Download Policy Committee - The Delaware HIV Consortium

Delaware HIV Consortium
Policy Committee and Planning Council
September 2010
Position Paper:
Recommendations for Adoption of Routine Opt-Out HIV Testing Procedures
for Adolescents and Adults 13 through 64 in Health-Care Settings
Recommendations for Adoption of Routine Opt-Out HIV Testing Procedures
for Adolescents and Adults 13 through 64 in Health-Care Settings
White Paper
Problem Statement
HIV is an infectious, preventable disease that remains a leading cause of illness and death in the
United States (U.S.).1 After initial exposure to HIV, a person may show no symptoms of the
disease at all for many years, while the disease advances within the body and can be transmitted
to others. While there is no cure for HIV, effective medical treatment can control the
advancement of the disease and help reduce its transmission.2 It is critical, therefore, that people
know their HIV status—for their own health and that of others—so that they can be linked to
medical treatment. To get into medical treatment, however, people must know their HIV status.
Reliable, inexpensive blood testing (also called screening) can detect HIV early in its
progression, even before symptoms begin. Currently, HIV blood testing is performed through
one of two processes: opt-in testing or routine opt-out testing. Opt-in HIV testing requires a
written consent process and documented pre-test counseling. Routine opt-out HIV testing
involves performing HIV testing as part of a patient’s routine health evaluation—similar to
screening for other treatable conditions—without pre-test counseling but preserving the patient’s
right to decline testing.3
The Centers for Disease Control (CDC) has disseminated and revised HIV testing
recommendations over the years in response to extensive research findings on an evolving
epidemic and considers opt-in testing requirements as barriers to testing. The CDC last updated
its recommendations in 2006, recommending routine opt-out HIV testing for all adults and
adolescent patients 13 through 64 in health-care settings, including pregnant women, while
recommending opt-in testing in all other settings.4 In 2009, Delaware adopted the CDC’s optout recommendations for pregnant women only with tremendous success but still requires opt-in
testing for others 13 through 64 in health-care settings.5 Of concern, Delaware is consistently in
the top 10 in the nation in terms of annual AIDS incidence per capita (number of new AIDS
infections per year).6 Additionally, the disease continues to evolve in Delaware at the same time
that the sense of urgency associated with it in early years has declined. This report will show the
importance of Delaware’s adopting the CDC’s remaining HIV testing recommendations. By
doing so, Delaware can incorporate routine opt-out HIV testing into health-care settings for
everyone 13 through 64, thus identifying those who are HIV positive and linking them into
effective HIV medical treatment as early as possible.
Introduction
What is HIV/AIDS?
HIV is an infectious, life-threatening condition that interferes with the body's ability to fight off
viruses, bacteria and fungi that cause disease. It can be transmitted through sexual contact,
through blood to blood transmission, and from mother to child during or at birth or through
breastfeeding. HIV operates on a four-stage continuum: an initial infection period following
2
exposure that may include “flu-like” symptoms for a week or two; the seroconversion stage,
when the body develops anti-bodies to the disease (generally about three months after exposure);
an asymptomatic stage that can last for many years during which time people generally feel and
look healthy; and a late-stage period when the immune system damage is more severe and other
conditions present themselves, allowing for the advanced diagnosis of AIDS. The time it takes
to go through these stages varies. For most people, the progression is fairly slow and can last
for many years before they feel sick. Nonetheless, people are infectious during all four stages.7
What is Routine HIV Opt-Out Testing?
Research has shown that reliable, inexpensive blood testing (or screening) can detect HIV early
in its progression, even before symptoms begin. Two varying processes are used for HIV blood
testing. Opt-in HIV testing, the more historical process, requires a separate, written consent
process and documentation of pre-test counseling. The CDC views both of these requirements
as barriers to broader HIV testing in health-care settings, noting that more patients accept
recommended HIV testing when it is offered routinely to everyone, without singling them out
for risk assessments. Routine opt-out HIV testing, on the other hand—the process recommended
by the CDC—involves performing HIV testing as part of a patient’s routine health evaluation,
similar to screening for other medical conditions. It requires providers and/or clinicians to notify
a patient that the test will be performed and that the patient has the right to decline or defer
testing. Most types of routine health screenings are done in this manner, in that consent is
inferred unless the patient declines testing.4
Revised CDC 2006 HIV Testing Recommendations
The CDC’s 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and
Pregnant Women in Health-Care Settings are as follows:
For adult and adolescents between 13 and 64 in all health-care settings:
 HIV screening is recommended for patients between the ages of 13 and 64 in all healthcare settings after the patient is notified that testing will be performed, 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 should not be required; general consent for
medical care should be considered sufficient to encompass consent for HIV testing.
