffuse reticulonodular opacitiesHIV+, CD4 74, VL 37,000. Bronchoscopy  PCP.Despite Rx, died of progressive respiratory failure
  4. 4. Audit of 397 death in UK 2005: Scenario leading to AIDS-related deaths % of AIDS deaths Diagnosed too late for effective Rx 40% Under care with untreatable complication 29% Treatment ineffective due to poor adherence 12% Chose not to receive treatment 8% Known positive, not under regular care 6% MDR HIV, ran out of options 5%BHIVA Audit – Johnson et al 2006
  5. 5. Benefit of HIV Therapy vs Diagnostic Delay  Antiretroviral therapy reduces HIV-related morbidity and mortality, and reduces perinatal transmission, but 21% of US HIV+ persons do not know their status  50% of newly diagnosed patients have < 200 CD4 cells • High risk of AIDS-related complications • Many patients have multiple, missed opportunities for early testingMMWR: Vol 57(39), 2008. Campsmith ML et al. JAIDS. 2010; 5:619-624.
  6. 6. Epidemiology  1.2 million HIV cases in US • Heterosexual transmission increasing most rapidly • Women and minorities are disproportionately affected 1000 HIV Cases per 100,000 People 800 600 Equal Case rate in 400 AI/NA & Caucasians 200 0 African Hispanic Multiple Native Caucasian Amer Indian Asian American races Hawaiian Alaska Nat 2005 2006 2007 2008 2009MMWR: Vol 57(39), 2008. Campsmith ML et al. JAIDS. 2010; 5:619-624. CDC HIV Surveillance Reports.
  7. 7. American Indian
  8. 8. CDC and ACP Guidelines for HIV Testing  Early diagnosis of HIV reduces morbidity and mortality  HIV screening should not be contingent on an assessment of patients behavioral risk  Opt-out HIV screening recommended for all patients • CDC recommends age range from 13 – 64; ACP has no upper bound • Exception if HIV prevalence known to be < 0.1% of patients screened  At least yearly testing for people at high risk for infectionMMWR. 2006; 55(RR-14). Qaseem A, et al. Ann Intern Med. 2009; 150:125-131.
  9. 9. Screening and Testing for HIV is Cost Effective CDC recommends routine offer of HIV testing if prevalence of undiagnosed infection is > 0.1% 140,000 Incremental Cost Effectiveness 120,000 100,000 QALY without consideration of HIV transmission ($/QALY) 80,000 60,000 40,000 Testing in VA is cost effective even at very low HIV prevalence 20,000 QALY with consideration of HIV transmission 0 $50,000/QALY 0 0.1 0.2 0.4 0.6 0.8 1 Prevalence (%)Sanders GD, et al. NEJM. 2005; 352:570.
  10. 10. Survival Gains of ART Compared With Other Disease Interventions 200 Survival Gains (months) 180 160 140 120 100 80 60 40 20 0 Node + Node – 2 vessel 3 vessel BMT OI Proph ART Chemo/breast CABG/PTCA Lymph- AIDS Care cancer omaWalensky R et al. JID 2006;194:11-19
  11. 11. Frequency and Delayed HIV Diagnosis & Types of Missed Opportunites HIV Diagnosis with < 200  Public facility: 1994 – 2001 CD4 Cells (%) • 6 visits before HIV diagnosis USA (1998) • 40% of visits were to either the USA (2003) ED or to an urgent care clinic Italy (2004)  VA data: 1998 – 2002 Canada (2004) • 6 visits before HIV diagnosis Scotland (2004) • Visits prior to diagnosis USA (2004) - Primary care clinic: 56% UK & Ireland (2005) - Subspecialty clinic: 50% USA (VA) (2007) - Psychiatry clinic 31% 0% 20% 40% 60% - Substance abuse clinic: 16%Girardi DE et al. (J Acquir Immune Defic Syndr 2007; 46: S3–S8. Gandhi NR et al. Med Care. 2007; 45:1105-1109. Samet J et al. ArchIntern Med. 1998; 158:734. Liddicoat R, et al. J Gen Intern Med. 2004; 19:349.
