The document discusses expanding HIV screening in the Veterans Administration. It notes that prior to 2009, only 50-70% of veterans with known HIV risk factors were being tested. Many newly diagnosed patients had CD4 counts below 200. The VA implemented several interventions to increase testing rates including streamlining consent, using electronic medical records to identify at-risk patients, and providing regular feedback to facilities. These efforts led to a 2-3 fold increase in HIV testing rates across the VA and more patients being diagnosed earlier with higher CD4 counts.
HIV screening and treatment in as changes occur in our healthcare system. Targeted towards specific healthcare centers in Baltimore. Features some data from the Department of health and mental hygiene and new data on HIV transmission across continuum of HIV care.
A collection of important CCS Cases for USMLE step 3 that are practiced in Dr.Red USMLE step 3 CCS Workshop ( Archer CCS workshop). Please also find brief high-yield guidelines for some of these cases in the document.
Fast-track the end of AIDS in the EU - practical evidence-based interventions.
Presentation by: Cary James, Terrence Higgins Trust
In a two-day meeting under the auspices of the Maltese Presidency of the Council of the European Union (30-31 January 2017), HIV experts from across the European Union discussed how to reverse this trend and how to prepare Europe to achieve the set target of ending AIDS by 2030.
David L. Wyles, MD of UC San Diego Department of Medicine presents"Acute HCV Infection in HIV+ MSM: Sexual Transmission of a Non-Sexually Transmitted Disease?"
Presented by Michael Horberg, MD, MAS, FACP, FIDSA,
Executive Director Research, Mid-Atlantic Permanente Medical Group, Director, HIV/AIDS Kaiser Permanente, at the 2012 National Chlamydia Coalition meeting.
Kathleen Brady from the Philadelphia Department of Public Health presented her annual updated on the HIV Epidemic in Philadelphia at a February 2015 combined meeting of the Philadelphia Ryan White Part A Planning Council and the HIV Prevention Planning Group.
Special Needs for HIV+ Incarcerated PopulationsAdam Thompson
This presentation was developed for use at the Virginia Department of Corrections Academy for Staff Development. The purpose is to support clinicians and health care providers in correctional settings who provide care to Persons Living with HIV.
Pharmacy Essentials for HIV Screening and Management.2019hivlifeinfo
Pharmacy Essentials for HIV Screening and Management
This downloadable slideset provides an in-depth review of key pharmacy strategies for expanding and supporting safe and effective HIV screening and treatment services to patients at risk of or living with HIV infection.
Jennifer Cocohoba Headshot
Jennifer Cocohoba, PharmD
Format: Microsoft PowerPoint (.ppt)
File Size: 1.93 MB
Released: January 31, 2019
HIV screening and treatment in as changes occur in our healthcare system. Targeted towards specific healthcare centers in Baltimore. Features some data from the Department of health and mental hygiene and new data on HIV transmission across continuum of HIV care.
A collection of important CCS Cases for USMLE step 3 that are practiced in Dr.Red USMLE step 3 CCS Workshop ( Archer CCS workshop). Please also find brief high-yield guidelines for some of these cases in the document.
Fast-track the end of AIDS in the EU - practical evidence-based interventions.
Presentation by: Cary James, Terrence Higgins Trust
In a two-day meeting under the auspices of the Maltese Presidency of the Council of the European Union (30-31 January 2017), HIV experts from across the European Union discussed how to reverse this trend and how to prepare Europe to achieve the set target of ending AIDS by 2030.
David L. Wyles, MD of UC San Diego Department of Medicine presents"Acute HCV Infection in HIV+ MSM: Sexual Transmission of a Non-Sexually Transmitted Disease?"
Presented by Michael Horberg, MD, MAS, FACP, FIDSA,
Executive Director Research, Mid-Atlantic Permanente Medical Group, Director, HIV/AIDS Kaiser Permanente, at the 2012 National Chlamydia Coalition meeting.
Kathleen Brady from the Philadelphia Department of Public Health presented her annual updated on the HIV Epidemic in Philadelphia at a February 2015 combined meeting of the Philadelphia Ryan White Part A Planning Council and the HIV Prevention Planning Group.
Special Needs for HIV+ Incarcerated PopulationsAdam Thompson
This presentation was developed for use at the Virginia Department of Corrections Academy for Staff Development. The purpose is to support clinicians and health care providers in correctional settings who provide care to Persons Living with HIV.