 Prevention counseling should not be required with HIV diagnostic testing or as part of
HIV screening programs in health-care settings.
For pregnant women
 HIV screening should be included in the routine panel of prenatal screening tests for all
pregnant women.
 HIV screening is recommended after the patient is notified that testing will be performed
unless the patient declines (opt-out screening).
 Separate written consent for HIV testing should not be required; general consent for
medical care should be considered sufficient to encompass consent for HIV testing.
 Repeat screening in the third trimester is recommended in certain jurisdictions with
elevated rates of HIV infection among pregnant women.4
3
Current Status on the 2006 Recommendations in Delaware
As stated, Delaware adopted the full CDC recommendations for pregnant women only in 2009.
They are now codified under Title 16. Chapter 12. Informed Consent and Confidentiality.
Subchapter I. HIV-Related Tests.5 Additional changes to the code have been drafted in 2010 for
the adoption of routine opt-out testing in health-care settings for all other persons 13 through 64.
These changes define routine opt-out testing and outline consent requirements to read “…that the
general consent for medical care shall encompass testing for HIV and that testing may be
performed as a part of routine care unless it is declined and that the declination is noted in the
medical record. A separate consent for HIV testing is not required.” The draft language also
modifies the definition of “Informed Consent” by eliminating the extensive pre-test counseling
requirements of opt-in testing. The new consent language states that the person being tested, or
the legal guardian of that person, should be informed “…both verbally and in writing, to an
extent reasonably comprehensive to general lay understanding, of the nature of the proposed
testing and of the risks and alternatives to testing which a reasonable person would consider
material to the decision whether or not to undergo testing.” Both of these modifications help
eliminate the unnecessary paperwork and extensive counseling requirements of opt-in testing
that make it less likely that medical providers will offer HIV testing. Additionally, the draft bill
adds language mandating a required offer of HIV testing of pregnant women in their third
trimester, an offer that currently is mandated only for those at high-risk for acquiring HIV. This
offer requirement further improves chances of eliminating mother to child transmission during or
at birth or through breastfeeding. 8
Description of the HIV/AIDS Pandemic
Brief History of HIV/AIDS Worldwide and in the U.S.
The year 1981 is recognized as the start of the HIV/AIDS epidemic in the U.S. By 1985—just
four years later—HIV was recognized in each region of the world and was infecting more than
130,000 people in the U.S. annually. HIV testing became available that year, primarily to protect
the blood supply. By 1987, however, HIV testing and counseling had become a priority as a
prevention strategy for those most at risk of infection, for those practicing high-risk behaviors,
and for people seeking treatment for sexually-transmitted diseases (STDs). Also in 1987, the first
anti-viral drug was developed. Despite this improvement in care, AIDS still was the leading
cause of death among U.S. men ages 22-45 in 1992.
The year 1995 ushered in an era of more effective medical treatment that drastically increased
survival—highly active antiretroviral therapy (HAART)—which utilized a combination of drugs.
By 1997, deaths from AIDS had dropped 40% compared to the prior year; and by 2000, the
number of persons in the U.S. infected annually with HIV had dropped to 56,300. Despite these
successes, by 2002 HIV was the leading cause of death worldwide among those 15 through 59.2,9
By 2008, an estimated 33.4 million people were living with HIV/AIDS in the world, 2 million
had died from it, and another 2.7 million were newly infected (430,000 of them children). Today,
women account for about 50% of all infections; and, in most regions of the world, women and
girls are being affected in increasing numbers. Young people account for about 40% of all new
adult (15+) infections worldwide. Of note, fewer than 40% of young people have basic HIV
information, and less than 40% of people living with HIV worldwide know their status. 10
4
Over the years, the spread of the virus generally has slowed in some countries while escalating or
remaining unchanged in others. In the U.S., the total number of people living with the infection
(1.1 million) has increased due to effective treatment, while the national incidence of annual new
infections has been relatively stable since the year 2000 (with an estimated 56,000 persons
becoming infected annually).11,12 At the same time and of concern, the sense of urgency
associated with the disease in early years has declined as people with HIV live longer, more
productive lives. A 1995 poll showed 44% of respondents viewing HIV/AIDS as the most
urgent health problem in the U.S. In March 2009, just 6% viewed it that way.13 While treatment
drastically improved survival rates for people living with HIV/AIDS, diagnosing HIV infection
at earlier rates has always been lacking. Based on research that recognized testing as a priority
prevention strategy and in light of the evolving epidemic, the CDC periodically recommended
revised testing strategies over the years, most recently in 2006, as noted.
