Download Universal HIV Screening

Universal HIV Screening
August 18, 2016
Kevin L. Ard, MD, MPH
Objectives
• Summarize HIV screening recommendations
• Describe HIV testing algorithms
• Discuss how to overcome barriers to HIV
screening
Case
• 22 year-old man admitted
to the hospital with
personality change
• 1.5 years of weight loss,
fatigue, and depressed
mood
• Treated with SSRI; seen
by PCP every 1-2 months
• TSH, CBC, CMP normal;
No HIV test performed
Photo available at http://morningreporttgh.blogspot.com/2014/08/cns-lesions-and-hiv-recently-in-morning.html
Too many people with HIV are unaware of
their infections.
• 13% of people living with HIV in the US have not been
diagnosed.
• That’s 156,300 people.
• Some groups are less likely to be diagnosed than
others:
– 33% of black MSM, 25% of Hispanic MSM, and 10% of
white MSM with HIV are undiagnosed.
– Less than half of transgender women living with HIV may
be aware of their diagnoses.
1.
2.
3.
HIV in the United States: At a glance. CDC. June 2016. Available at:http://www.cdc.gov/hiv/statistics/overview/ataglance.html.
Wejnert C, et al. Age-specific race and ethnicity disparities in HIV infection and awareness among men who have sex with men – 20 US cities, 2008-2014. J Infect Dis.
2016. 213(5):776.
Herbst JH, et al. Estimating HIV prevalence and risk behaviors among transgender persons in the United States: a systematic review. AIDS Behav. 2008;12(1):1.
Missed HIV screening opportunities are
frequent.
NYC health system:
• 218 patients diagnosed with HIV 2012-2013
• 31% had CD4 < 200 at presentation
• Average of 4.72 medical visits in the 3 years
prior to diagnosis
Liggett A, Futterman D, Umanski GI, Selwyn PA. Missing the mark: Ongoing missed opportunities for HIV diagnosis at an urban medical center despite universal screening
recommendations. Fam Pract. 2016 Aug 9. Epub ahead of print.
HIV screening is recommended for all
adults.
• CDC: Recommended for all patients ages 13-64
years in health care settings in an opt-out
fashion.
– Sexually active MSM should be screened at least
annually.
1.
2.
• USPSTF: Screen adolescents and adults ages
15-65 years as well as younger/older people at
increased risk.
Branson BM, et al. Revised recommendations for HIV screening of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006. 55(RR14):1.
Human immunodeficiency virus (HIV): Screening. United States Preventive Services Task Force. 2013. Available at:
http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/human-immunodeficiency-virus-hiv-infectionscreening?ds=1&s=hiv%20screening.
4th-generation tests are the preferred
initial test for HIV.
HIV 1,2 antibodyantigen assay
Positive:
HIV 1,2
differentiation assay
Positive:
HIV infection
Negative
Negative or
indeterminate
HIV RNA
Branson BM, et al. Laboratory testing for the diagnosis of HIV infection: Updated recommendations. CDC. 2014. Available at:
www.cdc.gov/hiv/pdf/HIVtestingAlgorithmRecommendation-Final.pdf.
What are the barriers to screening?
Time was the biggest barrier in one study
of CHCs.
Concern about HIV testing
Proportion of physicians reporting
Constraints on providers’ time
63%
Time required for counseling
47%
Need for additional training
37%
Patient would perceive stigma, staff
uncomfortable
32%
Lack of funding
16%
Perception that HIV is not a problem in
the community
16%
Lack of data to justify routine screening
16%
Mayer KH, et al. HIV and hepatitis C virus screening practices in a geographically diverse sample of American community health centers. AIDS Patient Care STDs. 2016;
30(6):237.
Questions?
10