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). 

Rationale for Routine Screening

Rationale for Routine HIV Screening in Health Care Settings

• Expanding Epidemic

• Late HIV Testing and Diagnosis

• Negative Impact of Late Diagnosis

• Reduced Transmission with Known HIV Status

• Precedent for Effectiveness of Universal Screening

Rationale for Routine HIV Screening in Health Care Settings

• Expanding Epidemic

• Late HIV Testing and Diagnosis

• Negative Impact of Late Diagnosis

• Reduced Transmission with Known HIV Status

• Precedent for Effectiveness of Universal Screening

HIV: New Infections and Deaths, 1987-2006

Source: Centers for Disease Control and Prevention

New Infections

Deaths

HIV: New Infections and Deaths, 1987-2006

Source: Centers for Disease Control and Prevention

New Infections

Deaths

Estimated HIV Prevalence, US, 1977-2006

Source: Campsmith M, et al. CROI 2009: Abstract 1036.

Estimated AIDS Cases and Deaths, US, 1985-2006

Source: Centers for Disease Control and Prevention

1993 Definition

Implementation

Estimated AIDS Cases and Deaths, US, 1985-2006

1993 Definition

Implementation

Source: Centers for Disease Control and Prevention

Estimated AIDS Cases, Deaths, & Prevalence, US, 1985-2006

Source: Centers for Disease Control and Prevention

1993 Definition

Implementation

Estimated AIDS Prevalence, US, 1985-2006

Source: Centers for Disease Control and Prevention

HIV and AIDS Prevalence

Source: Hall HI, et al. JAMA. 2008;300:520-9.

AIDS Prevalence HIV Prevalence

Source: Centers for Disease Control and Prevention

Rationale for Routine HIV Screening in Health Care Settings

• Expanding Epidemic

• High Rate of Late HIV Diagnosis

• Negative Impact of Late Diagnosis

• Reduced Transmission with Known HIV Status

• Precedent for Effectiveness of Universal Screening

HIV Progression CD4 Cell Count Decline Over Time

HIV Infection

HIV Progression CD4 Cell Count Decline Over Time

Severe Immunosuppression

HIV Infection

HIV Interview Project: HIV Testing Patterns, 2000-2003

Source: Centers for Disease Control. MMWR. 2003;52:581-6.

Study Background

- Data analyzed from interview project conducted 2000-2003

- 16 US HIV testing sites

- 5980 HIV-infected persons interviewed

Source: Centers for Disease Control. MMWR. 2003;52:581-6.

HV Testing in Relation to AIDS Diagnosis

- Late Tester: Tested < 1 Year before AIDS Diagnosis

- Intermediate Tester: Tested 1-5 Years before AIDS Diagnosis

- Early Tester: Tested > 5 Years before AIDS Diagnosis

HIV Interview Project: HIV Testing Patterns, 2000-2003

27.8%

22.7%49.5%

Chart Title

Early Tester

Intermediate Tester

Late Tester

Late Tester = AIDS Diagnosed within 1 Year of HIV Diagnosis

HIV Interview Project: HIV Testing Patterns, 2000-2003

Source: Centers for Disease Control. MMWR. 2003;52:581-6.

Early versus Late Testers: Reasons for HIV Testing

Source: Centers for Disease Control. MMWR. 2003;52:581-6.

CDC Analysis of HIV Reporting Data, 1996-2005

Source: Centers for Disease Control. MMWR. 2009;58:661-5.

Study Background

- Data analyzed from HIV reporting 1996-2005

- 34 US states

- N = 281,421 persons receiving diagnosis of HIV

Source: Centers for Disease Control. MMWR. 2009;58:661-5.

CDC Analysis of HIV Reporting Data, 1996-2005

HV Testing in Relation to AIDS Diagnosis

- Late Tester = AIDS diagnosis < 1 year of HIV diagnosis

Chart Title

Late Tester

38.3%

Other

61.7%

Missed Opportunities for Earlier HIV Diagnosis

Source: Centers for Disease Control. MMWR. 2006;55:1269-72.

Study Background

- Data analyzed for HIV cases in SC from 2001-2005

- HIV cases cross-linked to all health care visits

- 4,315 cases of HIV in South Carolina

Missed Opportunities for Earlier HIV Diagnosis

Source: Centers for Disease Control. MMWR. 2006;55:1269-72.