A Snapshot of HIV/AIDS in Delaware
HIV can strike anyone as a result of certain behaviors, regardless of race, sex, ethnicity,
geographic location, age, or sexual preference. Statistics from the State of Delaware Division of
Public Health, the Delaware Youth Risk Behavior Survey, and other sources show the broad
nature of HIV disease in Delaware, changes in its dispersion across the state, a shifting in the
state’s risk populations, disparities among population, and youth behaviors that are cause for
concern. Examples of Delaware information from these sources are as follows:
Delaware Facts
Overall Number Living With HIV/AIDS
 3,511people have HIV/AIDS as of August 2010—1,304 have HIV; 2,207 have AIDS. 14
Current Rate of AIDS Infections
 Delaware consistently ranks in the top 10 states per capita in AIDS cases in the U.S.15
Increasing Geographic Dispersion of New Cases
 In early years of the epidemic, the majority of new HIV cases were concentrated in large
networks in the City of Wilmington and New Castle County—primarily in 10 of the
states 98 zip code areas (10% of the zip code areas).
 Between 2004 and 2008, new HIV cases were scattered throughout the state in smaller
concentrations, in approximately 48 of the state’s 98 zip code areas (49% of the zip code
areas).16
Risk Populations
 Delaware’s risk populations shifted from 2000 through 2009—from 42% Injecting Drug
Users (IDU), 30% Men Sleeping with Men (MSM) and 16% Heterosexuals (HET) to
36% HET, 27% MSM, and 27% IDU.
Race and Ethnicity
 1 in 83 African Americans (AAs) has HIV/AIDS compared to 1 in 233 Hispanics and 1
in 636 Caucasians.
 66% of Delaware’s HIV/AIDS cases today are AAs compared to 44% in the late 1980s,
yet the AA community accounts for only 21% of the state’s population.
 In 2008, there was a sharp rise in newly diagnosed infections among AA females.
5
Gender
 71% of new infections through 2009 were male, although males are only 49% of the
state’s population.
 33% of new infections from 2000 to 2009 were female, compared to 20% of new
infections through the late 1980s, indicating that female infections are increasing.
Age:
 70% of reported HIV/AIDS cases through 2009 are 30-49 years of age.
 11% of those living with HIV/AIDS are 50 or older.
 15% of new HIV infections in the U.S. are people 50 or older, who mistakenly think they
are not at risk for HIV or other sexually transmitted diseases (STDs).17
Youth
 57.5% of Delaware’s high school students reported having sexual intercourse.
 10% of high school students reported having sexual intercourse before age 13.
 21% of high school students reported having sexual intercourse with four or more
persons during their lives.
 22.8% of middle school students reported having sexual intercourse.
 6.4% of middle school students reported having sexual intercourse before age 11.18
 1 in 4 new STDs occur among teenagers.
 1 in 3 youth will have contracted an STD by the age of 24.
 Delaware ranks 11th in the nation in teen pregnancies.19
 Local HIV clinics and counseling and testing sites have seen increases in the recent
number of newly-infected young clients, primarily MSMs, testing either as HIV positive
or as AIDS-defined (over numbers in prior years). Of a total of 9 clients testing positive
between February 2007 and April 2009, four tested positive since February 2009.20
Why is Routine Opt-Out HIV Testing Critical?
