routine hiv screening in health care settings

Routine HIV Screening in Health Care Settings

David Spach, MD

Clinical Director

Northwest AIDS Education and Training Center

Professor of Medicine, Division of Infectious Diseases

University of Washington Seattle

This project was funded under cooperative agreement number U65/PS000821 from the Centers for Disease Control and Prevention (CDC). 

2006 CDC HIV

Screening Recommendations

2006 CDC HIV Screening RecommendationsSummary of Key Recommendations

• Routine Screening for HIV Infection

• Indications for Repeat HIV Screening

• Consent and Pretest Information

• Diagnostic Testing

• Recommendations for Pregnant Women

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

2006 CDC HIV Screening RecommendationsSummary of Key Recommendations

• Routine Screening for HIV Infection

• Indications for Repeat HIV Screening

• Consent and Pretest Information

• Diagnostic Testing

• Recommendations for Pregnant Women

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

2006 CDC HIV Screening RecommendationsOrganizations that Support CDC Recommendations

American Academy of HIV Medicine (AAHIVM)

American College of Obstetrics and Gynecology (ACOG)

American College of Physicians (ACP)

American Medical Association (AMA)

HIV Medicine Association (HIVMA)

National Association of Community Health Centers (NACHC)

National Medical Association (NMA)

Routine Screening for HIV Infection

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

• All patients aged 13-64 in all health care settings

(Unless prevalence of undiagnosed HIV < 0.1%)

Routine Screening for HIV Infection

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

• All patients aged 13-64 in all health care settings

(Unless prevalence of undiagnosed HIV < 0.1%)

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

Routine Screening for HIV Infection

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Screen Unless Yield of Screening is Less than

1 Infection per 1000 Patients Tested

• All patients aged 13-64 in all health care settings

(Unless prevalence of undiagnosed HIV < 0.1%)

Source: Wilson JMG, Jungner G. Principles and Practice of Screening for Disease. WHO Public Health Paper.

No.34. 1968.

.

WHO Criteria that Justify Routine Screening for a Medical Test

• Serious health disorder that can be detected before symptoms develop

• Treatment is more beneficial when begun before symptoms develop

• Reliable, inexpensive, acceptable screening test

• Costs of screening are reasonable in relation to anticipated benefits

• Treatment must be accessible

Source: Wilson JMG, Jungner G. Principles and Practice of Screening for Disease. WHO Public Health Paper. No.34. 1968.

Routine Screening for HIV Infection

Source for Images: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

• All patients aged 13-64 in all health care settings

• Patients seeking treatment for STDs

Secondary Syphilis Gram’s Stain Gonorrhea

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Routine Screening for HIV Infection • All patients aged 13-64 in all health care settings

• Patients seeking treatment for STDs

• Patients initiating tuberculosis treatment

Image Source: HIV Web Study (www.HIVwebstudy.org)

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

2006 CDC HIV Screening RecommendationsSummary of Key Recommendations

• Routine Screening for HIV Infection

• Indications for Repeat HIV Screening

• Consent and Pretest Information

• Diagnostic Testing

• Recommendations for Pregnant Women

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Indications for Repeat HIV Screening

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Injection-Drug Users & their Sex Partners

Persons who Exchange Sex for Money or Drugs

Sex Partners of HIV-Infected Persons

Persons or their Partners with >1 Sex Partner

Since their Most Recent HIV Test

• Persons at high risk

Indications for Repeat HIV Screening

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

• Persons at high risk

• Persons starting a new sexual relationship

Indications for Repeat HIV Screening

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

• Persons at high risk

• Persons starting a new sexual relationship

• Clinical judgment

2006 CDC HIV Screening RecommendationsSummary of Key Recommendations

• Routine Screening for HIV Infection

• Indications for Repeat HIV Screening

• Consent and Pretest Information

• Diagnostic Testing

• Recommendations for Pregnant Women

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Consent and Pretest Information

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

• Voluntary testing

Consent and Pretest Information

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

• Voluntary testing

• Permission from patient required

Permission Required

Consent and Pretest Information

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

• Voluntary testing

• Permission from patient required

• Written consent should not be required

Written Consent Should Not be Required

Consent and Pretest Information

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

• Voluntary testing

• Permission from patient required

• Written consent should not be required

• Prevention counseling not required in conjunction with screening

Prevention Counseling Not Required

in Conjunction with HIV Screening

2006 CDC HIV Screening RecommendationsSummary of Key Recommendations

• Routine Screening for HIV Infection

• Indications for Repeat HIV Screening

• Consent and Pretest Information

• Diagnostic Testing

• Recommendations for Pregnant Women

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Diagnostic Testing for HIV

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Images Source: HIV Web Study (www.HIVwebstudy.org)

• Clinical manifestations of HIV/AIDS

Kaposi’s Sarcoma

Oral Hairy Leukoplakia Pneumocystis pneumonia

Oral Candidiasis

Diagnostic Testing for HIV

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

• Clinical manifestations of HIV/AIDS

• Acute HIV (Recent high risk exposure + illness consistent with acute HIV)

High Risk Exposure

Diagnostic Testing for HIV

Source: Vanhems P, et al. AIDS. 2000;14:375-81.

• Clinical manifestations of HIV/AIDS

• Acute HIV (Recent high risk exposure + illness consistent with acute HIV)

Signs and Symptoms of 160 Patients with Acute HIV

Laboratory Studies with Initial HIV InfectionHigh Level Viremia

HIV RNA levels abruptly rise within several weeks after acute infection

Infection

HIV RNA

Laboratory Studies with Initial HIV InfectionHigh Level Viremia Precedes Detectable Antibodies

Antibody Titer

Infection

HIV RNA Antibody Titer

Detectable Antibody

Laboratory Studies with Initial HIV Infection

“Window Period”

Detectable AntibodyDetectable Antibody

Window Period

Infection

Antibody Titer

HIV

RN

A (c

opie

s/m

l)

Laboratory Studies with Acute HIV

Antibody Titer

Detectable Antibody

Acute HIV

Infection

HIV RNA

• Positive HIV-1 RNA Assay and Negative HIV Antibody Test

Antibody Titer

Detectable Antibody

2006 CDC HIV Screening RecommendationsSummary of Key Recommendations

• Routine Screening for HIV Infection

• Indications for Repeat HIV Screening

• Consent and Pretest Information

• Diagnostic Testing

• Recommendations for Pregnant Women

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Recommendations for HIV Screening in Pregnancy

Source: CDC. MMWR 2006;55(no. RR-14):1-17.

Recommendations

• Universal Opt-Out Screening

• Timing of HIV Testing

• Rapid Testing During Labor

• Address Reasons for Declining Test

• Repeat Test in 3rd Trimester in Certain Circumstances

Resources for HIV Testing in PregnancyCDC: One Test/Two Lives

http://www.cdc.gov/hiv/topics/perinatal/1test2lives/

Resources for HIV Testing in PregnancyACOG: Perinatal HIV Recommendations

http://www.acog.org/departments/dept_notice.cfm?recno=39&bulletin=3527

Resources for HIV Testing in PregnancyNational Clinicians Consultation Center: Perinatal HIV Hotline

http://www.nccc.ucsf.edu/about_nccc/perinatal_hotline/

1-888-448-8765

Acknowledgement

The project was funded under cooperative agreement

number U65/PS000821 from the Centers for Disease

Control and Prevention (CDC).