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HIVI
HIV Initiative of Kaiser Permanente and Care Management Institute
New KP HIV Testing and Prevention Guidelines
2011
In a Nutshell
Test, test, test!
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For HIV
Other sexually transmitted infections (STI)
Assess present and ongoing risk behavior
Treat all newly diagnosed and active STI
Give prevention messages and refer for greater
prevention interventions
Engage in continued care
Making the Case for the Updated Guidelines
National HIV/AIDS Strategy Goals…By 2015
Reduce New Infections
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↓New Infections by 25%
↑to 90% Americans who know their HIV Status
↓Transmission by 30%
Improve Access and Outcomes
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↑to 85% HIV+ in care within 3 months of Diagnosis
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Seamless system of testing and linkage to care
Increase HIV providers
Set quality standards and monitor
Reduce HIV-Related Health Disparities
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↑ by 20% HIV+ MSM*, Blacks, Latinos with HIV RNA BLQ*
*--MSM: Men having sex with men; BLQ: Below limits of quantification
With Good Treatment, Comes Great Outcomes
Trends in Annual Age-Adjusted Rate of Death Due to HIV Disease
Deaths per 100,000 members
25
20
<1.0% of KPNC HIV+
15
US CDC
10
KPNC
5
0
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
* Standardized to age distribution of 2000 US population. KP death counted if among known HIV+ member who died while
enrolled or within 3 months after termination with death cause coded as due to HIV or as an AIDS-defining diagnosis. US data
points estimated from CDC slide set.
78% on ART in 2009 for all KP; <1/3 nationally on ART
Geographic variation (64-83%)
KP HIV Care Quality Measures
Diagnosing HIV
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Testing for HIV among HIV- patients diagnosed with STI
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HIV co-testing with each pregnancy
Determining % of new HIV diagnoses who met AIDS
criteria (CD4< 200/µL)
Getting Patients Into Care
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Time until newly diagnosed KP HIV-infected members
receive 1st CD4 count
Our HIV testing and prevention program address all of these metrics.
HIV Testing Rates
Regions are improving.
FROM KPSC:
FROM KPNC:
Number of
members tested
175,000
Figure 33. Number of KPNC members tested for HIV and
rate of testing: 1995 - 2009
Members tested
per 1000
43.5
41.7
45
37.8
135203 40
131639
35
30.3 29.6 30.3 29.3 28.7 29.0 29.6 29.8 31.5
118985
112483
125,000 27.4
104080
30
90188 94798
100,000
25
88671
75018 77125 82740 81601 81413 84556
20
75,000 65602
15
50,000
10
25,000
5
150,000
33.8
36.1
0
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Number of members tested
But still need more patients ever tested.
Tests per 1000 members
HIV Antibody Testing (1)
HIV Antibody Co-testing in STI+, HIV- Patients, all KP
HIV- and diagnosed with ≥1 STI (chlamydia, gonorrhea, primary syphilis, new
hepatitis B or new hepatitis C) during the measurement period, % also tested
for HIV within a -10 to +90 day window around the STI test date for each STI.
Year
Number HIV Tests
Performed
Number Diagnosed with
STI
Percent
2007
11,161
25,183
44.3%
2008
13,211
30,646
43.1%
2009
13,185
26,513
49.7%
1st edition of KP HIV Testing Guidelines began in latter 2008
HIV Antibody Testing (2)
However, we have greatly improved with the “Big 3”:
HIV cotesting in KP among patients diagnosed with
syphilis, gonorrhea, chlamydia
Year
Number HIV Tests
Performed
Number Diagnosed
with STI
Percent
2007
8,250
16,234
50.8%
2008
10,763
18,099
59.5%
2009
10,929
17,690
61.8%
But we can do better.
We are testing earlier
Previously, >40% had CD4<200 /µL at time of diagnosis
Early detection of members newly identified with HIV, excluding transfers,
percent of patients whose lowest CD4 <200 cells (i.e., AIDS-defining)
Percent CD4<200
Members newly diagnosed with CD4 < 200 cells
(lowest in 1st 90 days, all regions combined)
27.5
27.0
26.5
26.0
25.5
25.0
24.5
27.1
25.7
2007
2008
25.6
2009
Year
Median lowest CD4 within 90 days of HIV infection diagnosis:
364/µL (2009); not much change over time
The New Guidelines
1. Obtain a Thorough Sexual History
Routinely obtain a thorough sexual history from all patients
≥ 12 years of age to assess risk behaviors and stratify for
appropriate testing.
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Risk assessment is essential to the evaluation of HIV and/or other STI
acquisition and transmission.
Risk behaviors include sex with multiple or new partners, sex with highrisk partners, unprotected sex, sex while intoxicated, and sex in exchange
for money.
Higher-risk population groups for STIs in the US might include
adolescents and young adults, blacks/African Americans, Hispanics,
men who have sex with men (MSM), military recruits, inmates and former
inmates, intravenous drug users (IVDUs) and former IVDUs, sex workers,
mentally ill persons, mentally disabled persons, persons living in lowincome urban areas, persons living in the southern United States, persons
with a history of an STI, and pregnant women.
2. Testing for HIV/STI
Screen and promptly treat all identified individuals ≥ 12 years
of age at risk for the following STIs:
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Human immunodeficiency virus (HIV)
Neisseria gonorrhea
Chlamydia trachomatis
Syphilis
Hepatitis B
Hepatitis C
Trichomoniasis (for women)
Evidence shows the presence of other STIs, including herpes simplex
(HSV), increases the risk of HIV transmission and acquisition.
3. Provide Behavioral Counseling
Provide behavioral counseling and additional risk reduction
interventions for all sexually active individuals ≥12 years of age
at risk for HIV/STI acquisition.

