Welcome to CDC course:“Fundamentals of Waived Rapid HIV Testing

and Prevention Counseling”

Sponsored by the Northwest AIDS Education and Training Center

and the Idaho Family Planning, STD and HIV Program

Your Trainers Today:Judy Thorne, MPA

HIV Education Coordinator, Master of Public Health Program, Idaho State University/Boise

and Jan Nissl, RN

Healtwise, Inc. and St. Luke’s Regional Medical Center

Thank you for having us!

Goals for today…

• Reminder: completion of forms (PIF’s, evaluations)

Learning Objectives:• Identify at least 2 benefits to waived testing• Understand the testing/counseling process• Role play the client-centered approach• Problem solve potential rapid test scenarios• Develop local referrals/resources

What are the current stats for

HIV and AIDS?

Adults and Children Living with HIV/AIDS

Total: 40+ million Data from UNAIDS

N. America1.2 million

Caribbean420,000

Latin America1.5 million

Western Europe550,000

Sub-SaharanAfrica 28.5 million

Asia & Pacific6.6 million

Australia & NewZealand 15,000

North Africa500,000

Eastern Europe1 million

Idaho’s numbers?

HIV in Idaho – Prevalence **Idaho diagnoses only, with additional 20-25% undiagnosed

District 1 57 73 District 2 29 30 District 3 63 77 District 4 248 199 District 5 51 54 District 6 48 43 District 7 37 34• Total 533 511

HIV AIDS

1,044(As of Sept. 2008)

True/False:

The 40-49 yr old age group is most affected by HIV in Idaho

Idaho HIV positive by age at diagnosis

0

20

40

60

80

100

120

140

160Age under 5

12-May

13-19

20-29

30-39

40-49

Over 49

Older Adults11-15% of U.S. AIDS cases in over 50 group

Challenges:• access to health care, income, social support• minority and ethnic groups• age

– stigma– barriers: misdiagnosed OIs

2006 CDC Guidelines

• Routine voluntary screening for all persons aged 13-64 (normalize testing)

• Opt-out testing and counseling not required• Repeat HIV screening yearly for those with

known risk• Routine screening for all pregnant women

-repeat screening in 3rd trimester in areas with high HIV rates

Rapid HIV Testing• Provides same-day results.• Detects HIV antibodies (exposure) not virus• Offsets no-return rate (2.1 million tests yearly)

– 31% of positives do not return for results. – 39% of negatives do not return for results.

• Increases ability to reduce new HIV infections (CDC).

• Allows people to know their status (21% are unaware of their HIV infection).

What are some advantages for

rapid testing?

Advantages of Rapid Test

• Know HIV status (KYS)

• Earlier access to care for all clients

• Decreased transmission

• Effective treatment available– Healthcare workers

• Cost effective

• Success stories – pregnancy (decline in neonatal transmission to <1%)

What symptoms might a person

present with?

Acute Retroviral Syndrome

• Fever• Lymphadenopathy

• Pharyngitis• Rash

• Myalgia/arthralgia• Diarrhea

• Headache• Nausea/Vomiting

• Hepatosplenomegaly• Weight loss

• Thrush• Neurologic symptoms

96%74%70%70%54%32%32%27%14%13%12%12%

CDC. Guidelines for using antiretroviral agents…MMWR 2002;51(RR-7)

Opportunistic Infections

What populations of people

may not actively seek testing

and why?

Missed Opportunities for Testing

• Pregnant women:– Who do not receive regular if any prenatal care– Who are not offered testing

• Immigrant populations• Injection drug users• Homeless individuals• Historically; lesbian, gay, bisexual, transgender,

questioning (LGBTQ) individuals do not seek care• Those not considered at risk (i.e. older adults)

Why advocate for

rapid HIV testing?

2007 Updated HIV Treatment Guidelines

• Antiretroviral therapy should be initiated in patients with history of an AIDS defining illness or with a CD4 T-cell count <350 cells/mm3

• Treatment for the following groups regardless of CD4 T-cell count:– pregnant patients– patients with HIV-associated nephropathy– patients co-infected with hepatitis B when treatment

for hepatitis B virus is indicated

*Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents December 1, 2007

What is HIV

Life Cycle of HIV-1Life Cycle of HIV-1

04/18/23 Unit One

Antiretroviral Strategies

Penetration

Transcription

UncoatingReverse Transcription

Integration

TranslationProcessing

AssemblyRelease

CD4 AnaloguesNRTI’sNNRT’sIntegrase InhibitorsTAT InhibitorsProtease InhibitorsInterferons

Fusion InhibitorsEntry Inhibitors

Maturation Inhibitor

Resources for Consultation

• Local experts identified for PEP

(ID consultant, hospital epidemiologist)

• National Clinicians’ Postexposure Prophylaxis Hotline (PEPline), telephone 888-448-4911.

• HIV Services Clinics in Boise, Pocatello, Spokane serving north Idaho

(Ryan White Grantees)

– Counseling and confidential testing– Comprehensive medical care– Case management– Adherence counseling– Mental health– Support groups – Clinical trials– Education

                                                                   

                                                                                        

Web Sites to Access the Guidelines

• http://www.aidsetc.org

• http://aidsinfo.nih.gov

• http://www.cdc.gov

Guidelines

• http://aidsinfo.nih.gov/guidelines/

State Laws Applicable to HIV Testing and Counseling

• Idaho Reportable Diseases (39-602)

•Confidentiality and Disclosure (39-609)(relates to informed consent)

•Unlawful to Transmit (39-608)

•Minors – Consent to Treatment (39-3801)

•Public Law 104-146 Spousal Notification“good faith effort be made to notify marriage partners”

Idaho Code web-site link

www. idahohealth.org

(click on STD/AIDS information, Idaho Code)