The Negative Impact of Not Knowing One’s Status: The CDC estimates that one in five
(21%) persons living with HIV in the U.S. do not know that they are infected. The majority of
annual new infections (as much as 54%) are caused by individuals who do not know their
negative status.21,22 Some of these individuals are already accessing health-care services but
opportunities to test and diagnose them are being missed.23 Locally, Delaware’s statistics show
that 87 people infected with HIV in 2008 were infected by a partner that did not know he/she had
HIV.22 Additionally, Christiana Care Health System (Christiana Care) HIV clinics, which treat
approximately 53% of those in care for HIV disease in Delaware, report that over 50% of those
entering its care are immediately diagnosed with AIDS,24 an indication that those patients were
likely unaware of their HIV status. This figure is even more concerning when compared to
national statistics, which show that 32% of individuals with an HIV diagnosis reported to the
CDC in 2008 received an AIDS diagnosis within 12 months of initial HIV diagnosis.25
The Benefits of Knowing One’s HIV Status: As stated, HIV is an infectious disease that can
strike anyone as a result of certain behaviors; and, while there is no cure for HIV, effective HIV
medical treatment can control the advancement of the disease and help reduce its transmission.
It is critical, therefore, that people know their HIV status—for their own health and that of
others—so that they can be linked to medical treatment. To get into medical treatment, however,
6
people must know their HIV status; and the only way to know one’s status is through blood
testing. Research has shown that prevention strategies that include universal, opt-out HIV
testing have been highly effective in reducing the transmission of HIV and providing other
important benefits as well:

Knowing One’s HIV Status and Accessing Medical Care Reduces HIV Transmission: The
CDC estimated that at least 95% of those with HIV infection in 2006 that were aware of their
HIV status and in HIV medical care did not transmit the virus to others that year. This
represents an 89% decline in the estimated rate of HIV transmission since the peak level of
new infections in the mid-1980s—from 44 transmissions per 100 people living with HIV in
1984 to five transmissions per 100 in 2006. The CDC attributed the decline to effective
prevention efforts, the availability of improved testing, and treatment.26 Examples of how
HIV treatment reduces transmission are as follows:
o Overall U.S. Reductions in Transmission Rates With Testing and Treatment: In the U.S.,
the annual HIV incidence rate is down from its peak of more than 150,000 in the 1980s to
approximately 56,000 annually as a result of testing and medical care, according to the
CDC.2,9 Delaware has seen reductions in the incidences of HIV infections—from 300 in
2001 to 166 in 2008, a 44.6% reduction.27 Information maintained on Christiana Care
HIV clients show that 76% of clients engaged in HIV medical care with them have an
undetectable viral load,24 which can be helping with the reduction of transmission.
o Transmission Reduction Among Sexual Partners: According to a six-year Partners in
Prevention HSV/HIV Transmission Study in Africa, coordinated by the International
Clinical Research Center at the University of Washington, the use of antiretroviral drugs
cut the spread of HIV by over 90%. The study of 3,440 discordant couples (one HIV
positive and one not) showed that a lifelong regime of daily drugs can keep the viral load
(amount of virus in the body) at a low level, which acted to reduce the likelihood of
transmission of HIV to a sexual partner. Of the nearly 350 positive partners given
antiretrovirals, researchers observed a reduction in HIV transmission to partners by 92%.
The study did not advocate HIV-infected individuals having unprotected sex. Rather, it
advocated “test and treat” as a way to manage the spread of HIV.28
o Perinatal HIV Transmission Reduction: Perinatal HIV transmission—the transmission of
HIV from mother to child during pregnancy, labor and delivery, or breastfeeding—can be
reduced with testing and treatment. Perinatal HIV transmission is the most common
route of HIV infection in children and is now the source of almost all AIDS cases in
children in the U.S.; but perinatal transmission can be avoided. As early as 1994, research
showed that certain medicines provided to infected pregnant women and their newborns
reduced the risk of HIV transmission.29 Since then, increased testing of pregnant women
and subsequent treatment for those infected have resulted in a dramatic decline in the
number of children perinatally infected with HIV. About 100–200 infants in the U.S. still
are infected annually, primarily to women who were not tested early enough in pregnancy
or who did not receive prevention services.30 The state of Delaware required prenatal
medical providers to offer routine opt-in testing of pregnant women through 2008, which
helped Delaware minimize perinatal transmission. Then, in 2009, Delaware approved
7
Senate Bill 86, which adopted the CDC’s opt-out testing recommendations for pregnant
women, which includes re-testing those at risk in their third trimester, even if they have
initially tested negative.5 Delaware’s statistics show that 61 HIV-infected women gave
birth from 2007 through 2009. In 2009, one child was born infected to a woman who had
tested HIV negative early in her pregnancy and was considered at low risk for contracting
the disease and was not, therefore, offered another test.31 The current draft bill amending
Delaware’s HIV testing requirements adds language mandating a required offer of HIV
testing of all pregnant women in their third trimester, regardless of risk. This additional
offer of testing will further improve chances of eliminating perinatal transmission in
Delaware.

