HIV testing in North Carolina- A pathway to Universal Access

HIV testing in North Carolina- A pathway to Universal Access

Peter A. Leone, MD Professor of Medicine

University of North CarolinaMedical Director

NC HIV/STD Prevention and Care NCDHHS

Stemming the Tide of HIV Transmission in the United States

• Number Infected

• Number unaware of their HIV infection

• Estimated new infections annually

• Those with unrecognized infection account for ~51% of new infections

• 1,039,000-1,185,000

• 220,000-250,000 (~21%)

• 56,000

• ~29,000

Glynn M, Rhodes P. 2005 HIV Prevention Conference

• Onset of symptoms or illness acts as a cue for testing 42% of HIV positive in U.S. tested due to illness (MMWR 2003)

HIV incidence

Hall et al, JAMA 2008

HIV Diagnosis in Men

Hall et al. JAIDS 2009

Estimates of New Infections, 2006, By Race/Ethnicity, Risk Group, and Gender,for the Most Affected U.S. Subpopulations*

Impact of HIV/STD on MSM• HIV: 53% all new infections• Syphilis: 65% all P&S infections• Evidence of growing role in other STD

– GC (20+% of cases in GISP)– Prevalence of GC, CT underestimated due to

limited rectal, pharyngeal screening– Outbreaks of LGV

• High rates of HIV co-infection (syphilis 40-60%, GC 5-10%)

HIV/STD disparities among African-Americans in the U.S.

Est. annual B:W Incidence / % all cases incidence Prevalence Ratio in blacks

HIV 56,000 7:1 45%GC 718,000 18:1 70%CT 2.8 m 8:1 48%P&S syphilis 11,500 6:1 46%Trichomoniasis 7.4 m 10:1 59%HSV-2 1.6 m 3:1 30%

Based on:

HIV estimated incidence (JAMA 2008) STD Surveillance 2007NHANES assessments of HSV-2 and TrichomoniasisWeinstock Persp Sex Rep Health 2004

HIV Incidence is High Among African American MSM

• HIV incidence among African American men aged 15-22 4%

• HIV incidence among African American men aged 23-29 15%

MMWR, HIV incidence among young MSM – 7 US Cities, 1994-2000, June 01, 2001

African American MSM have very high HIV prevalence rates and unrecognized

infection HIV infection and Unrecognized Infection

among MSM, 5 US Cities, aged >18:Black, Non-Hispanic 46% (67%)White, Non-Hispanic 21% (18%)Multiracial 19% (50%)Hispanic 17% (48%)Other 13% (50%)MMWR, HIV Prevalence, unrecognized infection and HIV Testing among MSM –

5 US Cities, June 2005, April, 2005, June 24, 2005.

HIV Prevalence: General US HIV Prevalence: General US PopulationPopulation

n/a, not available.1. Morris M et al. Am J Public Health. 2006;96(6):1091-1097.2. McQuillan GM et al. J Acquir Immune Defic Syndr. 2006;41(5):651-656.

Add HealthAdd Health11::Young adultsYoung adults(%, 95% CI)(%, 95% CI)

NHANESNHANES22::Aged 18 to 39 Aged 18 to 39 (%, 95% CI)(%, 95% CI)

NHANESNHANES22::Aged 40 to 49 Aged 40 to 49 (%, 95% CI)(%, 95% CI)

WhitesWhites 0.022 (0, 0.64)0.022 (0, 0.64) 0.26 (0.05, 1.24)0.26 (0.05, 1.24) 0 (0, 0.45)0 (0, 0.45)

BlacksBlacks .492 (0.18, 0.87).492 (0.18, 0.87) 1.42 (0.71, 2.84)1.42 (0.71, 2.84) 3.58 (1.88, 6.71)3.58 (1.88, 6.71)

White menWhite men n/an/a 0.52 (0.11, 2.45)0.52 (0.11, 2.45) 0 (0, 0.89)0 (0, 0.89)

White womenWhite women n/an/a 0 (0, 0.31)0 (0, 0.31) 0 (0, 0.92)0 (0, 0.92)