OverviewIntegrating HPC into the Rapid HIV Test Process

Before Testing During Testing After Testing

Tasks Tasks Tasks

1. Introduce & orient client to session

(includes obtaining informed consent & assessing readiness)

2. Identify client’s risk behavior & circumstances

3. Identify client’s safer goal behavior

4. Develop action plan

5. Make referrals & provide support

6. Summarize & close session

QA Tasks Throughout the Rapid Test Process:

Program ManagementTraining, Documentation and Records

TroubleshootingSafe Work Practices

HIV Prevention Counseling Steps

Integrating HIV Prevention Counseling with Rapid HIV Testing

1. Introduce and orient the client to the session

2. Identify client's risk behavior and circumstances

3. Identify client's safer goal behavior

4. Develop an action plan

5. Make referrals and provide support

6. Summarize and close the session

The Six Steps of HIV Prevention Counseling

(HPC)

Conduct STEPS

4, 5, & 6 of HPC

Give test resultsExplain the meaning

and facilitate a confirmatory test, if preliminary positive

Interpret results

Conduct STEPS 2 & 3 of HPC (While the

test is being processed)

Facilitate HIV testing process:

QA Testing Universal Precautions

Assess clients’

readiness to take test & receive test results

in the same day

STEP 1 HPCRisk Screening*

Information on tests and obtaininformed consent

Provide

Why do you need my name?Why do you need my name?

Discuss & ExplainDiscuss & Explain

• Informed ConsentInformed Consent

• Names-reporting StateNames-reporting State

• Confidential TestingConfidential Testing

• Age or Parental ConsentAge or Parental Consent

It’s not about you…It’s not about you…

It is all about me…It is all about me… (as in your client)(as in your client)

• I want to be comfortable.I want to be comfortable.– Is your testing environment appropriate?Is your testing environment appropriate?

• I want to leave satisfied.I want to leave satisfied.– Are they leaving with what Are they leaving with what theythey came in for? came in for?

• I want to be listened to and heard.I want to be listened to and heard.– Are you making eye contact? Is your paper away? Are you out Are you making eye contact? Is your paper away? Are you out

from behind that desk?from behind that desk?

• I would like answers to my questionsI would like answers to my questions• The customer is always rightThe customer is always right

HIV and AIDSHIV and AIDS

The BasicsThe Basics

• HIV antibody test not AIDS TestHIV antibody test not AIDS Test

• TransmissionTransmission

• Think through a reactive result today. Think through a reactive result today. What would comfort them?What would comfort them?

So what does that mean?So what does that mean?

The results are in…The results are in…

• Be prepared to explain and speak Be prepared to explain and speak correctly about the test you have chosen.correctly about the test you have chosen.– Preliminary Positive/Reactive NOT PositivePreliminary Positive/Reactive NOT Positive– Manufacture’s GuidelinesManufacture’s Guidelines– Screening vs. ConfirmatoryScreening vs. Confirmatory

» This all can be given to them beforehandThis all can be given to them beforehand

Window PeriodWindow Period

So I had unprotected sex last So I had unprotected sex last night…night…

• Three Months (97%)Three Months (97%)

• Many within 25 daysMany within 25 days

• 6 months for those in high risk categories6 months for those in high risk categories– IDU, Partners of POZ – in some cases HRH, IDU, Partners of POZ – in some cases HRH,

MSMMSM– Or just explain 3% take 6 months and let them Or just explain 3% take 6 months and let them

decide.decide.

***Remind them their partners have a window period too.***Remind them their partners have a window period too.

Then where can I go?Then where can I go?

What other tests or referral…What other tests or referral…

• Sexually Transmitted Infections/STD’sSexually Transmitted Infections/STD’s

• Hepatitis CHepatitis C

• PregnancyPregnancy

• Hepatitis A & B Vaccinations (MSM, ?)Hepatitis A & B Vaccinations (MSM, ?)

• PAPPAP

• Birth ControlBirth Control

Who am I going to tell?Who am I going to tell?

SupportsSupports

• Does anyone know you are here today?Does anyone know you are here today?

• Is that someone you would call?Is that someone you would call?

• How do you think you would respond to a How do you think you would respond to a reactive result today?reactive result today?– Now be sure it does not appear that you can Now be sure it does not appear that you can

see the result, already.see the result, already.

Be sure they understand process if result is reactive and how Be sure they understand process if result is reactive and how involved you personally or your agency will be.involved you personally or your agency will be.

Follow up & Follow ThroughFollow up & Follow Through

You need another test…You need another test…

• Review Window PeriodReview Window Period

• Encourage condom use during this timeEncourage condom use during this time– Though you may have received a negative Though you may have received a negative

result today, you may still have the virus and result today, you may still have the virus and you could transmit to your partner.you could transmit to your partner.

– Having HIV also makes you susceptible to Having HIV also makes you susceptible to other Sexually Transmitted Infectionsother Sexually Transmitted Infections

– Make the ReferralMake the Referral

Essentials during a CTR session:

• Maintain client-centered focus• Explain various test options• Explain possible results in a rapid test• Explain reactive test/confirmatory testing/state reporting

prior to obtaining informed consent• Assess readiness for results in 20 minutes• Obtain signature for informed consent• Run test• Allow client to guide action plan • Provide test results in neutral manner• Assist client as needed (confirmatory testing, resources)

JEANJEAN

• What is important to key into about her What is important to key into about her friends?friends?– ConfidentialityConfidentiality– SupportSupport

• What about her boyfriend?What about her boyfriend?– Prison StatsPrison Stats– Injection Drug Use/Hepatitis CInjection Drug Use/Hepatitis C

• What is her risk reduction plan, does she What is her risk reduction plan, does she need a follow up and when?need a follow up and when?