HIV Testing Just Got A Lot Easier:

Putting ACTS into ActionAETC NRC Training ExchangeMay 23, 2006

Donna Futterman, MDStephen Stafford

Today’s Agenda

The Tipping Point for Routine HIV Testing

The Evolution / Intelligent Design of

HIV C&T

Results from ACTS in Action

A User’s Guide to the ACTS Approach

& Tools

ACTS Role Play

Questions & Discussion2

Unfinished Business

HIV is the worst epidemic in history

40,000 new cases each year; 25-50% among youth

1 in 4 (300,000) HIV+ Americans don’t know they’re infected

80% of young HIV+ gay and bisexual men didn’t know their status

41% of those diagnosed HIV+ were diagnosed with AIDS within one year of their positive HIV test 3

Taking Care of Business

Case finding hasn’t kept up with treatment advances

Patients overwhelmingly accept HIV testing when a provider recommends it

The mobilization for prenatal testing missed a golden opportunity to routinize screening for all, but it remains a successful model for how to proceed 4

Routine Testing: The Benefits

REDUCES HIV TRANSMISSION HIV+ people who know their status

reduce high-risk sex by about 50%

Lower viral loads from ARVs also reduce Tx

PROLONGS LIFE HIV treatment can increase survival by

many years and improve quality of life

5

Routine Testing: Best Practice 2003, CDC issues “Advancing HIV

Prevention: New Strategies for a Changing Epidemic” calling for routine testing in communities with ≥ 1% HIV prevalence

2005, routing testing found cost/care effective in settings with ≥ .05% HIV prevalence

CDC, HRSA & DOHs working toward routine testing by streamlining counseling & consent

ACTS makes provider-delivered routine testing feasible in various care settings

6

Keeping Up with the Times1986

Environment No effective

treatment Discrimination

against those infected: MSM, IDU, immigrants & sex workers

Policy C&T regulations often

written to limit testing: mandated counseling written consent

2006Environment Many effective

treatments HIV discrimination

reduced & at-risk populations have changed

Policy C&T regulations

remain largely unchanged:

separates C&T from routine medical care

prevention value of pre-test counseling minimal

7

Why Don’t Providers Routinely Test?

2001 qualitative research investigated HCP motivators and barriers impacting HIV testing of adolescents

Commissioned by AAP, conducted by professional qualitative research firm

Interviewed 55 Bronx-based providers and administrators in public and private settings

Key findings informed ACTS initiative

8

“Not Enough Time,Not Enough Experience,

Not Aware of Risk”

Found that conventional HIV testing is: time-intensive specialized stigmatized separated from routine care

9

It’s Time for a Paradigm Shift!

HIV testing has become such a huge obstacle that many providers and patients prefer to sail around it.

It’s Time for a Paradigm Shift!

HIV testing has become such a huge obstacle that many providers and patients prefer to sail around it.

10

The Provider Imperative:Less Referring, More

Screening

YOU can help solve the solvable problem of finding the ±300K unidentified HIV+ patients

YOU can provide links to effective prevention counseling

YOU can engage HIV+ patients into early care

YOU are an essential player in the team that will meet public health HIV/AIDS goals

11

Fast Facts on ACTS

ACTS is a concise, comprehensive system that makes provider-delivered HIV testing feasible in clinical care settings

Provides instruction & tools for making operational and clinical practice changes

Meets CDC and DOH testing requirements

Condenses 45-minute process to 5-10 minutes

Allows for better allocation of counseling resources

12

ACTS in ACTIONResults from a Randomized

Control Trial 10 Bronx clinics randomized to receive ACTS rapid counseling in late 2004

Divided into 5 ACTS Sites & 5 Control Sites

Data collected on HIV testing rates

Eligible patients included those age 15-64, non-maternity patients

13

ACTS in ACTIONACTS Sites Double HIV Testing

Rates

0%

5%

10%

15%

20%

25%

2003 2004 2005

Control Average ACTS Average14

Elements of the ACTS SystemMeeting with the HIV coordinator,

clinic administrator and medical director to develop implementation plan

Academic detailing session(s) to train clinic staff on ACTS

ACTS manual and toolkit containing information, materials and resources for providers, clinic staff and patients

15

Laying the Foundation for ACTS with Key Staff

Address Philosophical Barriers Skepticism about patients’ HIV risk Other health problems viewed as

priority Concerns about loss of prevention

Address Logistical Barriers Which staff will test Documentation & consent forms Patient flow & results follow-up Billing issues 16

ACTS Site Prep Checklist

17

Training Staff to Utilize ACTS

Academic Detailing Provider-led training Catered Follow-up trainings with new staff

Ongoing Support Regular meetings with key staff to

problem-solve barriers Ongoing data reporting to all staff via

meetings and newsletters

18

ACTS Materials

19

It’s All in the ManualPart I – ACTS HIV Counseling and Testing System

ACTS Pocket CardTalking Points for Translating ACTS into ActionEssential FormsPatient Education

Part II – ACTS BackgroundersChapter 1 – HIV Counseling: Delivering ResultsChapter 2 – HIV Testing ProceduresChapter 3 – Working with Special PopulationsChapter 4 – Prevention EssentialsChapter 5 – The ACTS Imperative

Part III - Resources

concise

comprehensive

20

The Pocket Guide to ACTS

21

ACTS Talking Points

22

Forms

23

ACTS Chart Stickers

24

ACTS Update Newsletter

25

Patient HIV Info Brochures

26

The Deal

27

The “A” in ACTS

28

Transmission Basics: The Risk Continuum ConceptPage 75

Talking Points Page 10ACTS PRE Screen Page 24

Taking a Sexual and Drug Use History Page 77

Reality-Based Prevention CounselingPage 78

29

The “C” in ACTS

30

The “T” in ACTS

31

The “S” in ACTS

32

Talking Points: Delivering HIV+ Results

Give results and allow time to process• Rapid• Conventional

Discuss meaning of results Provide support Link to care Discuss prevention Review HIV reporting and partner notification

options Screen each name for domestic violence risk

33

Putting ACTS into ACTION:

Who Benefits?Your Patients

Your Practice Do what many providers can’t / won’t do Bill for additional counseling visit Participate in national pilot intervention

Our Community Help us fine-tune ACTS; understand how

it works Do your part to make ACTS a model for

others Be on record as having solved this

problem!

Public Health34

ACTS in ACTIONFuture Plans for ACTS

Continued regional & national dissemination

Presentation of ACTS at 2006 International AIDS Conference & Ryan White Clinical Care Conference in August

Expansion of ACTS to Bronx control sites in September 2006

Ongoing implementation:• CDC-sponsored South Africa Youth Clinics • Pediatric ER at Montefiore • National Assembly on School-Based Health Care

35

Hearing ACTS in Action

Alex 36 year old white male Engaged to be married in 6 months Visiting for routine BP check-up

Keisha 40 year old African American woman Divorced mother of 3, dating 1 man

exclusively Visiting for a vaginal infection

36

Questions & Discussion

37

Take a few moments toevaluate this presentation.

Visithttp://www.aidsetc.org/aidsetc?page=cf-acts-eval

to quickly submit your comments

38

Contact Us / Order MaterialsDonna Futterman, MD

DFutterman@AdolescentAIDS.org

Stephen StaffordStephenS@AdolescentAIDS.org

Michelle Lyle, MPHMLyle@AdolescentAIDS.org

Adolescent AIDS ProgramChildren’s Hospital at Montefiore

718-882-0232AdolescentAIDS.org

5.23.06