Implementing HIV Screening at Hub and Spoke Sites and Other Drug Treatment Settings

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1 Implementing HIV Screening at Hub and Spoke Sites and Other Drug Treatment Settings Dennis Fleming, MA CDPH/Office of AIDS DHCS Statewide SUD Conference August 23, 2018 Anaheim, CA Agenda What s New in the Field of HIV What s Old and What s New in HIV Testing Best Practices Resources Rationale for Testing Persons with SUD CDC Guidelines Required by Hub and Spoke grant Persons who inject drugs at higher risk Using alcohol and other drugs may alter judgment, and this may lead to risky behaviors Persons using substances may engage in sex work or trade sex for drugs/money, which may lead to risky behavior Early diagnosis leads to better health outcomes for individual and community U = U (Undetectable = Untransmittable) 1

2 HIV in California What s New in HIV/AIDS Treatment Many more options; pill combinations; new classes of medications Still no cure PrEP Pre exposure Prophylaxis Efficacy in MSM, IDU, Sero discordant Heterosexual Couples U = U Undetectable equals Untransmittable (sexual) Getting to Zero Campaigns world wide HIV Testing/Screening Definitions Screening performing HIV test for all persons in a defined population Diagnostic testing performing HIV test for persons with clinical signs or symptoms consistent with HIV infection Targeted (Focused) Testing performing HIV test for subpopulations at higher risk (behavioral, clinical, or demographic characteristics) Routine, Opt out Screening performing HIV screening after notifying patient that: 1) test will be performed 2) patient may decline 3) Assent is inferred unless patient declines 2

3 What s New (Relatively) In HIV Screening Separate Written Consent NOT required for HIV testing General medical care consent is sufficient No certification/special training required for medical professionals Physicians, NP, PA, nurses, medical assistants working within legal scope of practice Growing emphasis on routine opt out testing Blood draw for lab based HIV testing is best practice Preventative Counseling NOT required Though linkage to care and referral to PreP or Partner Services advisable CDC Guidelines (Routine, Opt Out for Adults and Adolescents in Health Care Settings 2006) At least once for all patients aged All patients initiating treatment for TB All patients seeking treatment for STI All pregnant women At initial visit Repeat in 3 rd trimester (especially in high prevalence areas/high risk cases) During labor/delivery (especially if undocumented HIV status) Branson, BM, Handsfield, HH, et al. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings United States, MMWR Morb Mortal Wkly Rep 2006/55(RR14): 1 17 Repeat Screening Annually if; Injecting drugs and partner of person(s) injecting drugs Men who have sex with men (MSM) Sex worker Exchanging sex for food/drugs/housing etc Sex partners of HIV infected persons Heterosexual person with multiple partners or partner(s) with multiple partners More often (every 3 6 months) based on clinical judgement and/or indicated risk behaviors 3

4 CPT Codes HIV Test CPT Code Medi Cal Rate Comments HIV 1 Antigen/HIV 1 & HIV 2 Antibody $20.26 Recommended and commonly used in labs HIV 1 Antibody HIV 2 Antibody $7.91 $11.81 $19.72 Processed together (BioRad Geenius), but results are unique HIV 1 Qualitative Viral Load $38.21 Results Yes/NO HIV 1 Quantitative Viral Load $76.33 Must be ordered by physician Number Amount of virus in the blood Lab-based HIV Diagnostic Testing Algorithm I 4 th (CPT 87389)generation P24 antigen and HIV-1/2 antibody immunoassay (EIA) A1+ A1(-) Negative for HIV-1 and HIV-2 antibodies and p24 Ag A2 HIV-1 (CPT 86701)/HIV-2(CPT 86702) differentiation immunoassay (BioRad Geenius) HIV-1 + HIV-1 HIV-1 or Indeterminate HIV-1 + HIV-2 HIV-2 + or HIV-2 HIV-2 + HIV-1 antibodies HIV-2 antibodies HIV-2 antibodies detected detected detected *Qual RNA (CPT 87535) Initiate care Initiate care Initiate care (and viral load) (and viral load) (and viral load) RNA+ RNA ( ) *Physician may order quantitative RNA (CPT 87536) instead to Acute HIV-1 Infection Negative for determine viral load Initiate care HIV-1 Positive Test Result Linkage to Care and Other Services Immediately if acute infection identified Vital to Care Continuum Active Linkage/Warm Hand Off Collaborate with Health Department/CBO s Link to other services to ensure retention Partner Services Supporting disclosure to sexual/needle sharing partners Collaborate with health department Disease Intervention Specialists (DIS) 4

5 Negative Result Refer to Services PrEP (pre exposure prophylaxis) PleasePrepMe.org Gilead Patient Assistance Program Prevention Services Support Services Syringe Exchange SUD Treatment Mental Health Resources California Department of Public Health/Office of AIDS Dennis Fleming, MA Office of AIDS Website Resources CDC Capacity Building Assistance Program (CBA) Available free of charge to CBO s, health departments and healthcare organizations Provides training and TA to plan, implement and sustain HIV prevention programs HIV Testing Prevention programs for HIV positive and high risk negative persons Organizational development and policy 8_15web.pdf Contact Dennis Fleming (previous page) if you are interested 5

6 Resources National Clinical Consultation Center (at UCSF) HIV/AIDS and HCV Management (including testing) Perinatal HIV/AIDS Substance Abuse Management PrEP (Pre Exposure Prophylaxis) and PEP (Post Exposure Prophylaxis) consultation/ PrEP 6