Chart Title

Late Tester = AIDS Diagnosed within 1 Year of HIV Diagnosis

Late Tester

41.3%

Other

58.7%

Missed Opportunities for Earlier HIV Diagnosis

Source: Centers for Disease Control. MMWR. 2006;55:1269-72.

Chart Title

Late Tester = AIDS Diagnosed within 1 Year of HIV Diagnosis

Late Tester

41.3%

Other

58.7%

Among All Late Testers

73% with Prior Visit to

Health Care Facility

Median CD4 Cell Count At Time of Presentation to Care

Source: Keruly JC, Moore RD. Clin Infect Dis. 2007;45:1369-74.

Study Background

- N = 3,348 HIV-infected, antiretroviral therapy naïve adults

- Presented to Johns Hopkins HIV Clinic

CD4 Cell Count at Time of HIV Diagnosis

Source: Dybul M, et al. J Infect Dis. 2002;185:1818-21.

Study Background

- N = 2223 HIV-infected persons

- Community clinics in larger urban areas

- Evaluated CD4 count at time of HIV diagnosis

36% with CD4 < 200 cells/mm3

HIV Infection

CD4 Cell Count at Time of HIV Diagnosis

Source: Ogbuanu ID, et al. Am J Pub Health. 2009;Suppl1:111-17.

Study Background

- N = 759 HIV-infected persons

- Analysis of statewide data in South Carolina (2004-5)

- Evaluated CD4 count at time of HIV diagnosis

34% with CD4 < 200 cells/mm3

HIV Infection

Rationale for Routine HIV Screening in Health Care Settings

• Expanding Epidemic

• Late HIV Testing and Diagnosis

• Negative Impact of Late Diagnosis

• Reduced Transmission with Known HIV Status

• Precedent for Effectiveness of Universal Screening

Mortality and HAART Use Over TimeHIV Out-Patient Study, CDC, 1994-2003

Source: Centers for Disease Control and Prevention.

Per Person Survival Gains with Various Interventions for Chronic Diseases in US

Source: Walensky RP, et al. J Infect Dis. 2006;194:11-19.Figure Reproduced with permission from University of Chicago Press

Impact of Late Diagnosis on Antiretroviral Therapy

Advanced Immunosuppression

HIV Infection

Correlation of Baseline CD4 Cell Count and Outcome after Staring Antiretroviral Therapy

Source: Egger M, et al. Lancet. 2002;360:119-29.

Study Background

- N = 12,574 HIV-infected adults starting antiretroviral therapy

Risk of Death Associated with Deferral of ARV Therapy

Source: Kitahata M, et al. N Engl J Med. 2009;360:1897-9.

Study Background

- Two parallel analyses involving total of 17,517 asymptomatic ARV-naïve patients

- Time period 1996-2005

- Analysis 1 (N = 8364 Patients): Initiate therapy at CD4 351-500 cells/m3 or Defer

- Analysis 2 (N = 9,155 Patients): Initiate therapy at CD4 > 500 cells/m3

or Defer

CD4 Count Threshold AnalysisRelative Risk of Death with Deferral of Antiretroviral Therapy

351-500 cells/mm3 69%

More than 500 cells/mm3 94%

Rationale for Routine HIV Screening in Health Care Settings

• Expanding Epidemic

• Late HIV Testing and Diagnosis

• Negative Impact of Late Diagnosis

• Reduced Transmission with Known HIV Status

• Precedent for Effectiveness of Universal Screening

Knowledge of HIV Serostatus: Correlation with Sexual Transmission

Knowledge of HIV Serostatus: Correlation with Sexual Transmission

Source: Marks G, et al. J Acquir Immune Def Syndr. 2005;9:446-53.

Aware of HIV Status High-Risk Behavior

68%

Study Background

- Meta-analysis of 11 studies performed in US

- Evaluated unprotected anal or vaginal intercourse

Serum HIV RNA Level and Risk of HIV Transmission

Source: Quinn TC, et al. N Engl J Med. 2000;342:921-9.

Study Background

- 415 serodiscordant heterosexual couples in Rakai, Uganda

- Subjects NOT on antiretroviral therapy

HIV Serodiscordant Heterosexual Couples

Serum HIV RNA Level and Risk of HIV Transmission

Source: Quinn TC, et al. N Engl J Med. 2000;342:921-9.