Black menBlack men n/an/a 1.93 (0.77, 4.72)1.93 (0.77, 4.72) 4.54 (2.24, 8.97)4.54 (2.24, 8.97)

Black womenBlack women n/an/a 1.01 (0.36, 2.84)1.01 (0.36, 2.84) 2.78 (1.00, 7.45)2.78 (1.00, 7.45)

2005 HIV PREVALENCE REPORTED IN UNAIDS 2005 HIV PREVALENCE REPORTED IN UNAIDS 2006 REPORT ON THE GLOBAL AIDS 2006 REPORT ON THE GLOBAL AIDS

EPIDEMICEPIDEMICPREVALENCE (%)PREVALENCE (%)

Burkina FasoBurkina Faso 2.02.0CameroonCameroon 5.45.4GhanaGhana 2.32.3RwandaRwanda 3.13.1SenegalSenegal 0.90.9UgandaUganda 6.76.7CambodiaCambodia 1.61.6IndiaIndia 0.90.9HaitiHaiti 3.83.8

UNAIDS. 2007 AIDS Epidemic Update

Communicable Disease Surveillance Unit

HIV 2006 (incidence HIV 2006 (incidence estimates)estimates)

22 States Participating22 States ParticipatingNC ranked 4NC ranked 4thth (FL, NY, LA) (FL, NY, LA) NCNC

2,356 persons 2,356 persons (32.2/100,000) - (32.2/100,000) - 40% higher than 40% higher than the US the US

NC NC Males represented Males represented 72%72%

Blacks representedBlacks represented 67%67%

Black rate was Black rate was 99 times the rate for times the rate for whiteswhites

US US 56,300 persons 56,300 persons (22.8/100,000)(22.8/100,000)

USUS Males represented Males represented 73%73%

Blacks Blacks represented 45%represented 45%

Black rate was 7 Black rate was 7 times the rate times the rate for whitesfor whites

AHI in North Carolina

• AHI were more likely to be adolescents (≤21 years old) and less likely to be women vs. prevalent infection

• 28% of AHI (N=35) were adolescents of whom 51% (N=18) were identified from 2007-2008 (versus 2002-2006, p=0.03).

• Adolescent AHI were predominately MSM of color (74%), compared to only 23% of adult acutes (p< 0.0001).

Kuruc et al. IAS 2009


7% 8%

68%

28%

22%

62%

Population HIV Disease

White, non-Hispanic

Black, non-Hispanic

HispanicAsian/PI, 2%

AI/AN, 1%Asian/PI, <1%

AI/AN, 1%

N.C. Population and new HIV N.C. Population and new HIV Disease Reports, 2007Disease Reports, 2007


NC adult/adolescent HIV NC adult/adolescent HIV disease 2007disease 2007

Females

IDU9%

Hetero-sexual

86%

Other5%

MalesMSM/IDU

3%IDU5%

MSM72%

Other1%

Heterosexual19%


Disparities for Males 2007 HIV Disparities for Males 2007 HIV DiseaseDisease

15.7/100,000 White males15.7/100,000 White males 85.2/100,000 Black or African 85.2/100,000 Black or African American males (more than 5 American males (more than 5 times that of Whites)times that of Whites)

38.0/100,000 Hispanic males 38.0/100,000 Hispanic males (more than 2 times that of (more than 2 times that of Whites )Whites )


Disparities for Females 2007 HIV DiseaseDisparities for Females 2007 HIV Disease

2.8/100,000 2.8/100,000 White femalesWhite females 42.9/100,000 42.9/100,000 Black or African American Black or African American

femalesfemales (more than 15 times that of Whites) (more than 15 times that of Whites) 12.2/100,000 12.2/100,000 Hispanic femalesHispanic females

(more (more than 4 times that of Whites)than 4 times that of Whites)

• ~35,000 living with HIV

• Each year ~ 25 - 30 percent of new HIV disease cases in North Carolina represent persons diagnosed concurrently with both HIV infection and AIDS.

Late HIV Diagnosis in North Carolina

AIDS Rates 1987-2006: U.S. and N.C.