  12. 12. 2005: Status of HIV Testing in the VA No HIV testing in 50 – 70% of patients with known risk factors 50% of newly diagnosed patients had < 200 CD4 cells How were these problems addressed?
  13. 13. Identified Impediments to HIV Testing Organizational barriers • Written informed consent & pre-test counseling requirements • Constraints on provider time • Uncertain capacity to manage newly diagnosed patients Provider behaviors • Lack of recognition of HIV risk factors • Discomfort with HIV counseling and discussion of risky behaviors • Lack of prioritization of HIV testing Patient behaviors • Fear of stigma
  14. 14. Interventions Organizational changes • Streamlined, scripted & nurse-based consent process; verbal consent • Telephonic notification of negative test results • Assure assistance in counseling & HIV clinic f/u for new HIV+ pts Provider behavior • Education through academic detailing & social marketing • Regular clinic level feedback regarding HIV testing rates • Electronic clinical reminder to identify previously untested patients Patient fear of stigma • Substitution of routine, non-risk based testing
  15. 15. How did the Electronic Medical Record (EMR) help the HIV testing program? 100% access to records Able to identify patients not previously tested and avoid repeatedly offering tests the previously tested Able to identify patients at higher risk of disease through lab results and ICD-9 codes Able to use data to create reports, provide feedback Decision support tools at point of care including clinical reminders to providers
  16. 16. What does the VA ComputerizedPatient Record System (CPRS) look like?
  17. 17. Cover Sheet
  18. 18. Problem List
  19. 19. Medications
  20. 20. Laboratory Results
  21. 21. Reports tab– imagingreport
  22. 22. Progress Note Tab
  23. 23. Using CPRS-Based Decision Support (Clinical Reminders) Used for a wide variety of purposes in the VA • Screening for depression, traumatic brain injury • Screening for Tobacco & alcohol use • Hypertension identification and management • Diabetes monitoring • Vaccination rates • Etc. Contribute to attainment of performance standards HIV testing Clinical Reminder is among the simplest and best accepted
  24. 24. Electronic prompt for identification and testing of patients at-risk for HIV infection
  25. 25. Implementation Plan In-Person Launch Meeting Met with facility leadership, e.g., COS and leadership of nursing, laboratory, ambulatory care and primary care Promoted program at primary care team meetings • Consent process • Emphasize that HIV testing is not a performance measure • Tips for proposing HIV testing Provide educational materials Emphasized use of site-wide rather than provider- specific feedback
  26. 26. Handout package Pocket cardOverview Sheet Poster & Pamphlet
  27. 27. Tips for Proposing HIV Testing Would you like a free HIV test? As a veteran, you’re entitled to an HIV test. In addition to doing some tests to check for cholesterol, diabetes, etc., we’re now offering HIV testing. Would you like us to check for HIV infection?
  28. 28.  Quarterly feedback • HIV testing rate • Rate of clinical reminder resolution
  29. 29. VISN 22: Pre- vs Post Incident HIV Testing Rate VA facilities in Southern California & Nevada 2 – 3 fold Increased Testing Rate, which is Sustainable 80% HIV testing HIV evaluation without testing Reminder Resolution (%) 70% 60% 50% 40% 30% 20% 10% 0% -1 1 2 -1 1 2 -1 1 -1 1 2 -1 1 Intervention Year Control Site A Site B Site C Site D Site E
  30. 30. Post vs Pre Odds Ratio of HIV Testing Analysis of Patient Level Factors 18 – 30 yearsAge 31-50 years 51-64 years > 64 yearsIncome Low High CaucasianEthnicity African American Hispanic Other MissingMarital status Single Married OtherHomeless No YesHCV Risk Fx No YesHCV Infection No YesHBV Infection No YesPrior STD No Yes NoIllicit Drug Use Yes 0 1 2 3 4Goetz MB et al. J Gen Intern Med. 2008; 23:1200-1207. Post vs Pre Odds Ratio
