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Routine HIV Screening in Health Care Settings

Routine HIV Screening in Health Care Settings. Rationale for Routine Screening. David Spach, MD Clinical Director Northwest AIDS Education and Training Center Professor of Medicine, Division of Infectious Diseases University of Washington Seattle.

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Routine HIV Screening in Health Care Settings

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  1. Routine HIV Screening in Health Care Settings Rationale for Routine Screening David Spach, MDClinical DirectorNorthwest AIDS Education and Training CenterProfessor of Medicine, Division of Infectious DiseasesUniversity of Washington Seattle This project was funded under cooperative agreement number U65/PS000821from the Centers for Disease Control and Prevention (CDC). 

  2. 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

  3. 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

  4. HIV: New Infections and Deaths, 1987-2006 New Infections Deaths Source: Centers for Disease Control and Prevention

  5. HIV: New Infections and Deaths, 1987-2006 New Infections Deaths Source: Centers for Disease Control and Prevention

  6. Estimated HIV Prevalence, US, 1977-2006 Source:Campsmith M, et al. CROI 2009: Abstract 1036.

  7. Estimated AIDS Cases and Deaths, US, 1985-2006 1993 Definition Implementation Source: Centers for Disease Control and Prevention

  8. Estimated AIDS Cases and Deaths, US, 1985-2006 1993 Definition Implementation Source: Centers for Disease Control and Prevention

  9. Estimated AIDS Cases, Deaths, & Prevalence, US, 1985-2006 1993 Definition Implementation Source: Centers for Disease Control and Prevention

  10. Estimated AIDS Prevalence, US, 1985-2006 Source: Centers for Disease Control and Prevention

  11. HIV and AIDS Prevalence HIV Prevalence AIDS Prevalence Source: Hall HI, et al. JAMA. 2008;300:520-9. Source: Centers for Disease Control and Prevention

  12. 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

  13. HIV Progression CD4 Cell Count Decline Over Time HIV Infection

  14. HIV Progression CD4 Cell Count Decline Over Time HIV Infection Severe Immunosuppression

  15. HIV Interview Project: HIV Testing Patterns, 2000-2003 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.

  16. HIV Interview Project: HIV Testing Patterns, 2000-2003 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 Source: Centers for Disease Control. MMWR. 2003;52:581-6.

  17. HIV Interview Project: HIV Testing Patterns, 2000-2003 Late Tester = AIDS Diagnosed within 1 Year of HIV Diagnosis Source: Centers for Disease Control. MMWR. 2003;52:581-6.

  18. Early versus Late Testers: Reasons for HIV Testing Source: Centers for Disease Control. MMWR. 2003;52:581-6.

  19. CDC Analysis of HIV Reporting Data, 1996-2005 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.

  20. CDC Analysis of HIV Reporting Data, 1996-2005 Late Tester38.3% Other61.7% HV Testing in Relation to AIDS Diagnosis- Late Tester = AIDS diagnosis < 1 year of HIV diagnosis Source: Centers for Disease Control. MMWR. 2009;58:661-5.

  21. Missed Opportunities for Earlier HIV Diagnosis 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 Source: Centers for Disease Control. MMWR. 2006;55:1269-72.

  22. Missed Opportunities for Earlier HIV Diagnosis Late Tester41.3% Other58.7% Late Tester = AIDS Diagnosed within 1 Year of HIV Diagnosis Source: Centers for Disease Control. MMWR. 2006;55:1269-72.

  23. Missed Opportunities for Earlier HIV Diagnosis Among All Late Testers 73% with Prior Visit to Health Care Facility Late Tester41.3% Other58.7% Late Tester = AIDS Diagnosed within 1 Year of HIV Diagnosis Source: Centers for Disease Control. MMWR. 2006;55:1269-72.

  24. Median CD4 Cell CountAt Time of Presentation to Care Study Background- N = 3,348 HIV-infected, antiretroviral therapy naïve adults- Presented to Johns Hopkins HIV Clinic Source: Keruly JC, Moore RD. Clin Infect Dis. 2007;45:1369-74.

  25. CD4 Cell Count at Time of HIV Diagnosis HIV Infection 36% with CD4 < 200 cells/mm3 Study Background- N = 2223 HIV-infected persons - Community clinics in larger urban areas- Evaluated CD4 count at time of HIV diagnosis Source:Dybul M, et al. J Infect Dis. 2002;185:1818-21.

  26. CD4 Cell Count at Time of HIV Diagnosis HIV Infection 34% with CD4 < 200 cells/mm3 Study Background- N = 759 HIV-infected persons - Analysis of statewide data in South Carolina (2004-5)- Evaluated CD4 count at time of HIV diagnosis Source:Ogbuanu ID, et al. Am J Pub Health. 2009;Suppl1:111-17.