13.9

12.7

0

5

10

15

20

25

30

35

40

45

19871988198919901991199219931994199519961997199819992000200120022003200420052006

Year of Report

Rate (per 100,000) .

NC US

Missed opportunities for HIV diagnosis in the South

• In a South Carolina there were 4315 cases of HIV reported between 2001-2005)*– 41% had AIDS diagnosis within 1 year of AIDS diagnosis– 16.5 had AIDS diagnosis within 30 days– Of 1748 late testers, 1303 (~75%) had a health care

visit(s) from 1997-2005.• Number of health care visits with no HIV test: 7988 (average 4

per person• Visits with diagnosis that should trigger HIV testing: 1711• No risk at visit: 6277

* CDC MMWR Weekly Report Dec. 1, 2006

Identification of HIV Status to Reduce Transmission

• Goal of new CDC recommendations to increase number who know HIV+ status

• People do not perceive risk• Clinicians do not offer test• Stigma more with “identified” risk and infection

less so with testing itself• Knowing HIV+ status can reduce transmission by:

- Behavior change - Addressing Co-morbidity - HAART reducing viral load

MMWR 55:1-7, 2006

Inungu J. AIDS atient Care STDs 16:293, 2002

New CDC RecommendationsIn health care settings:

· HIV screening is recommended in all health care settings, after notifying the patient that testing will be done unless the patient declines (opt-out screening)

· Persons at high risk for HIV infection should be screened for HIV at least annually

· Separate written consent for HIV testing is not required. General consent for medical care is sufficient to encompass consent for HIV testing

· Prevention counseling need not be conducted in conjunction with HIV testing

Knowledge of HIV Infection and Behavior

Reduction in unprotected anal or vaginal intercourse with HIVNegative partners - HIV positive aware vs HIV positive unaware:

68% (95% CI: 59%–76%) Source: Marks G, et al. Meta-analysis of high risk sexual behavior, aware vs unaware. JAIDS. 2005

Forth coming CDC Recommendations for HIV testing in non-health care settings

• Single positive EIA is adequate for referral• Ryan White Funds can be used for initial

evaluation and confirmation• Strong component for linkage and retention

to care – 50% by 3 months; 75% by 6 mo. • Further define frequency of testing for high

risk individuals

North Carolina Rules and Statutes


Branch Strategies for Branch Strategies for HIVHIV

Expand and make HIV testing routineExpand and make HIV testing routine Continue NC STAT programContinue NC STAT program Get newly diagnosed persons into careGet newly diagnosed persons into care CD4 and Vl on all newly Dx individualsCD4 and Vl on all newly Dx individuals Keep persons diagnosed with HIV in care Keep persons diagnosed with HIV in care

Changes to NC Administrative CodeNov. 1, 2007

• Opt-out HIV screening in medical settings and for prenatal and STD visits

• Pretest counseling not required • Post-test counseling required only for positives• HIV tests at first prenatal visit and 3rd trimester• Mandatory HIV test at L&D for all women for

whom HIV status is unknown and in infant if test not obtained from mother

Further Modification to “Routinize” HIV testing in Medical Care Settings"Testing for HIV may be offered as part of

routine laboratory testing panels using a general consent which is obtained from the patient for treatment and routine laboratory testing,so long as the patient is notified that they are being tested for HIV and given the opportunity to refuse testing."

Web site addresses

• For CDC testing guidelines, go to http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

• For the changes to North Carolina testing rules, go tohttp://www.epi.state.nc.us/epi/hiv/regulations.html

• For epidemiological data in North Carolina, go tohttp://www.epi.state.nc.us/epi/hiv/stats.html

North Carolina HIV Testing Initiatives

• DOC opt-out screening• Jail Screening 28 county sites• ED screening/testing- 3 EDs in Triangle• Rapid HIV testing in 25 counties• Community Health Centers screening• GRGT• Free Neonatal testing (2010)


HIV Tests North Carolina HIV Tests North Carolina DHHS LaboratoryDHHS Laboratory

0

50000

100000

150000

200000

250000

300000

2001 2002 2003 2004 2005 2006 2007 2008 2009


18222053

2650

180017021551 1594

20442237

0

500

1000

1500

2000

2500

3000

1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

# of reports .

North Carolina HIV Disease ReportsNorth Carolina HIV Disease Reports

NC ED in Syphilis HMAMissed opportunities

142,470 visits to the ED during the study period 420 (0.3%) patients had an HIV test 6% positive (25/420)

554 (0.4%) patients had an RPR test 5.8% positive (32/554)

Agreement between RPR and HIV test orders was low (kappa = 0.35, 95% CI: 0.30, 0.40).