Knowing One’s Status Improves and Extends the Lives of Those Infected: Infected persons
who know their HIV status and initiate early HIV medical treatment can gain years of life
and improve its quality.2

Knowing One’s Status Improves Behaviors: Studies have shown that people who are aware
of their HIV status adopt behaviors that reduce HIV transmission to others.32,33

Knowing One’s Negative Status Helps Keep Persons HIV Negative: Awareness of one’s HIV
negative status encourages people to take precautions to remain HIV negative.34
Importance of Finding Those “Lost to Care”: In Delaware in 2009, 964 persons (25% of all
those identified HIV positive in Delaware) were identified as “lost to care”—patients who cannot
be verified as having seen a doctor or nurse or had laboratory work performed in the last 12
months.35 Without care, HIV positive persons get sicker, endangering their own lives and others
with whom they have sexual relationships or share needles. Having routine opt-out HIV testing
available in health-care settings could help in finding these individuals during other visits to such
facilities in order to re-connect them to care.
The Effects of Stigma: People who fear getting testing because of stigma are deprived of all of
the benefits of knowing their HIV status: accessing medical care, reducing the transmission of
the disease, and improving the quality and length of their own lives. Speaking about stigma at
the 17th International AIDS Conference in August 2008, current U.N. Secretary-General Ban Ki
Moon said, “Stigma remains the single most important barrier to public action. It is a main
reason why too many people are afraid to see a doctor to determine whether they have the
disease, or to seek treatment if so. It helps make AIDS the silent killer, because people fear the
social disgrace of speaking about it, or taking easily available precautions. Stigma is a chief
reason why the AIDS epidemic continues to devastate societies around the world."36 Including
HIV testing as a part of routine testing for patients 13 through 64 in health-care settings reduces
the stigma associated with opt-in HIV testing based on risk and increases people’s chances of
knowing their HIV status.32
Cost Effectiveness of Routine HIV Opt-Out Testing
HIV can be detected by reliable, inexpensive and noninvasive screening tests.3 The lifetime cost
of treating HIV, on the other hand, is estimated to be as much as $618,900, exclusive of other
8
supportive services.37 According to the CDC, a series of studies concluded that, for almost all
areas, HIV testing is as cost effective as other routine screening programs for diseases such as
colon cancer and breast cancer.32,39 Preventing the disease and its transmission to other persons,
therefore, is both a health concern and a cost savings measure.
Current Status of Routine HIV Opt-Out Testing in Delaware
In 2009, Delaware adopted Senate Bill 86, which approved opt-out testing for pregnant women;
but it has gone no further.5 Nationally, the support for the CDC’s recommendations are much
broader: 45 states and the District of Columbia are now consistent with the CDC’s guidelines;
the Veterans’ Administrations has had the signed consent requirement removed from its federal
statute; CMS, administrators of Medicaid and Medicare, has encouraged coverage for HIV
screening and the following organizations have endorsed routine opt-out testing:
American College of Obstetricians Gynecologists
American College of Physicians
HIV Medicine Association
American College of Emergency Physicians
American Academy of Pediatrics
American Medical Association
National Medical Association
American Academy of HIV Medicine40
Recommendations
The CDC believes everyone should get tested routinely for HIV in health-care settings in a
manner consistent with how they get tested for other diseases and conditions. It is a key
prevention tool in the fight against HIV/AIDS. Testing can detect HIV early in its progression
and provides people with awareness of their HIV status. Once aware of their HIV status, those
who test HIV positive can be linked with effective medical treatment that improves their health
and reduces transmission rates. Awareness of status has been further shown to promote less
risky behavior in those that are positive and helps people who test HIV negative stay that way.
Delaware has adopted the CDC’s 2006 recommendations regarding routine opt-out HIV testing
for pregnant women, helping to virtually eliminate perinatal transfer of the virus from mother to
child. More needs to be done to foster further earlier detection of HIV infection and linkage to
care among others in the population.
