Routine HIV Screening in thePrimary Care Setting

Michigan Primary Care AssociationAnnual Meeting

September 28, 2009Grand Rapids, MI

Why Are We Doing This?

Among 4,127 persons with AIDS*, 45% were first diagnosed HIV-positive within 12 months of AIDS diagnosis (“late testers”)

Late testers, compared to those tested early (>5 yrs before AIDS diagnosis) were more likely to be: Younger (18-29 yrs) Heterosexual Less educated African American or Hispanic

MMWR June 27, 2003 *16 states

Awareness of Serostatus Among People Awareness of Serostatus Among People with HIV and Estimates of Transmissionwith HIV and Estimates of Transmission

~75%Aware of Infection

~ 25%

Unaware of Infection ~54%

of New Infections

~46% of New

Infections

People Livingwith HIV/AIDS

New Sexual Infections Each Year

Marks G, et al AIDS 2006; 20:1447-1450.

Accounting for:

Revised CDC RecommendationsAdults and Adolescents - I

Routine, voluntary HIV screening for all persons 13-64 in health care settings, not based on risk

All patients with TB or seeking treatment for STDs should be screened for HIV

Repeat HIV screening of persons with known risk at least annually

Revised RecommendationsAdults and Adolescents - II

When acute retroviral infection is a possibility, use an RNA test in conjunction with an HIV antibody test

Settings with low or unknown prevalence: Initiate screening If yield from screening is less than 1 per

1000, continued screening is not warranted

Revised RecommendationsAdults and Adolescents - III

Opt-out HIV screening with the opportunity to ask questions and the option to decline testing

Separate signed informed consent should not be required

Prevention counseling in conjunction with HIV screening in health care settings should not be required

Revised RecommendationsAdults and Adolescents - IV

Screening is voluntary Inform patients orally or in writing

that HIV testing will be performed unless they decline.

Arrange access to care, prevention, and support services for patients with positive HIV test results

Approaches to HIV Testing

Diagnostic testing: performing an HIV test based on clinical signs or symptoms

Targeted testing: performing an HIV test on subpopulations of persons at higher risk based on behavioral, clinical or demographic characteristics

Screening: performing an HIV test for all persons in a defined population

Approaches to HIV Testing

Opt-out screening: performing an HIV test after notifying the patient that the test will be done; consent is inferred unless the patient declines

Anonymous testing: patient-initiated, usually through the Board of Health or in a public clinic

Outreach testing: performing tests at events and non-medical locations, usually for education and prevention

What makes Routine Screening a good idea?

1. Serious health disorder that can be detected before symptoms develop

2. Treatment is more beneficial when begun before symptoms develop

3. Reliable, inexpensive, acceptable screening test

4. Cost of screening are reasonable in relation to anticipated benefits

5. Treatment must be accessible

Principles and Practice of Screening for Disease-WHO Public Health Paper, 1968

11

Health Center Routine HIV Screening Model Developed by NACHC

• Mississippi• North Carolina• South Carolina

Pilot States

Objective:

To develop a model for the integration of HIV testing into routine primary care at Non-Ryan White funded health centers along with a model for post test counseling and referral to specialty care

Guiding Principles

Unit of analysis is the Patient HIV is a chronic disease Routine testing across organization same day Apply redesign and Collaborative learning

models, change theories, and lessons learned Build on existing infrastructure Leverage Community and State Partnerships Intense coaching to create momentum, trust,

support, and quality outcomes

Redesign Principles

Don't Move the Patient.  This principle focuses on the importance of organizing the work of a patient visit around the patient rather than organizing the patient around the work.  For instance, this means that a center should avoid moving patients from place to place to place during a single visit (e.g., check in area to a vitals room then on to the exam room).  Rather, the goal is to deliver routine services to patients in the exam room.

Increase Clinician Support.  This principle assumes clinicians can be optimally productive only with optimum support.  This requires that practices ensure the proper ratio of nursing or other support staff to clinicians as well as being sure clinicians are focused on clinical work, not other supportive services that can be delivered by other members of the care team.

