Engaging HIVInfected Persons in Medical Care

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Engaging HIV-Infected Persons in Medical Care

• Jeffrey H. Samet, MD, MA, MPH
• Chief, Section General Internal Medicine
• Boston Medical Center
• Professor of Medicine and Public Health
• Boston University Schools of Medicine and Public
  Health

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Objectives

• Appreciate the historical context of HIV testing
  over the course of the AIDS epidemic
• Understand the theoretical and pragmatic stages
  involved in getting an HIV- infected individual
  into medical care
• Describe Center for Disease Control and
  Prevention (CDC) 2006 recommendations for HIV
  testing

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HIV/AIDS
1970's - 2007
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June 5, 1981. Vol. 30, No. 21
In the period October 1980- May 1981, 5 young
men, all active homosexuals, were treated for
biopsy-confirmed Pneumocystis carinii pneumonia
(PCP) at 3 different hospitals in Los Angeles,
California. Two of the patients died. All 5
patients had laboratory-confirmed previous or
current cytomegalovirus (CMV) infection and
candidal mucosal infection.
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Presentation of Kaposis Sarcoma
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Identification of the Pathogen
1984 - French Scientists identified LAV and Dr.
Robert Gallo identified HTLV-III.
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HIV Testing

• 1985- FDA licensed ELISA, Western Blot assays
• 1987-CDC guidelines for counseling and testing
  include IDUs, those with STDs, and women
• 1989-Rhame Maki recommend a minimum requirement
  of testing all patients acknowledging sexual
  contact with homosexual men, needle sharing, and
  multiple unsafe heterosexual contacts. Also
  encouraged testing of prenatal patients.

CDC. August 1987. MMWR 36(31)509-515. Rhame
FS, Maki DG. NEJM. 19893201248-1254.
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Azidothymidine (AZT) Therapy

• Placebo controlled RCT of AZT in patients with
  AIDS or AIDS-related complex (n282)
• AZT administration can decrease mortality and
  frequency of opportunistic infections(plt0.001)

Fischl MA, Richman DD, Grieco MH, et al. NEJM.
1987317185-191.
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AZT Therapy
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AZT and Vertical Transmission

• 1994 - ACTG trial 076 - AZT reduced risk of
  vertical transmission when administered during
  pregnancy
• Transmission rate was 23 vs. 8 (placebo vs.
  AZT) (plt0.001)

Sperling, RS. et al. New Engl J Med.
19963351621-1629.
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Protease Inhibitors
Available as of 1996
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FDA Approved Antiretroviral Agents
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Gary Larson 1985
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Late Presentation to HIV Care Western Australia

• Review of sequential AIDS diagnoses from 1988 to
  1991 (n106)
• 39 (41/106) were late presenters (knowledge of
  HIV status lt 8 weeks before AIDS presentation)
• 6/41 late presenters died during initial
  admission, compared with only 1 of the 65 earlier
  presenters (plt0.02)

Gillieatt SJ, Mallal SA, French MA, Dawkins RL.
Med J Australia. 1992157117-118.
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Late Presentation to HIV Care Great Britain

• Survey of adults with AIDS diagnosed during
  1989-1992 and reported to Public Health
  authorities in England and Wales (n4,127)
• 49 (1742/3556) had lack of awareness defined as
  9 months or less between first positive test and
  diagnosis of AIDS
• Lack of awareness associations infection via
  heterosexual contact (OR 4.46, 95 CI 3.15 to
  6.33) non-white (1.99, 1.51 to 2.61) female
  (0.50, 0.33 to 0.76).

Porter K, Wall PG, Evans BG. BMJ. 199330720-23.
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Late Presentation to HIV Care United States

• Review HIV-infected patients initiating care from
  8/89 to 1/91 (n96)
• CD4 lymphocyte count as indicator of treatment
  delay
• Mean CD4 count of 369/mm3 (29 with CD4 lt200/mm3)

Katz MH, Bindman AB, Keane D, Chan AK. Arch
Intern Med. 19921521369-1534.
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Late Presentation to HIV Care United States

• Review of HIV-infected patients initiating care
  at Boston City Hospital (BCH) and Rhode Island
  Hospital (RIH) (n374)
• Median CD4 counts were 300/ mm3 (BCH) and 445/
  mm3 (RIH)
• At BCH, 30 had CD4 counts lt 200/mm3, 51 201 -
  500/mm3, and 19 gt500/mm3
• Haitian ethnicity (p0.05) and HIV-related
  symptoms (p0.005) were associated with lower CD4
  cell counts
• Female sex (p0.009) was associated with higher
  CD4 cell counts

Samet JH, Retondo MJ, Freedberg KA, Stein MD,
Libman H. Am J Medicine. 199497347-353
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Late Diagnosis of HIV Infection

• Review of reported AIDS cases, San Francisco,
  1/01 through 12/05, (n2139)
• 39 (830/2139) were late testers (i.e., HIV
  diagnosis lt12 months prior to AIDS diagnosis)
• Factors associated with testing late
• Age lt30 at AIDS diagnosis
• Acquiring HIV through heterosexual contact
• Having no risk factor reported
• Having private or health insurance at AIDS
  diagnosis
• Being born outside of the United States
• Men who had sex with men and also injected drugs
  had a decreased likelihood of testing late.

