Handling TB and HIV Co-Infection Fargo, North Dakota September 15-16, 2010

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1 Handling TB and HIV Co-Infection Fargo, North Dakota September 15-16, 2010 Opt Out Testing for HIV CW C.W. Shafer, MD Denise Larson September 16, 2010 C.W. Shafer, MD Falls Community Health/ Sioux Falls Family Medicine Residency Program Sioux Falls, SD OPT OUT OUT TESTING FOR HIV 16 SEPTEMBER,

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4 : State of the Union 2006: 1,106,400 persons in the United States were living with HIV. CDC estimates 56,300 new infections in 2006 At the end of 2006, approximately 21% (232,700 persons) of those infected with HIV did not know they were infected. 4

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6 : Objectives 1. Increase HIV screening of patients, including pregnant women, in healthcare settings. 2. Foster earlier detection of HIV infection. 3. Identify and counsel persons with unrecognized HIV infection and link them to clinical and preventive services. 4. Further reduce perinatal transmission in the United States. 6

7 : 2006 Major Revisions For all patients in healthcare settings: 1. HIV screening is recommended for pts in all healthcare settings after the patient is notified that testing will be performed, unless the pt declines (opt out screening). 2. Persons at high risk for HIV infection should be screened at least annually. 7

8 : 2006 Major Revisions, Con t. 3. Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. 4. Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening in healthcare settings. : 2006 Major Revisions For Pregnant Women 1. HIV testing should be included in the routine panel of prenatal screening tests for all pregnant women. 2. HIV screening is recommended for pts in all healthcare settings after the patient is notified that testing will be performed, unless the pt declines (opt out screening). 8

9 : 2006 Major Revisions For Pregnant Women, Con t. 3. Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. 4. Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women. 9

10 Dreaded Statistics I Disease Disease Present Absent Pos Test: True False Positive Positive Neg Test: False True Negativee Negativee Sens= TP/TP+FN Spec=TN/TN+FP Positive Predictive Value=TP/TP+FP Dreaded Statistics II Prevalence: 10% HIV No HIV Pos Test 99 9 Neg Test Positive Predictive Value: 92% n= 1,000 10

11 Dreaded Statistics III Prevalence: 1% HIV No HIV Pos Test Neg Test Positive Predictive Value: 50% n= 10,000 Dreaded Statistics IV Prevalence: 0.1% HIV No HIV Pos Test Neg Test 1 98,901 Positive Predictive Value: 9% n= 100,000 11

12 Dreaded Statistics V (assumed False Pos. rate: 0.1%) HIV Prev. False Pos True Pos Ratio FP:TP 1 in ,000 1:100 1 in ,000 1:10 1 in 1, :1 1 in 10, :1 1 in 100, :1 Available HIV tests Enzyme Immunoassay (EIA) Rapid EIA Blood Urine Saliva Western Blot HIV RNA (RT PCR) EIA detuned assay Combined Ab/Ag 12