5/8/2012 BACKGROUND. Panelists. Session Objectives. Session Agenda. Moving Toward Universal Testing HIV Testing of TB Cases. Jennifer Flood, MD

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1 Moving Toward Universal Testing HIV Testing of TB Cases Jennifer Flood, MD Chief, Tuberculosis Control Branch California Department of Health INTRODUCTION OF PANELISTS California TB Controllers Association Annual Meeting May 15, 2011 Los Angeles, CA Panelists Stephanie Spencer Program Liaison, TB Control Branch, CDPH Julie Low TB Controller for Orange Julie Higashi TB Controller for San Francisco Previously controller for Santa Clara Cathy Miller Organized this session, TB Control Branch, CDPH Session Objectives Define universal HIV testing Discuss how to overcome common barriers to universal testing Overview on how the HIV-TB toolkit can facilitate the implementation Develop an intervention for local program to implement universal HIV testing in their TB programs Session Agenda Jenny Flood (Neha Shah for first session): Overview of universal HIV testing Julie Low and Julie Higashi: Lessons from the field Stephanie Spencer: Introduction of the HIV/TB toolkit Intervention development Participants will work in small groups at their tables Each participant will choose a table Each table focus on a specific barrier to implementing universal HIV testing Groups will brainstorm ways to address this barrier using the worksheet provided Each group will have time to report back Discussion BACKGROUND 1

2 Why get HIV tested? Because the President did Why is HIV testing important for TB patients?* TB is the leading cause of death for people with HIV/AIDS HIV risk factor for progression from TB infection to TB disease Risk of developing TB disease is 7% - 10% each year for people who are infected with both TB and HIV *Slide adapted from CDC TB Self-Study modules and CDC TB/HIV factsheet Why is HIV testing important for TB patients?* Progression to TB disease is often rapid among HIVinfected persons TB outbreaks can rapidly expand in HIV-infected patient groups. When HIV is diagnosed early, interventions and treatment can lead to improved health outcomes, including slower progression and reduced mortality Knowing HIV status reduces risky sexual practices HIV TESTING RECOMMENDATIONS * Adapted from CDC TB/HIV factsheet 2006 CDC recommendations* HIV screening for all TB patients Screen all TB suspects and contacts If high risk for HIV, test annually Normalize and ease HIV testing No more separate consent No more mandatory prevention counseling Use opt-out testing Use of rapid testing is encouraged *Adapted from 2006 MMWR: revised Recommendations for HIV testing of Adults, Adolescents, and Pregnant women in health-care settings Why all patients and not risk-based HIV testing? Targeted testing or risk-based testing is not effective Individuals may not perceive themselves to be at risk for HIV Individuals may not disclose their risks Provider assessment of patient s high risk behavior often incomplete Routine testing able to capture everyone regardless of risk and helps reduce stigma 2

3 US and California trends in TB and HIV National objective for known HIV status among TB cases: 88.7% by 2015 US: 81.7%* California 2008: 65% 2011: 77.8% Proportion TB cases infected with HIV in 2011 US: 7.9%* California: 4.3% OPT-OUT TESTING * Trends in Tuberculosis United States, 2011 MMWR, March 23, 2012 / 61(11); What is Opt Out Screening? As of Jan 1, 2008, opt-out testing in California permitted Opt-out = HIV screening will be done routinely unless a patient explicitly refuses Eliminates requirements for pretest counseling, informed consent, and post-test counseling. Opt-IN Patient requests or is offered the test Based on risk assessment for HIV and STDS Explicit consent obtained, usually written Opt-in versus Opt-out Opt-OUT Patient informed she/he may be tested for HIV as part of routine blood work, unless patient requests not to be Everyone screened No separate consent for HIV testing; general medical consent covers What Should I Say To the Patient? "Mr. Jones, we'll be running some blood work today. The TB Clinic also performs routine screening for HIV on all patients and we'll be doing that as part of your visit today. You do have the right to decline any of these tests, however they are all very important to your health. HIV TESTING OPTIONS Do you have any questions before we begin? 3

4 Rapid versus convention testing? Rapid testing Better if patients unlikely to return for results Oral specimen collection Point-of-care test requirements Immediate results Results are preliminary, require confirmation Staff training and support requirements Conventional testing Poor return rates, requires 2 visits Results are confirmatory Reliance on lab, so less intensive for site staff Logistically easier PROVIDING HIV RESULTS Probably not correct Concerns about providing results? Not sure what to say Now sure how to deliver results Worried how patient will respond Not sure if I am equipped to conduct NEXT STEPS for patient Concerned about whether result is a TRUE POSITIVE Disclosing An HIV Negative Result Always state result in a direct and neutral tone Wait for the patient s response Assess their emotional state Answer any questions they have Discuss the Window Period What Is The Window Period? HIV tests detect antibodies After becoming infected, the body takes time to develop antibodies Period of time between infection and when a test can detect antibodies is called the window period. Usually between 2 weeks to 6 months after exposure, with many people developing enough antibodies by 12 weeks (3 months) Make referrals if necessary 4

5 Disclosing an HIV Positive Result Always state result in a direct and neutral tone Wait for the client s response Assess their emotional state Answer any questions they have Link them to HIV Care. Stay in touch until they have been linked to care Some TB Clinics already integrated with HIV clinics or have same providers Discuss Partner Services Patient Responses to a Positive Result Vary Widely Many patients are aware of their own level of risk Some patients will be completely surprised Most patients contain their emotions during the session Strong emotional responses: Manage like those to other serious conditions HIV testing in children Health and Safety Code Child < 12 years of age is not competent to give consent for HIV test and written consent is required from parents, guardians or the court, if a dependent of the court. PEDIATRIC CASES AND HIV Health and Safety Code Provider can t administer an HIV test to a minor unless written consent is obtained from parents, guardian, etc. (also the case of a dependent adult applies here to the provider) HIV testing in children < 18 months: assays to detect HIV virus > 18 months: ELISA, Western Blot Summary All TB cases should have HIV screening TB suspects and contacts to TB patients should also be HIV tested Opt-out is standard of care Identify your program s barriers to universal HIV testing 5

6 Acknowledgements Saul Kanowitz Jennifer Flood Chris Hall Christopher Ried Stephanie Spencer Cathy Miller Vanessa Sweeney THANK YOU QUESTIONS? The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. 6