  31. 31. Pre- vs Post-Intervention Risk-Based HIV Testing VA facilities in North-East and South-Central US 35% Increase in Testing 30% 12% 78% 158%HIV Testing Rate 25% 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 Control Sites Local Implementation Control Sites Local Central National Implementation No Implementation Implementation Implementation Pre-Intervention Post-Intervention
  32. 32. 2009 Changes in VA HIV Testing Policy
  33. 33. VHA Directive – HIV Screening Current VHA policy: HIV testing is a part of routine medical care Providers should routinely provide HIV testing to all Veterans who give verbal consent Veterans who test positive for HIV infection are to be referred for state-of-the-art HIV treatment as soon as possible after diagnosis VHA Directive 2009-036, August 17, 2009
  34. 34. 2009 Changes in VA HIV Testing Policy Organizational barriers • Informed consent & pre-test counseling requirements • Constraints on provider time • Limited opportunity for timely, in-person post-test notification • Uncertain capacity to manage newly diagnosed patients Provider behaviors • Incomplete recognition of HIV risk factors • Reliance on trained counselors to order HIV tests • Discomfort with HIV counseling • Lack of prioritization of HIV testingUse of verbal consent and routine testing removes only two barriers
  35. 35. Pre- vs Post-Intervention Routine HIV Testing Multi- VISN QI Project 30% Increase in Testing 25% 50% 390% 556%HIV Testing Rate 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 8 HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH Control Sites Local Central No Implementation HHH Implementation Implementation Pre-Intervention Post-Intervention
  36. 36. Veterans Ever Tested for HIV by Year2009-2011 9.2% Ever Tested 13.5% Ever Tested n= 20% Ever Tested n=524,267 795,126 n= 1,221,328 2009 2010 2011 Outpatient Visits n= Outpatient Visits n= Outpatient Visits n= 5,713,265 5,888,599 6,114,034VETERANS HEALTH ADMINISTRATION
  37. 37. Changes in HIV Testing vs Use of HIV Testing Clinical Reminder Sites without Clinical Reminder Sites with Clinical Reminder 16 14HIV Tests (thousands) 12 10 8 6 4 2 0 2009 2010
  38. 38. Percentage of HIV Positive Tests inCY 2011, by VISN% HIV Tests Performed in 2010 that were Positive 0.7% Mean: 0.38% *CDC Threshold for routine HIV testing 0.6% Median: 0.35% Range: 0.14-0.64% 0.5% 0.4% 0.3% 0.2% 0.1% 0.0% * 19 23 11 2 17 6 21 18 12 10 20 1 4 15 3 9 7 8 5 16 22 VISN VETERANS HEALTH ADMINISTRATION
  39. 39. Increased Testing Results in Earlier Diagnosis VA Atlanta & VA Greater Los Angeles CD4 Count < 200 Cells/µL Mean CD4 Cells/µL 60% 500 50% 400 40% 300 30% 200 20% 10% 100 0% 0 Los Angeles Atlanta Los Angeles AtlantaGoetz MB, Rimland D. J AIDS. 2011. 57:e23-e25.
  40. 40. Summary of Results Routine HIV testing is feasible in primary care clinics  Routine testing increased by 390 – 556% Clinical reminders based technology to promote HIV testing is widely effective and may not require a specialized intervention Promotion of routine HIV testing in primary care clinics supports the CDC goal that every American aged 13 – 64 know their HIV status
  41. 41. Summary of Justification for Promoting HIV Testing in VHA HIV care is most effective with early diagnosis US HIV prevalence generally exceeds CDC testing threshold HIV Testing is not cost-free but is an excellent use of healthcare dollars ACP recommends offering HIV testing to all adults Effective interventions have been developed
  42. 42. HIV Consensus Early diagnosis and treatment improves outcomes Undiagnosed & infected persons cannot benefit from HAART Early stage patients are asymptomatic Antiretroviral therapy decreases risk of disease transmission Patients who know their status reduce their to others HIV Testing is cost-effective & allows patients to get treatment
  43. 43. Acknowledgements VA HSR&D funding: QUERI cord funds, SDP 06- 001, SDP 08-002 VA Office of Public Health: moral, financial and logistical support Local leaders, clinical champions, primary care providers, facility leadership in VISNs 1, 3, 16 and 22 QUERI-HIV/HEP colleagues: Steve Asch, Allen Gifford, Jane Burgess, Tuyen Hoang, Hersch Knapp, Henry Anaya and many, many others

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