Only 31% (173/554) of patients receiving an RPR test also had an HIV test performed. Of these, 8 (4.6%) tested positive for HIV and 15 (8.7%) tested positive for syphilis; 4 (2.3%) were co-infected with both HIV and syphilis

Klein et al CDC STD Prevention Conference 2010


North Carolina AHI Initial North Carolina AHI Initial Presentation to Care Presentation to Care

n=128n=128

McKellar et al. North Carolina Acute HIV Infection Research Consortium 2009McKellar et al. North Carolina Acute HIV Infection Research Consortium 2009

Number of healthcare visits Number of healthcare visits prior to diagnosis of AHIprior to diagnosis of AHI

• Diagnosed at first contactDiagnosed at first contact51 51 (40%)(40%)

• 1 visit before HIV diagnosis 1 visit before HIV diagnosis 41 41 (32%)(32%)

• >> 2 visits before HIV diagnosis 2 visits before HIV diagnosis25 (20%)25 (20%)

• Previous data suggested 52% of Previous data suggested 52% of AHI seen AHI seen >>3x before diagnosed 3x before diagnosed with AHI with AHI

Weintrob 2001McKellar et al. North Carolina Acute HIV Infection Research McKellar et al. North Carolina Acute HIV Infection Research Consortium 2009Consortium 2009

Geography Aint enough:Still Not Getting to the

Infected PopulationRIOT Forsyth603 Screened for Syphilis and HIV3 new syphilis cases4 new HIV Identified

GRGT at Winston Salem State:158 tested for HIV157 tested for syphilisNo new positives for HIV or syphilis

One recent AHI : 11 HIV+ , 10 new syphilis dx,

7 co-infected (N=16)

Planned vs. Actual HIV Testing<25% of individuals reporting medium or high risks reported an HIV test in the previous year.

Those with a medium or high self-perceived HIV risk, and with heavier alcohol consumption did not match intent to test with actual testing

The difference between intent and actual testing higher-risk > lower-risk groups regardless of whether tests obtained for any reason or only voluntary

Ostermann et al. Arch Intern Med 2007

NC Delay to HIV Testing

• Over one-quarter of patients reported delayed seeking an HIV test for over 4 years.

• Patients who reported HIV infection in more recent calendar years had a shorter duration of testing delay.

Self-reported HIV testing delay in North CarolinaS Napravnik APHA 2009

Late Entry into CareUNC HIV Clinic 2000-03

• SE reports greatest proportion of AIDS cases and deaths1,2

• On presentation, HAART indicated for3:– 75% of patients based on CD4 count, HIV RNA level,

and an AIDS clinical condition– 71% solely on CD4 count– 78%, 57%, and 84% of patients entering HIV care

≤1 year, 1-2 years, and >2 years from HIV diagnosis, respectively (p=0.02)

1. CDC. First 500,000 AIDS cases–United States, 1995. MMWR Morb Mortal Wkly Rep 1995;44(46):849-53.2. CDC. Update: AIDS–United States, 2000. MMWR Morb Mortal Wkly Rep 2002;51(27):592-5.3. Gay CL et al. AIDS. 2006;20(5):775-8.

Why are we not getting to folks

• Stigma of risk• Stigma of HIV Infection• Lack of access to health care or no primary care• Co-morbidities• HIV not perceived as lethal disease • Testing as “risk reduction”• Delay in linkage to care• Sero-sorting

Mental Illness and Substance Abuse NC HIV Infected Individuals

Whetten et al. Southern Medical Journal 2005

Pence et al. JAIDS 2005

NC HIV ComorbidityMental Illness:- mood disorders (32% past year/21% past month)- anxiety (21%/17%) Substance use: 22%/11%

50% with past-year disorders and 40% with past-month disorders met the criteria for multiple diagnoses

Comorbidity was associated with younger age, White non-Hispanic

race/ethnicity, and greater HIV symptomatology.