Pharmacy Essentials for HIV Screening and Management.2019hivlifeinfo
Pharmacy Essentials for HIV Screening and Management
This downloadable slideset provides an in-depth review of key pharmacy strategies for expanding and supporting safe and effective HIV screening and treatment services to patients at risk of or living with HIV infection.
Jennifer Cocohoba Headshot
Jennifer Cocohoba, PharmD
Format: Microsoft PowerPoint (.ppt)
File Size: 1.93 MB
Released: January 31, 2019
01 merlin wilcox_research as a route in to global health_personal reflectionsjintc
Presentation given by Dr Merlin Wilcon on Friday 13th April 2012 to the 4th RCGP Junior International Committee Annual General Meeting in Croydon, London
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
1. Expanding HIV Screening in the
Veterans Administration
Matthew B. Goetz, MD
Chief, Infectious Diseases, VA Greater Los Angeles HCS
Clinical Coordinator, QUERI-HIV/HCV
Professor of Clinical Medicine, David Geffen School of
Medicine at UCLA
2. What should be done for this patient?
54 yo male new dx HCV+; abnormal LFTs and chronic pruritis
PMH: Depression, viral pericarditis, GSW to thorax 1977
SHx: denies tobacco and ETOH, admits MJ; denies IDU
PE: Folliculitis 2 to pruritis, otherwise unremarkable
Lab: 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. What should be done for this patient?
54 yo male new diagnosis HCV+; abnormal LFTs and chronic pruritis
PMH: Depression, viral pericarditis, GSW to thorax 1977
SHx: denies tobacco and ETOH, admits MJ; denies IDU
PE: Folliculitis 2 to pruritis, otherwise unremarkable
Lab: 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 6,030,000
One month later: Admitted with 2 weeks SOB, cough
ABG: pH 7.48, PCO2 28, pO2 58;
CXR: diffuse reticulonodular opacities
HIV+, CD4 74, VL 37,000. Bronchoscopy PCP.
Despite Rx, died of progressive respiratory failure
4.
5. 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
6. 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
testing
MMWR: Vol 57(39), 2008. Campsmith ML et al. JAIDS. 2010; 5:619-624.
7. 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 2009
MMWR: Vol 57(39), 2008. Campsmith ML et al. JAIDS. 2010; 5:619-624. CDC HIV Surveillance Reports.
9. 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 infection
MMWR. 2006; 55(RR-14). Qaseem A, et al. Ann Intern Med. 2009; 150:125-131.
10. 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.
11. 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 oma
Walensky R et al. JID 2006;194:11-19
12. 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. Arch
Intern Med. 1998; 158:734. Liddicoat R, et al. J Gen Intern Med. 2004; 19:349.
13. 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?
14. 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
15. 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
16. 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
17. What does the VA Computerized
Patient Record System (CPRS) look
like?
24. 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
25. Electronic prompt for identification and testing of patients at-risk for HIV infection
26.
27.
28. 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
30. 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?
31. Quarterly feedback
• HIV testing rate
• Rate of clinical
reminder resolution
32. 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
33. Post vs Pre Odds Ratio of HIV Testing
Analysis of Patient Level Factors
18 – 30 years
Age 31-50 years
51-64 years
> 64 years
Income Low
High
Caucasian
Ethnicity African American
Hispanic
Other
Missing
Marital status Single
Married
Other
Homeless No
Yes
HCV Risk Fx No
Yes
HCV Infection No
Yes
HBV Infection No
Yes
Prior STD No
Yes
No
Illicit Drug Use Yes
0 1 2 3 4
Goetz MB et al. J Gen Intern Med. 2008; 23:1200-1207. Post vs Pre Odds Ratio
34. 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
36. 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
37. 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 testing
Use of verbal consent and routine testing removes only two barriers
38. 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
39. Veterans Ever Tested for HIV by Year
2009-2011
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 6,114,034
VETERANS HEALTH ADMINISTRATION
40. Changes in HIV Testing vs
Use of HIV Testing Clinical Reminder
Sites without Clinical Reminder Sites with Clinical Reminder
16
14
HIV Tests (thousands)
12
10
8
6
4
2
0
2009 2010
41. Percentage of HIV Positive Tests in
CY 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
42. 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 Atlanta
Goetz MB, Rimland D. J AIDS. 2011. 57:e23-e25.
43. 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
44. 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
45. 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
46. 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