Behavioral counseling is the provision of education, skills training, and
guidance on how to change sexual behavior, delivered alone or in
combination with other interventions, intended to promote sexual risk
reduction or risk avoidance.

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High-intensity behavioral counseling may be delivered in primary care
settings or in other sectors of the health system after referral from the primary
care clinician or system.
Risk-reduction counseling (e.g., strategies targeting condom use,
abstinence, etc.) may be available through various community
organizations.

Strong linkages between the primary care setting and the community may
greatly improve the delivery of this service.
4. Special Attention to Pregnancy
Screen all pregnant women for HIV antibody, syphilis,
and hepatitis B early during each pregnancy. Screen
at risk pregnant women for gonorrhea, chlamydia and
hepatitis C. Retest before 36 weeks in women at risk
for exposure to HIV and/or any other STIs during the
course of pregnancy.
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Risk factors include HIV infected partner or partner at risk for HIV, new or
multiple sex partners during pregnancy, illicit drug use, exchanges sex for
money or drugs, history of STI during this pregnancy or one year prior to
pregnancy, signs or symptoms of acute HIV infection.
Pregnancy risk for exposure may include a newly diagnosed STI during
pregnancy, documented or suspected injection drug use, or partner with
known HIV infection.
How to Get this Done
Practice Steps for Implementation of Guidelines Recommendations.
The guideline recommendations are shown schematically.
Regular patient discussions should include
questions about sexual behavior and substance use.
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Ask about:
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Unprotected sexual activity
Multiple sexual partners
Current or previous STI or contacts with them
Recreational drug use, including crystal meth
Chronic alcohol use
Exchanged monkey or drugs for sex
For men: Incarcerations and sex while in jail
Ask: Sample Questions for All Patients
“I’d like to ask you some questions related to your sexual
health that I ask all my patients?”
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Are you sexually active? If no, have you ever had sex?
How many lifetime sexual partners have you had? Timeframe?
Are/were your sexual partners with men, women, or both?
Did/do you have vaginal, anal and/or oral sex?
Have you ever been diagnosed with an STD or thought you might have
one? Has your partner?
Have you ever been tested for HIV or advised to be tested? Has your
partner?
How do you protect yourself from STIs and HIV?
We will soon have “Video Doctor” on kp.org to help you.
Ask: For Married Patients and Couples
“I’d like to ask you some questions related to your sexual
health. These are questions that I ask all my patients
regardless of the type of relationship they are in.”
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Do you or your partner has sex with other people outside of your
relationship? How do you protect yourself from STDs and HIV?
Have you or your partner ever been diagnosed with an STD?
Have you or your partner ever been tested for HIV?
How long have you been married/together?
Before you were a couple did you have sex with other people?
If yes, with men, women, or both?
Before you were married, did your partner have sex with other people?
If yes, with men, women, or both?
Screening (1)
Screening (2)
Many regions have lab panels on KPHC for these tests.
Most states do not require written consent for HIV testing.

None do for the other tests.
For GC/Chlamydia, test all orifices of potential exposure.
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If available, use NAAT analysis for swabs from genitalia, anus,
oropharynx
Intervene
Intervening with Simple, Initial Messages
Using “simple” but effective messages work.
THEY TAKE ONLY A FEW SECONDS.
Some good options:
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“Condoms are effective for preventing HIV and most STI”
“Oral contraceptives do not prevent HIV or STI”
“Substance use with sex increases your risk of contracting HIV
or an STI”
“Having an active STI (including herpes) greatly increases your
risk of getting HIV or another STI”
If There is an STI or HIV
If there’s an active STI—Treat it now!

Consider follow-up testing if you are not sure was adequately
or successfully treated.
If HIV+--Refer to your HIV care team right away!
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They can even help you give your patient the results.
Refer to HIV Treatment Practice Resource for initial
evaluation and other details
NOTE: New evidence shows that HIV+ patients well controlled
on anti-HIV medications don’t transmit HIV to others.
Reinforce all prevention messages
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If this is a repeat STI, consider referral to health education
for further patient education.
If All of Tests are Negative (1)
Determine the patient’s ongoing risk
Even if “low risk”, there is still the need for ongoing
prevention to keep the patient HIV-/STI
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Advise patients to stay negative; practice safer sex
Reinforce basic prevention messages
Reassess risk at future visits

Sexual and Substance Risk can CHANGE over a patient’s lifetime.
“Higher risk” but test negative are the most important
population for whom to target prevention
IF All of Tests are Negative (2)
Remind your patients that a negative test doesn’t mean they are
“immune” to any STI or that they can’t get HIV or another STI
Consider Hepatitis B vaccine or Gardisil® if appropriate.
Screen and treat for undiagnosed depression
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Associated with high-risk behavior in gay men
Refer if persistent substance use
Establish a repeat testing schedule if risk will be ongoing.
Remember…
Test!!!
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Screen for HIV and other STI
Counsel your patients about safer sex and substance use
Don’t be afraid to speak to your patients regardless of their
(or your) age
Refer your patients to www.kp.org/hiv for more information
Look for smartsets/phrases in KPHC
“Working together, I am confident that we can
stop the spread of HIV and ensure that those
affected get the care and support they need.”
--President Barack Obama
Thank you
For more info and a copy of the guidelines, go to:
http://cl.kp.org/portal/site/NCAL/template.FRAME/?search=cmi%20guidelines
For a copy of KP Treatment Practice Resource:
http://cl.kp.org/portal/site/NCAL/template.FRAME/?search=Treatment%20Practice%20Resource