HIV testing in North Carolina- A pathway to Universal Access

Peter A. Leone, MD Professor of Medicine University of North Carolina Medical Director NC HIV/STD Prevention and Care NCDHHS

Stemming the Tide of HIV Transmission in the United States

• Number Infected • 1,039,000-1,185,000 • Number unaware of their HIV infection • 220,000-250,000 (~21%) • Estimated new infections annually • 56,000 • Those with unrecognized infection account for ~51% of new infections • ~29,000 • Onset of symptoms or illness acts as a cue for testing 42% of HIV positive in U.S. tested due to illness (MMWR 2003) Glynn M, Rhodes P. 2005 HIV Prevention Conference

Hall et al, JAMA 2008

HIV incidence

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 incidence HIV GC CT 56,000 718,000 2.8 m P&S syphilis 11,500 Trichomoniasis 7.4 m HSV-2 1.6 m Based on: HIV estimated incidence (JAMA 2008) STD Surveillance 2007 NHANES assessments of HSV-2 and Trichomoniasis Weinstock Persp Sex Rep Health 2004 B:W Incidence / Prevalence Ratio 7:1 18:1 8:1 6:1 10:1 3:1 % all cases in blacks 45% 70% 48% 46% 59% 30%

HIV Incidence is High Among African American MSM

• HIV

incidence

aged 15-22 among African American men

4%

• HIV

incidence

aged 23-29 among African American men

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

White, Non-Hispanic Multiracial Hispanic

46%

21% 19% 17%

(67%)

(18%) (50%) (48%) Other 13% (50%) MMWR, HIV Prevalence, unrecognized infection and HIV Testing among MSM – 5 US Cities, June 2005, April, 2005, June 24, 2005.

Whites Blacks White men White women Black men Black women

HIV Prevalence: General US Population

Add Health 1 : Young adults (%, 95% CI) NHANES 2 : Aged 18 to 39 (%, 95% CI) NHANES 2 : Aged 40 to 49 (%, 95% CI) 0.022 (0, 0.64) .492 (0.18, 0.87) n/a n/a n/a n/a 0.26 (0.05, 1.24) 1.42 (0.71, 2.84) 0.52 (0.11, 2.45) 0 (0, 0.31) 1.93 (0.77, 4.72) 1.01 (0.36, 2.84) 0 (0, 0.45) 3.58 (1.88, 6.71) 0 (0, 0.89) 0 (0, 0.92) 4.54 (2.24, 8.97) 2.78 (1.00, 7.45)

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.

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

PREVALENCE (%)

Burkina Faso Cameroon Ghana Rwanda Senegal Uganda Cambodia India Haiti 2.0

5.4

2.3

3.1

0.9

6.7

1.6

0.9

3.8

UNAIDS. 2007 AIDS Epidemic Update

 

HIV 2006 (incidence estimates)

22 States Participating NC ranked 4 th (FL, NY, LA)

NC  2,356 persons (32.2/100,000) 40% higher than the US  US  56,300 persons (22.8/100,000) NC    Males represented 72% Blacks represented Black rate was rate for whites 9 67% times the  US    Males represented 73% Blacks represented 45% Black rate was 7 times the rate for whites

Communicable Disease Surveillance Unit

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

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

22% Black, non-Hispanic 62% Asian/PI, 2% AI/AN, 1% 68% White , non-Hispanic 7% Population Hispanic Communicable Disease Surveillance Unit 28% 8% HIV Disease Asian/PI, <1% AI/AN, 1%

MSM 72%

NC adult/adolescent HIV disease 2007

IDU 5% Males MSM/IDU 3% Hetero sexual 19% Females Other 5% Other 1% Hetero sexual 86% IDU 9% Communicable Disease Surveillance Unit

Disparities for Males 2007 HIV Disease

 15.7/100,000 White males  85.2/100,000 Black or African American males (more than 5 times that of Whites)  38.0/100,000 Hispanic males (more than 2 times that of Whites )

Communicable Disease Surveillance Unit

Disparities for Females 2007 HIV Disease

 2.8/100,000 White females  42.9/100,000 Black or African American females (more than 15 times that of Whites)  12.2/100,000 Hispanic females (more than 4 times that of Whites)

Communicable Disease Surveillance Unit

Late HIV Diagnosis in North Carolina

• ~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.

