Philip J. Peters, MD
Transcript of Philip J. Peters, MD
HIV Testing Update
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HIV Screening for Patients 13-64 years:
A Guide for TB Clinic Providers
Best Practices in TB Control - August 28, 2012
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Philip J. Peters, MD Medical Officer
Division of HIV/AIDS Prevention Centers for Disease Control and Prevention
Atlanta, GA
Disclosures
• Conflicts of Interest: None
• Disclaimer: The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention
HIV Testing Update
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Question
What is responsible for the greater than 95% decline in perinatally acquired AIDS in the US?
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1. Widespread HIV screening of all pregnant women
2. Antiretroviral use during the antenatal, perinatal, and newborn periods
3. Reduction in number of pregnant women with HIV infection
4. 1 & 2
2006 Revised Recommendations
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Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.
HIV Testing Update
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CDC’s Recommendations
• HIV screening for all patients aged 13 to 64 years
– Opt-out screening: patients should be told screening
will be performed but may decline testing
– Prevalence of undiagnosed HIV infection > 0.1%
• Written consent and prevention counseling not
required
• Annual HIV screening for those at high risk for HIV
• Prompt clinical care for HIV-infected persons
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Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.
Learning Objectives
• Analyze the rationale for HIV screening recommendations
• Assess clinical benefits of routine HIV screening
• Formulate approaches to simplify routine HIV screening in practice
• Update on selecting HIV tests
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HIV Testing Update
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Estimated HIV Prevalence in the United States, 2008
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Campsmith ML, et al. CDC. Morb Mortal Wkly Rep. (MMWR). 2008;57(39):1073-1076. Campsmith ML, et al. J Acquir Immune Defic Syndr. 2010 Apr;53(5):619-24. CDC. HIV surveillance—United States, 1981-2008. MMWR 2011;60: 689-693.
1,178,350 persons living with HIV infection
Prevalence = 448 per 100,000 population
0.4% of population living with HIV infection
20% unaware of their diagnosis
Rate of Tuberculosis Cases per 100,000 Population – United States, 2011
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Rate of AIDS Diagnoses by MSA* of Residence - United States and Puerto Rico, 2008
* MSA = Metropolitan Statistical Area
Centers for Disease Control and Prevention. Rates of AIDS Diagnoses by Metropolitan Statistical Area (MSA) of Residence, 2008 - United States and Puerto Rico. Areas. Slide set. http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/index.htm. Accessed May 27,2011.
Centers for Disease Control and Prevention. Trends in Tuberculosis - United States, 2011. MMWR Morb Mortal Wkly Rep. 2012 Mar 23;61(11):181-5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm. Accessed August 1, 2012.
Geographic Comparison of Rates of AIDS Diagnoses and Tuberculosis Cases in the United States
HIV Testing Update
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Why Routine Screening?
• Patients do not always disclose or may not be aware of their risk1
– 39% of men who had sex with a man within the past year did not disclose to their health care provider2
– 51% of rapid test positive patients identified in Emergency Department (ED) screening had no identified risk3
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1. Chou R, et al. Ann Intern Med. 2005;143:55-73. 2. Bernstein KT, et al. Arch Intern Med. 2008;168(13):1458-1464. 3. Lyss SB, et al. J Acquir Immune Defic Syndr. 2007;44(4): 435-442.
Risk-Based HIV Testing Has Become Less Effective
• Patients with HIV infection often have multiple health-care visits before diagnosis – median of 7 visits over 5 years in one study1
• Risk-based testing frequently misses2,3:
– Young people (< 24 years) – Women and heterosexual men – Members of racial and ethnic minorities – People residing outside of urban areas
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1. Klein D, et al. J Acquir Immune Defic Syndr. 2003; 32(2): 143-152.
2. Institute of Medicine. Washington, DC: National Academy Press; 2001. 3. CDC. HIV surveillance—United States, 1981-2008. MMWR 2011;60: 689-693.
HIV Testing Update
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Late Diagnosis of HIV Infection
32%
68%
Percentage of Patients Diagnosed with HIV
Late in the Course of Infection 2009, US*
Late Diagnosis:AIDS Diagnosed within ayear of receiving HIVdiagnosis
Early Diagnosis
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* 46 states with confidential name-based HIV infection reporting (n= 45,336) Centers for Disease Control and Prevention. HIV Surveillance Report, 2010; vol. 22.
Probability Curve of Mortality According to Baseline CD4 Cell Count
0-24
25-49
50-99100-199
200-249
>=350
CD4 cell count (cells/µL)
0.00
0.05
0.10
0.15
0.20
Pro
ba
bili
ty o
f death
0 1 2 3 4 5
>=5
3-4.99
Viral Load (log10[copies/mL])
0.00
0.05
0.10
0.15
0.20
Pro
ba
bili
ty o
f death
0 1 2 3 4 5
AIDS
No AIDS
Clinical stage (CDC classification)
0.00
0.05
0.10
0.15
0.20
Pro
ba
bili
ty o
f death
0 1 2 3 4 5
Injection drug use
No injection drug use
Transmission group
0.00
0.05
0.10
0.15
0.20
Pro
ba
bili
ty o
f death
0 1 2 3 4 5
>=50
40-49
30-3916-29
Age(years)
0.00
0.05
0.10
0.15
0.20
Pro
ba
bili
ty o
f death
0 1 2 3 4 5
0-24
25-4950-99
100-199
200-249
>=350
CD4 cell count (cells/µL)
0.00
0.10
0.20
0.30
0.40
Pro
ba
bili
ty o
f A
IDS
or
de
ath
0 1 2 3 4 5
>=5
3-4.99
Viral Load (log10[copies/mL])
0.00
0.10
0.20
0.30
0.40
Pro
ba
bili
ty o
f A
IDS
or
de
ath
0 1 2 3 4 5
AIDS
No AIDS
Clinical stage (CDC classification)
0.00
0.10
0.20
0.30
0.40
Pro
ba
bili
ty o
f A
IDS
or
de
ath
0 1 2 3 4 5
Injection drug use
No injection drug use
Transmission group
0.00
0.10
0.20
0.30
0.40
Pro
ba
bili
ty o
f A
IDS
or
de
ath
0 1 2 3 4 5
>=5040-49
30-39
16-29
Age(years)
0.00
0.10
0.20
0.30
0.40
Pro
ba
bili
ty o
f A
IDS
or
de
ath
0 1 2 3 4 5
Years from starting HAART Years from starting HAART
AIDS or death Death
May M, et al. AIDS. 2007;21;1185 ART-CC.