Language has been drafted to revise the Delaware Code in accordance with the full CDC 2006
testing recommendations. It allows for routine opt-out HIV testing for patients 13 through 64
and pregnant women in defined health-care settings. This means that general consent for
medical care encompasses HIV testing and that such testing may be performed as a part of
routine care in health-care settings, unless declined in writing by the patient and noted in his/her
chart. It helps eliminate the unnecessary paperwork and extensive counseling requirements that
make it less likely that medical providers will offer HIV testing and helps reduce the stigma
associated with HIV testing. Additionally, the draft bill add language requiring an offer of HIV
9
testing for all pregnant women in their third trimester to help further reduce perinatal
transmission. The 2006 testing recommendations included in the draft bill are as follows:




For adult and adolescent patients 13 through 64 in all health-care settings:
HIV screening is recommended for patients between the ages of 13 and 64 in all healthcare settings after the patient is notified that testing will be performed, 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 should not be required; general consent for
medical care should be considered sufficient to encompass consent for HIV testing.
Prevention counseling should not be required with HIV diagnostic testing or as part of
HIV screening programs in health-care settings.
Adopting these recommendation will help reduce further the transmission of the virus among the
Delaware’s population so that the vision outlined in the nation’s first National HIV/AIDS
strategy can be reached:
“The United States will become a place where new HIV infections are rare and when
they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation,
gender identity or socio-economic circumstance, will have unfettered access to high
quality, life-extending care, free from stigma and discrimination.”41
References
1. Centers for Disease Control. MMWR Recommendations and Report, Revised Recommendations for
HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings. 2006:2.
2. The White House Office of National AIDS Policy. National HIV/AIDS Strategy for the United
States.2010:5-7
3. Centers for Disease Control. MMWR Recommendations and Report, Revised Recommendations for
HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings. 2006:1-9.
4. Centers for Disease Control. MMWR Recommendations and Report, Revised Recommendations for
HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings. 2006:1-27.
5. Delaware Code. Title 16. Chapter 12. Subchapter I. HIV-Related Tests. SS1204.
6. Delaware Division of Public Health. 2008 Delaware HIV/AIDS Surveillance Report. 2008:1.
7. The Body. The Stages of HIV Disease. 2008. Available at http://www.the body.com /content/art2506.
html.
8. Draft Bill: An Act to Amend Title 16, Chapter 7 of the Delaware Code Relating to Sexually
Transmitted Diseases and Chapter 12 Relating to Informed Consent and Confidentiality. 2010.
9. Global HIV/AIDS Timeline-Kaiser Foundation. Available at http://www.kff.org/hivaids/timeline/
hivtimeline.cfm.
10. UN AIDS 2009 AIDS Epidemic Update. Available at http://data.unaids.org/pub/Report/2009/JC1700
_Epi_ Update_2009_en.pdf:
11. Hall HI, Song R, Rhodes P. et al. Estimation of HIV incidence in the United States. JAMA 2008;
300(5):520-529.
12. Centers for Disease Control. HIV Prevalence Estimates—United States, 2006. MMWR 2008;57
(39):1073-76.
13. Kaiser Family Foundation.2009 Survey of Americans on HIV/AIDS:Summary of Findings on the
Domestic Epidemic. April 2009. Available at http://www.kff.org/kaiserpolls/upload/7889.pdf.
10
14. Delaware Division of Public Health. HIV/AIDS Monthly Surveillance Report. Aug. 2010. Available
at http://www.delawarehiv.org.surveillance.cfm.
15. Delaware Division of Public Health. 2008 Delaware HIV/AIDS Surveillance Report. 2008:1.
16. Delaware Division of Public Health. HIV Statistics.
17. Delaware Division of Public Health. 2008 Delaware HIV/AIDS Surveillance Report. 2008:1-44.
18. 2009 Youth Risk Behavior Survey. Delaware High School Survey, Delaware Trend Analysis
Report:9 and Delaware Middle School Survey:5.
19. Planned Parenthood of Delaware. Delaware Teen Sexual Health Fact Sheet.
20. Beautiful Gate Outreach, Christiana Care Health System. 2009 PowerPoint Presentation to Delaware
HIV Consortium Planning Council.