Serum HIV RNA Level (copies/ml) in HIV-Infected Partner

Antiretroviral Therapy and Risk of HIV Transmission

Source: Sullivan P, et al. 16th

CROI. 2009;Abstract 2bLB.

Study Background

- 2993 HIV serodiscordant heterosexual couples in Rwanda & Zambia

- On antiretroviral therapy if symptomatic or CD4 < 200 cells/mm3

Antiretroviral Therapy and Risk of HIV Transmission

Antiretroviral Therapy Started

The findings from Africa would be expected to occur in patients in the US who achieve HIV RNA < 50 copies/ml while taking with potent

antiretroviral regimens

Source: Marks G, et al. AIDS. 2006;20:1447-50.

Estimating Sexual Transmission of HIV Based on Awareness of HIV Status

Source: Marks G, et al. AIDS. 2006;20:1447-50.

Chart TitleUnaware of

HIV infection

25%

Aware of

HIV infection

75%

At the time of the study, available data suggested 25% of HIV-infected persons unaware of their HIV infection

Estimating Sexual Transmission of HIV Based on Awareness of HIV Status

Source: Marks G, et al. AIDS. 2006;20:1447-50.

Knowledge of HIV Infection New HIV Infections

Unaware of

HIV Infection

Aware of

HIV Infection

Estimating Sexual Transmission of HIV Based on Awareness of HIV Status

Source: Marks G, et al. AIDS. 2006;20:1447-50.

Knowledge of HIV Infection New HIV Infections

Unaware of

HIV Infection

Aware of

HIV Infection

Lower bound of estimate assuming no difference in average number

of at-risk partners in the unaware group

Estimating Sexual Transmission of HIV Based on Awareness of HIV Status

Source: Marks G, et al. AIDS. 2006;20:1447-50.

Knowledge of HIV Infection New HIV Infections

Aware of

HIV Infection

Unaware of

HIV Infection

Estimating Sexual Transmission of HIV Based on Awareness of HIV Status

Source: Marks G, et al. AIDS. 2006;20:1447-50.

Knowledge of HIV Infection New HIV Infections

Upper bound of estimate assuming twice as many at risk partners in the

unaware group

Aware of

HIV Infection

Unaware of

HIV Infection

Using Marks Model and 2008 CDC Data Estimating Impact of Knowledge of HIV Infection

on Sexual Transmission of New HIV Infections

Estimates Based on: Marks G, et al. AIDS. 2006;20:1447-50.

Using Marks Model & 2008 CDC Estimates of Awareness of HIV Status

Knowledge of HIV Infection New HIV Infections

Aware of

HIV Infection

Unaware of

HIV Infection

Using Marks Model and 2008 CDC Data Estimating Impact of Knowledge of HIV Infection

on Sexual Transmission of New HIV Infections

Estimates Based on: Marks G, et al. AIDS. 2006;20:1447-50.

Using Marks Model & 2008 CDC Estimates of Awareness of HIV Status

Knowledge of HIV Infection New HIV Infections

Lower bound of estimate assuming no difference in average number

of at-risk partners in the unaware group

Aware of

HIV Infection

Unaware of

HIV Infection

Rationale for Routine HIV Screening in Health Care Settings

• Expanding Epidemic

• Late HIV Testing and Diagnosis

• Negative Impact of Late Diagnosis

• Reduced Transmission with Known HIV Status

• Precedent for Effectiveness of Universal Screening

Source: Centers for Disease Control. MMWR 2006;55:592-7.

Perinatally Acquired AIDS Cases, by Year of Diagnosis, 1985-2006—United States and Dependent Areas

Perinatally Acquired AIDS Cases, by Year of Diagnosis, 1985-2006—United States and Dependent Areas

Routine HIV screening in pregnancy has played an important

role in preventing perinatal HIV infections

Source: Centers for Disease Control. MMWR 2006;55:592-7.

Screening Blood Donors for HIV and

Decreased Risk of Transmission of HIV

Screening Blood Donors Blood Transfusion

Screening Blood Donors for HIV and

Decreased Risk of Transmission of HIV

Screening Blood Donors Blood Transfusion

Universal HIV screening of blood donors has virtually eliminated transfusion-associated HIV

Acknowledgement

The project was funded under cooperative agreement

number U65/PS000821 from the Centers for Disease

Control and Prevention (CDC).