Years from starting antiretroviral therapy (ART)
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HIV Testing Update
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Tuberculosis and HIV
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A high proportion (7.9%) of people with tuberculosis
disease in the US are HIV infected [1]
Compared with HIV-negative patients, HIV-infected
patients with Mycobacterium tuberculosis infection
are markedly (21 – 34 times) more likely to develop
active tuberculosis disease [2]
1. Centers for Disease Control and Prevention. Trends in Tuberculosis - United States, 2011. MMWR Morb Mortal Wkly Rep. 2012 Mar 23;61(11):181-5. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6111a2.htm. Accessed August 1, 2012. 2. World Health Organization. Global Tuberculosis Control. 2011. Available at http://www.who.int/tb/publications/global_report/2011/en/index.html. Accessed January 31, 2012.
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Antiretroviral Therapy Reduces Rates of Sexual Transmission of HIV
HPTN 052:
Antiretroviral
therapy reduced
HIV transmission
by 96% in
discordant couples
Cohen MS, et al. N Engl J Med 2011;365:493-505.
HIV Testing Update
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Desired Outcome of Routine HIV Screening
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HIV Screening
HIV Diagnosis
Improve Survival
and Quality of Life
Prevent New HIV Infections
Link to Care
Implementing HIV Screening
Integrating HIV Screening into Practice
•Train staff to perform HIV opt-out screening
• Provide easily understood patient informational materials
•Be prepared for commonly asked questions
• Include testing reminders in patient’s electronic medical record
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Address Patients’ Misperceptions
•Many patients believe they were previously tested for HIV, particularly if blood was drawn
•Many patients assume an HIV test was performed and if they didn’t receive a call from the doctor, that they do not have HIV
HIV Testing Update
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Implementing HIV Screening (cont’d)
State Laws Regarding HIV Testing
• Requirements to obtain written consent are being phased out.
• Refer to National HIV/AIDS Clinicians’
Consultation Center’s Compendium of State HIV Testing Laws for questions about your state: http://www.nccc.ucsf.edu/
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Compendium of State HIV Testing Laws. National HIV/AIDS Clinicians’ Consultation Center (NCCC) Web site. http://www.nccc.ucsf.edu/consultation_library/state_hiv_testing_laws/.
Communicating Positive HIV Test Result
• Provide result by direct personal
contact
• Provide result confidentially
• Ensure patient understands test result
• Connect to services
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Positive
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Branson B, et al. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. (MMWR). 2006;55(RR-14):1-17.
HIV Testing Update
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Uni-Gold Recombigen
Reveal G3 OraQuick Advance
Clearview Complete HIV 1/2
Clearview HIV 1/2 Stat Pak
INSTI
Rapid HIV Tests
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Rapid HIV Tests
Advantages
Ensures patient receives test result
Option for an oral swab or finger stick instead of blood draw
Limitations
Results are manually read and charted
Training and oversight necessary
Can overburden nursing and other staff
More expensive
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HIV Testing Update
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Time to detection of HIV RNA, p24 antigen, and antibody during early HIV infection
HIV RNA (plasma)
HIV Antibody
0 10 20 30 40 50 60 70 80 90 100
HIV p24 Antigen
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Eclipse Acute HIV Infection Established HIV Infection
Infection
Reference: Branson BM. JAIDS. 2010; 55(S2): S102-105.
Days
Phase of
Infection
Earliest Viral
Detection
Antibody Detection
by Western blot
Time to detection of HIV RNA, p24 antigen, and antibody during early HIV infection
HIV RNA (plasma)
HIV Antibody
0 10 20 30 40 50 60 70 80 90 100
HIV p24 Antigen
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Eclipse Acute HIV Infection Established HIV Infection
Infection
Reference: Branson BM. JAIDS. 2010; 55(S2): S102-105.
Days
Phase of
Infection
Earliest Viral
Detection
Antibody Detection
by Western blot
HIV Testing Update
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Detects p24 antigen and HIV antibody
Time to result: 29 minutes
100 results/hour
FDA-approved June 22, 2010
4th Generation Combo Ag/Ab Assay
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HIV Screening. Standard Care.
• Free materials for providers – Annotated Guide to CDC
Recommendations – Resource Guide – AMA/AAHIVM CPT Coding Guide – ACP Guidance Statements – National HIV/AIDS Clinicians
Consultation Center Flyer
• Free patient materials
(available in English and Spanish)
– Brochure – Poster
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Download at www.cdc.gov/HIVStandardCare
Order free of charge from [email protected]
The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for
Disease Control and Prevention