Schwartz S, Hsu L, Dilley JW, Loeb L, Nelson K,
Boyd S. 2006. JAIDS 43491-494.
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Conceptual Framework Steps Between Acquiring
HIV and Establishing Primary Care
T5
Acquired Infection
HIV Testing
Linkage to Medical Care
Maintenance of Care
Awareness
T1
T2
T4
T6
T3
Samet JH, Freedberg KA, Savetsky JB, Sullivan LM,
Stein MD. AIDS. 20011577-85
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Help Seeking for HIV Infection (RWJF Cohort)

• Observational study of consecutive outpatients
  seeking initial HIV primary care at Boston City
  Hospital (BCH) and Rhode Island Hospital (RIH)
  between 2/94 and 4/96 (n203)
• Initial HIV primary care defined as
• initial positive HIV test result in last 4 months
  
• initial positive HIV test gt 4 months before
  presentation and no specific prior HIV Primary
  Care (PC) or past use of AZT

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T3
HIV Testing
Acquired Infection
Awareness
T1
T2

• RWJF Cohort (n203)
• 34 reported unawareness of HIV risk prior to
  testing (T3)
• Among 64 aware, the mean time between awareness
  and testing was 2.5 years with a median of 1 year
  (T2)

Samet JH, Freedberg KA, Savetsky JB, Sullivan LM,
Stein MD. AIDS. 20011577-85
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T3
Acquired Infection
HIV Testing
Awareness
T1
T2

• Survey of patients at an urban HIV clinic (n227)
• Nearly all acknowledged HIV risk factors, but 60
  reported not suspecting infection until receipt
  of positive test (T3).
• 48 of subjects who suspected HIV infection
  waited one year or more before being tested (T2).

Wenger NS, Kusseling FS, Beck K, Shapiro MF.
AIDS Care. 19946399-405.
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HIV Testing
Linkage to Medical Care
T4

• RWJF cohort (n189) 39 delayed medical care
  after initial positive HIV test for gt1 year, 32
  gt2 years, and 18 gt5 years
• Characteristics associated with delay
• history of IDU (plt0.001)
• history of alcohol problems in men (p0.03)
• not having a living mother (p.01)
• not having a spouse or partner (p.08)
• not being aware of HIV risk before testing
  (plt.001)
• being notified of HIV status by mail or phone
  (p.002)

Samet JH, Freedberg KA, Stein MD, et al. Arch
Intern Med. 1998158734-740.
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Linkage to Medical Care
HIV Testing
T4

• Survey of a probability sample of in-care
  HIV-infected persons (HCSUS) diagnosed by 2/93
  and in care within 3 years (n1540)
• Delay of gt3 months occurred for 29 of these,
  the median delay was 1 year.
• Medicaid insurance and having a usual source of
  care were protective against delay to care. Delay
  was greater for Latinos and African Americans
  compared to Whites.

Turner BJ, et al. Arch Intern Med. 20002614-2622
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8.1 years
T5
Acquired Infection
HIV Testing
Linkage to Medical Care
Awareness
1 years
X
1 years

• RWJF Cohort (n203)
• Median CD4 cell count was 280/µl
• Estimated mean time between acquiring HIV and
  initiating PC was 8.1 years (95 CI 7.5, 8.6)
  based on cohorts median CD4 cell count
• Male sex, older age, and no jail time associated
  with lower CD4 cell counts
• HIV testing is key to earlier engagement to
  medical care

Samet JH, Freedberg KA, Savetsky JB, Sullivan LM,
Stein MD. AIDS. 20011577-85.
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Linkage to Medical Care
Maintenance of Care
T6

• RWJF cohort (n198)
• Discontinuation from PC was defined as lt1
  follow-up appts. within 6 months of initiation
• Assessed via patient interviews admin. data
• Discontinuation occurred in 20 (40/198)
• Characteristics associated with discontinuation
• not having graduated from high school (p0.02)
• having been in jail in last 10 years (p0.01)
• no history of victimization (p0.04)
• active cocaine use at initial interview (p0.05)
• higher CD4 count (p0.06)

Samet JH, Freedberg KA, Savetsky JB, Sullivan LM
Padmanabhan L, Stein MD. J Health Care Poor
Undserv. 200314244-255.
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Issues In Testing

• Who?
• How?
• Where?
• Why?
• Why Not?