Redesign Principles

Create Broad Work Roles.  This principle emphasizes the importance of cross-training staff to perform multiple roles.  For example, nursing support can open the patient visit in the exam room rather than relying solely on front desk staff.  Another example, relevant to our current effort, is having nursing staff perform the oral swab rapid HIV tests in the exam room. 

Organize Care Teams.  This principle speaks to the high quality, integrated care that comes when a patient care team works together day in and day out to meet the needs of a defined patient population.  This team learns to work well together, anticipate each others needs, and become more intimately familiar with their patient panel.

Redesign Principles

Communicate Directly.  Direct communication in real-time helps insure that patients need are met, and met in a timely manner.  Direct communication also helps eliminate errors and misunderstandings that can occur when notes, voice messages or other indirect methods of communication are used.

  Start All Visits On Time.  This principle

speaks to the importance of a health center, and each care team, being prepared for the day that lies ahead and beginning the first patient visit of the day on time.  

Health CenterPatient Care Model with Integrated Rapid HIV Testing

Patient signs in. Encounter form printed and, together with ROUTINE SCREENING FLOW SHEET, placed in bin for pick-up by nurse/MA.

If blood work necessary, provider writes an order. Patient directed to laboratory for blood draw.

Front Desk

•Nurse/MA escorts patient to exam room. •During intake process (which may occur in a “vitals area” in some centers), nurse/MA offers RAPID HIV SCREENING in addition to blood pressure, temperature, etc. •Patient signs consent if accepting HIV test.

• If accepted, sample obtained and transported to lab for processing.

•Provider performs exam; orders necessary follow-up visits and/or referrals. •Nurse/MA enters results on Routine Screening Form.

• Negative results given by nurse/MA• Reactive results given by provider

Waiting Room

Exam Room

Laboratory

Check OutPatient takes encounter form and proceeds to check out area for scheduling of next visit.

Health Center HIV Screening Algorithm

Rapid HIV TestNegative Reactive

Inform patientGive “Negative” handout, if desired

Review risks, if appropriateDiscuss “window period”

No further testing

Inform pt preliminary results are reactiveGive “Reactive” results handoutDraw confirmatory Western BlotSchedule follow-up appt in 5 days

Negative PositiveWestern Blot

Patient likely negative unless recent risk

Review risks & preventionSchedule 3 mo repeat

Western Blot

Counsel patientContact DIS and ensure referral to HIV careComplete “Reactive Tracking Sheet”

Repeat Western Blot at 5 day follow-up visit

Indeterminate

Post Test Counseling & Referral

Rapid HIV TestReactive

Negative PositiveWestern Blot

Indeterminate

CHC* Notifies DIS of Reactive result

*CHC=Community Health Center

DIS may come to CHC to counsel pt regarding results, window period, risk reduction; if not CHC does counseling

DIS comes to CHC to counsel pt and Western Blot redrawn

•CHC informs pt preliminary results reactive•CHC provides written “Reactive” results handout•CHC draws confirmatory Western Blot•CHC schedules follow-up appt in 5 days

•DIS performs post-test counseling•DIS completes CDC data form•DIS refers to HIV specialty care and case management•DIS addresses partners notification

Pilot Results

10 health centers (26 clinical sites) in four states* have successfully applied this model.

As of March 31, 2008, 16,291 patients were offered testing, with 11,309 (69%) accepting;

17 (.15%) new cases of HIV were identified;

16 of the newly diagnosed cases of HIV were successfully linked to care or in contact with DIS or health center staff regarding decision to refuse care;

Fifty-six percent (56%) of patients tested through this pilot project were tested for the first time.

Results

African Americans and Latinos were significantly more likely to test than were Whites.

Women were more likely to test than were men.

Uninsured patients were more likely to test.

Patients insured under Medicare or Medicaid were less likely to test.

Patient age was not associated

The Initiative is spreading around the country

Ohio presently has four health center organizations who have integrated routine screening using the ‘Health Center Model” with plans to start in 5-7 additional sites.

Illinois has 7 health centers launching the “Health Center Model”

Michigan has one health center who plans to integrate the model soon.

For more Information contact

LaVerne WileyQuality Improvement Coordinator

Michigan Primary Care Association 513-861-4497

lwiley@mpca.net