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

45 40 35 30 25 20 15 10 5 0 NC US 19 87 19 88 19 89 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 Year of Report 13.9

12.7

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 Recommendations

In 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 HIV Negative 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 HIV



Expand and make HIV testing routine



Continue NC STAT program



Get newly diagnosed persons into care



CD4 and Vl on all newly Dx individuals



Keep persons diagnosed with HIV in care Communicable Disease Surveillance Unit

Changes to NC Administrative Code Nov. 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 3 rd 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 to http://www.epi.state.nc.us/epi/hiv/regulations.html

•

For epidemiological data in North Carolina, go to http://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)

300000

HIV Tests North Carolina DHHS Laboratory

250000 200000 150000 100000 50000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009

Communicable Disease Surveillance Unit

North Carolina HIV Disease Reports 3000 2500 2000 2650 2237 1702 1551 2044 2053 1822 1594 1800 1500 1000 500 0 19 83 19 85 19 87 19 89 19 91 19 93 19 95 19 97 19 99 20 01 20 03 20 05 20 07 20 09 Communicable Disease Surveillance Unit

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NC ED in Syphilis HMA Missed 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

30% 25% 20% 15% 10% 5% 0% 50% 45%

North Carolina AHI Initial Presentation to Care n=128

40% 35% 36% 17% 21% 11% 5% 2% 1% 1% 1% 1% 5%

Communicable Disease Surveillance Unit

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

Number of healthcare visits prior to diagnosis of AHI

• Diagnosed at first contact 51 (40%) • 1 visit before HIV diagnosis 41 (32%) • > 2 visits before HIV diagnosis 25 (20%) • Previous data suggested 52% of AHI seen >3x before diagnosed with AHI Weintrob 2001 McKellar et al. North Carolina Acute HIV Infection Research Consortium 2009

Geography Aint enough: Still Not Getting to the Infected Population RIOT Forsyth 603 Screened for Syphilis and HIV 3 new syphilis cases 4 new HIV Identified GRGT at Winston Salem State: 158 tested for HIV 157 tested for syphilis No 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 Carolina

S Napravnik APHA 2009

Late Entry into Care UNC HIV Clinic 2000-03

• SE reports greatest proportion of AIDS cases and deaths 1,2 • On presentation, HAART indicated for 3 : – 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 Comorbidity

Mental 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

A Care Bridge Coordination Program: Slide 49 Linking HIV-infected Patients with Care in North Carolina

Emily S. Brouwer, Leslie Strayhorn, Arlene C. Sena, Heidi Swygard, Peter A. Leone, Evelyn M. Foust, Sonia Napravnik, and Joseph J. Eron University of North Carolina, Departments of Medicine and Epidemiology North Carolina Department of Health and Human Services University of North Carolina, Centers for AIDS Research

Care Bridge Coordination Program Slide 50

•Testing sites •Disease Intervention Specialists (DIS) Care Bridge Coordinator •Clinics •Care Providers

Activities

  Received referrals beginning April, 2008 Received194 referrals to date   52 adults with newly diagnosed HIV 143 HIV-positive patients lost to follow-up

Slide 51

  Conducted 394 home visits Linked 137 patients to initial care or back to care  6 Refusals

Care Bridge Coordination New Client Referral Sites Slide 52

STD 18% Other* 31% Jail 13% DIS 38% * Includes: case managers from other counties, clinical trial sites, self-referral

Patients

 Some patients referred more than once and re-enrolled if lost-to-care  178 unique patients    73% Male, 27% Female 93% Black, 7% White or Hispanic Median age at referral: 41 years − (Range: 16 years-77 years)  72 currently active

Slide 53

The next wave is here : 6 4 2 0 18 16 14 12 10 8 NC PSEL Syphilis Rates 1999-2009* 15.7

13.6

11.5

7.4

4.7

5.3

5.6

6.8

6.3

5.6

19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 * 10

* Projected rate

PSEL Syphilis Rates by Gender, 2004-2009* 10 8 6 4 2 0 18 16 14 12 Male 7.3

3.4

Female 8.1

3.3

9.9

3.8

9.5

3.2

8.9

2.5

15.9

77% ↑ 4.4

2004 2005 2006 2007 2008 2009*

rate ratios

2.1 2.5 2.6 3.0 3.6 3.6

76% ↑

* Projected rate

Comorbidity (syphilis and HIV)

40 35 30 25 20 15 10 5 0 males females 2004 2005 2006 2007 2008

Distribution Male comorbidity cases Early Syphilis - HIV

2008 n=133 1999 n=34 25

%

30 25 20 15 10 5 0 20 15 10 5 0 15 19 20 24 25 29 25 29 30 34 40 44 45 49 50+ 15-1920-2425-29 25-2930-34 40-4445-49 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 List http://www.epi.state.nc.us/epi/hiv/services.html