  27. 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

  28. Mortality and HAART Use Over TimeHIV Out-Patient Study, CDC, 1994-2003 Source: Centers for Disease Control and Prevention.

  29. 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

  30. Impact of Late Diagnosis on Antiretroviral Therapy HIV Infection Advanced Immunosuppression

  31. Correlation of Baseline CD4 Cell Count and Outcome after Staring Antiretroviral Therapy Study Background- N = 12,574 HIV-infected adults starting antiretroviral therapy Source: Egger M, et al. Lancet. 2002;360:119-29.

  32. Risk of Death Associated with Deferral of ARV Therapy 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 Source:Kitahata M, et al. N Engl J Med. 2009;360:1897-9.

  33. 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

  34. Knowledge of HIV Serostatus: Correlation with Sexual Transmission

  35. Knowledge of HIV Serostatus: Correlation with Sexual Transmission Aware of HIV Status High-Risk Behavior 68% Study Background- Meta-analysis of 11 studies performed in US- Evaluated unprotected anal or vaginal intercourse Source: Marks G, et al. J Acquir Immune Def Syndr. 2005;9:446-53.

  36. Serum HIV RNA Level and Risk of HIV Transmission HIV Serodiscordant Heterosexual Couples Study Background- 415 serodiscordant heterosexual couples in Rakai, Uganda- Subjects NOT on antiretroviral therapy Source: Quinn TC, et al. N Engl J Med. 2000;342:921-9.

  37. Serum HIV RNA Level and Risk of HIV Transmission Serum HIV RNA Level (copies/ml) in HIV-Infected Partner Source: Quinn TC, et al. N Engl J Med. 2000;342:921-9.

  38. Antiretroviral Therapy and Risk of HIV Transmission Study Background- 2993 HIV serodiscordant heterosexual couples in Rwanda & Zambia- On antiretroviral therapy if symptomatic or CD4 < 200 cells/mm3 Source: Sullivan P, et al. 16th CROI. 2009;Abstract 2bLB.

  39. 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

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

  41. Estimating Sexual Transmission of HIV Based on Awareness of HIV Status At the time of the study, available data suggested 25% of HIV-infected persons unaware of their HIV infection Source: Marks G, et al. AIDS. 2006;20:1447-50.

  42. Estimating Sexual Transmission of HIV Based on Awareness of HIV Status Knowledge of HIV Infection New HIV Infections Unaware of HIV Infection Aware of HIV Infection Source: Marks G, et al. AIDS. 2006;20:1447-50.

  43. Estimating Sexual Transmission of HIV Based on Awareness of HIV Status Knowledge of HIV Infection New HIV Infections Lower boundof estimate assuming no difference in average number of at-risk partners in the unaware group Unaware of HIV Infection Aware of HIV Infection Source: Marks G, et al. AIDS. 2006;20:1447-50.

  44. Estimating Sexual Transmission of HIV Based on Awareness of HIV Status Knowledge of HIV Infection New HIV Infections Unaware of HIV Infection Aware of HIV Infection Source: Marks G, et al. AIDS. 2006;20:1447-50.

  45. Estimating Sexual Transmission of HIV Based on Awareness of HIV Status Knowledge of HIV Infection New HIV Infections Upper bound of estimate assuming twice as many at risk partners in the unaware group Unaware of HIV Infection Aware of HIV Infection Source: Marks G, et al. AIDS. 2006;20:1447-50.

  46. Using Marks Model and 2008 CDC DataEstimating Impact of Knowledge of HIV Infection on Sexual Transmission of New HIV Infections Using Marks Model & 2008 CDC Estimates of Awareness of HIV Status Knowledge of HIV Infection New HIV Infections Unaware of HIV Infection Aware of HIV Infection Estimates Based on: Marks G, et al. AIDS. 2006;20:1447-50.

  47. Using Marks Model and 2008 CDC DataEstimating Impact of Knowledge of HIV Infection on Sexual Transmission of New HIV Infections Using Marks Model & 2008 CDC Estimates of Awareness of HIV Status Knowledge of HIV Infection New HIV Infections Lower boundof estimate assuming no difference in average number of at-risk partners in the unaware group Unaware of HIV Infection Aware of HIV Infection Estimates Based on: Marks G, et al. AIDS. 2006;20:1447-50.

  48. 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

  49. Perinatally Acquired AIDS Cases, by Year of Diagnosis, 1985-2006—United States and Dependent Areas Source: Centers for Disease Control. MMWR 2006;55:592-7.

  50. 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.

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