Gaynes et al Psychosomatic 2008

Slide 49A Care Bridge Coordination A Care Bridge Coordination Program: Program:

Linking HIV-infected Patients Linking HIV-infected Patients with Care in North Carolinawith Care in North Carolina

Emily S. Brouwer, Leslie Strayhorn, Arlene C. Sena, Emily S. Brouwer, Leslie Strayhorn, Arlene C. Sena, Heidi Swygard, Peter A. Leone, Evelyn M. Foust, Heidi Swygard, Peter A. Leone, Evelyn M. Foust,

Sonia Napravnik, and Joseph J. EronSonia Napravnik, and Joseph J. Eron

University of North Carolina, Departments of Medicine and EpidemiologyNorth Carolina Department of Health and Human ServicesUniversity of North Carolina, Centers for AIDS Research

Slide 50

Care Bridge Coordination Care Bridge Coordination ProgramProgram

•Testing sites

•Disease Intervention Specialists (DIS)

Care Bridge

Coordinator •Clinics

•Care Providers

Slide 51

ActivitiesActivities Received referrals beginning April, 2008Received referrals beginning April, 2008 Received194 referrals to dateReceived194 referrals to date

52 adults with newly diagnosed HIV52 adults with newly diagnosed HIV 143 HIV-positive patients lost to follow-up143 HIV-positive patients lost to follow-up

Conducted 394 home visitsConducted 394 home visits Linked 137 patients to initial care or back to Linked 137 patients to initial care or back to

carecare 6 Refusals6 Refusals

Slide 52

Care Bridge Coordination Care Bridge Coordination New Client Referral SitesNew Client Referral Sites

STD18%

DIS38%

Jail13%

Other*31%

*Includes: case managers from other counties, clinical trial sites, self-referral

Slide 53

PatientsPatients Some patients referred more than once Some patients referred more than once

and re-enrolled if lost-to-careand re-enrolled if lost-to-care 178 unique patients178 unique patients

73% Male, 27% Female73% Male, 27% Female 93% Black, 7% White or Hispanic93% Black, 7% White or Hispanic Median age at referral: 41 years Median age at referral: 41 years

− (Range: 16 years-77 years) (Range: 16 years-77 years)

72 currently active72 currently active

The next wave is here:NC PSEL Syphilis Rates 1999-2009*

15.713.6

11.5

7.4

4.7 5.3 5.66.8 6.3 5.6

10

02468

1012141618

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009*

Rate per 100,000

* Projected rate

PSEL Syphilis Rates by Gender, 2004-2009*

7.3 8.19.9 9.5 8.9

15.9

3.4 3.3 3.8 3.2 2.54.4

02468

1012141618

2004 2005 2006 2007 2008 2009*

Rate per 100,000

Male Female

* Projected rate

rate ratios 2.1 2.5 2.6 3.0 3.6 3.6

77%↑

76%↑

Comorbidity (syphilis and HIV)

05

10152025303540

2004 2005 2006 2007 2008

% of reports

malesfemales

Distribution Male comorbidity casesEarly Syphilis - HIV1999 n=34

0

5

10

15

20

25

30

15-1920-2425-2925-2930-3440-4445-4950+

2008 n=133

0

5

10

15

20

25

15-19

20-24

25-29

25-29

30-34

40-44

45-49

50+

%

We Can Not Test and Treat are way out of this Epidemic

• Address Contextual/Structural issues• Health Care/ Public Health reform• Continue to expand HIV testing but must

strengthen linkage to care• Sexual Health and not Sexual Disease• Comprehensive sexual health education• Rights-based (Support same gender unions, etc)• Use social network for prevention education and

testing

Communicable Disease Branch Resource Listhttp://www.epi.state.nc.us/epi/hiv/services.html

Documents

HIV testing in North Carolina- A pathway to Universal Access