21. Centers for Disease Control HIV Surveillance Report: Diagnoses of HIV infection and AIDS in the
United States and Dependent Areas, 2008. Available at http://www.cdc.gov/hiv/topics/surveillance/
resources/qu/prevalence.htm.
22. Delaware Division of Public Health, Kennedy J. Speech at Faith Community Partnership Annual
Awards Luncheon. 2/10.
23. Jenkins TC, Gardner EM, Thrun MW, et al., Risk-Based Human Immunodeficiency Virus (HIV)
Testing Fails to Detect the Majority of HIV-Infected Persons in Medical Care Settings. Sex Transm Dis.
2006; 33:329-333.
24. Christiana Care Health System HIV Statistics.
25. Centers for Disease Control Factsheet: HIV in the United States: An Overview. Available at
http://www.cdc.gov/hiv/topics/ surveillance/resources/factsheets/us_overview.htm:4/.
26. Centers for Disease Control Factsheet: CDC’s HIV Prevention Progress in the United States.
Available at http://www.cdc.gov/hiv/topics/resources/factsheets/cdcprev.htm.
27. Delaware Division of Public Health. Delaware HIV/AIDS Surveillance Reports.
28. Donnell D, Baeten JD, Kiarie J, et al, for the Partners in Prevention HSV/HIV Transmission Study
Team. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort
analysis. Lancet. 2010;375:2092-2098.
29. Connor EM, Sperling RS, GelberR, et.al. Reduction of maternal-infant transmission of human
immunodeficiency virus type with zidovudine treatment. New England Journal of Medicine 1994;
331:1173-1180.
30. Centers for Disease Control Factsheet: Mother-to-Child (Perinatal) HIV Transmission and Prevention.
Available at: http://www.cdc.gov/hiv/topics/perinatal/resources/factsheets/perinatal.htm.
31. Delaware Division of Public Health HIV Statistics, 2010.
32. Centers for Disease Control. Questions and Answers for Professional Partners: Revised
Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings:
Why should I be tested for HIV? Available at Why should I be tested for HIV? Available at
http://www.cdc.gov/hiv/topics/testing/resources/qa/qa_professional.htm. .
33. Centers for Disease Control. MMWR Recommendations and Report, Revised Recommendations for
HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings. 2006:6.
34. Centers for Disease Control. Questions and Answers for the General Public: Revised
Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings:
Why should I be tested for HIV? Available at http://www.cdc.gov/hiv/topics/testing/resources/qa/qa_
general-public.htm
35. Delaware HIV Consortium, Delaware Health and Social Services. State of Delaware 2010-2014
Comprehensive HIV Prevention Plan and Statewide Coordinated Statement of Need. 2010;81-85.
36. U.N. Secretary General Ban Ki-Moon. Speech at the 17th International AIDS Conference. August
2008. Available at: http://www.washingtontimes.com/news/2008/aug/06/the-stigma-factor/
37. Schackman BR, Gebo KA, Walensky RP, et al. The lifetime cost of current human immunodeficiency
virus care in the United States. Med Care 2006;44(11):990-997. Results: From the time of entering HIV
care, per person projected life expectancy is 24.2 years, discounted lifetime cost is $385,200, and
11
undiscounted cost is $618,900 for adults who initiate ART with CD4 cell count <350/μL. Seventy-three
percent of the cost is antiretroviral medications, 13% inpatient care, 9% outpatient care, and 5% other
HIV-related medications and laboratory costs. For patients who initiate ART with CD4 cell count
<200/μL, projected life expectancy is 22.5 years, discounted lifetime cost is $354,100 and undiscounted
cost is $567,000. Results are sensitive to drug manufacturers' discounts, ART efficacy, and use of
enfuvirtide for salvage. If costs are discounted to the time of infection, the discounted lifetime cost is
$303,100.
38. Patel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States—an
analysis of cost-effectiveness. N Engl J Med 2005;352:586-595
39. Sanders GD, Bayoumi AM, Sundaram V, et al. Cost effectiveness of screening for HIV in the era of
highly active antiretroviral therapy. N Engl J Med 2005;352:570-585.
40. Branson, B. CDC - Division of HIV/AIDS Prevention Power Point.
41. The White House Office of National AIDS Policy. National HIV/AIDS Strategy for the United
States.2010:Opening pages.
.
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