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HIV Testing in Substance Abusers

• Assessment of patients entering substance abuse
  (SA) treatment 1992-1993 (n2315)
• No prior HIV testing among
• 27 IDUs 39 STD history
• 38 with multiple sexual partners
• Factors associated with previous HIV testing
• having a primary care physician (PCP)
• PCPs awareness of patients SA problem
• having received prior SA care

Samet JH, Mulvey KP, Zaremba, N, and Plough, A.
Am J Drug Alcohol Abuse. 199925269-280.
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Clinical and Historical Triggers to Suggest Risk
of HIV Infection
Clinical Triggers Historical Triggers Sexually
Transmitted Diseases Psychiatric
Hospitalization Herpes Simplex Virus,
Gonorrhea Alcohol Detoxification Abnormal
Pap Smear, Trichomoniasis Homelessness
Syphilis, Hepatitis B Cocaine or crack use
Condylomata acuminata, Pelvic Inflammatory
Disease Unsafe sex w/partner Other
Infections w/ unknown HIV status
TB, Vaginal Candidiasis Community-acquired
pneumonia, Varicella zoster Skin Psoriasis,
Seborrheic dermatitis Systemic Mononucleosis
syndrome, Weight Loss Bells palsy,
Generalized lymphadenopathy Pregnancy
Freedberg KA, Samet JH. Arch Intern Med.
19991591994-2000.
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T5
Linkage to Medical Care
Acquired Infection
HIV Testing
Awareness

• Review of 5 years of medical encounters prior to
  diagnosis of HIV in large HMO (n440)
• 62 had CD4 counts lt350/µL, 43 had lt200/µL and
  18 had lt50/µL at diagnosis
• Only 22 had a clinical indicator for HIV
  testing gt 1 year prior to diagnosis oral
  infection, pneumonia, night sweats, unexplained
  fever, seborrheic dermatitis, herpes zoster,
  unexplained weight loss, and lymphadenopathy gt 1
  site

Klein D, Hurley LB, Merrill D, Quesenberry CP Jr.
JAIDS. 200332143-152.
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T5
Acquired Infection
HIV Testing
Linkage to Medical Care
Awareness

• 10 year retrospective chart review of patients
  (n237) seen at an HIV intake clinic who
• tested positive during the 12 months prior to
  presentation
• had one medical encounter prior to a positive HIV
  test
• 49 (1702/3472) of all medical visits had
  triggers (median visits/patient 5)
• In only 28 of visits in which triggers were
  identified, clinicians addressed HIV testing

Liddicoat RV, Horton NJ, Urban R, Maier E,
Christiansen D, Samet JH. J Gen Intern Med. 2004
19349-356.
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Routine Inpatient Testing

• Initial implementation of Think HIV program in
  one hospital (routine voluntary HIV counseling
  and testing)
• Compared program results with historical control
  period
• Think HIV patients were 3.4 times more likely
  to undergo testing than the controls
• Approximately 2 new HIV diagnoses/month compared
  to 1/month in control

Walensky RP, Losina E, Steger-Craven K, Freedberg
KA. Arch Intern Med. 2002162887-892.
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Refusing HIV Testing

• Data from multiple sites in Think HIV (n9,129
  1/02 to 12/02)
• 67 (6,153/9,129) refused HIV testing
• Demographic factors associated with being more
  likely to refuse white race older age higher
  education female gender non-English speaking
  Hispanic, Haitian, or other race
• Reasons given for refusal not at risk,
  already tested

Liddicoat RV, Losina E, Kang M, Freedberg KA,
Walensky RP. AIDS Patient Care STDS. 2006
2084-92.
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Routine Clinic Testing

• HIV added to group of tests offered to patients
  at STD clinic in Arizona
• Informed of option, sign consent if desire test
• 68 (12,176/17,875) accepted testing
• 68 (5.6/1,000) were HIV positive
• 58 (85) were informed of result and referred for
  treatment
• High acceptance rate if included in routine
  battery of tests offered at STD clinic

Campos-Outcalt D, Mickey T, Weisbuch J, Jones R.
Pub Health Rep. 2006121175-180.
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Provider Responsibility

• CDC data indicate that only 10 of men and 17 of
  women with HIV infection report that their
  initial HIV testing was suggested by their
  healthcare provider
• Illness was the most common reason for testing
• Physicians can make a substantial impact by
  routinely recommending testing, thus increasing
  the likelihood of early diagnosis

MMWR. April 18, 2003. 52(15)329-332.
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Provider Characteristics

• More recent medical graduates are more likely to
  discuss HIV testing with patients
• Patients are more likely to accept an HIV test if
  provider stresses potential benefits for
  themselves, partners, and offspring
• Providing culturally relevant information may
  influence patients to accept HIV testing

Valdiserri RO, et al. 1999132317-2330.
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HIV Testing in the United States

• 2002 National Survey of Family Growth
  face-to-face interviews with males and females
  aged 15-44 (n12,571)
• Half (51) had been tested in their lifetime 15
  in the past 12 months.
• Sources of tests Private physicians and HMOs
  (45) Public clinic (22)
• 29 reported talking with a health professional
  after being tested.
• One third in the high-risk groups reported never
  being tested.

Anderson JE, Chandra A, Mosher WD. 2005 Advance
Data from Vital and Health Statistics No. 363
November 8.
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HIV Testing Recommendations, 2006

• For patients in all health-care settings
• Opt-out screening
• Screen high-risk persons at least annually.
• No separate written consent for HIV test
• Prevention counseling not required
• For pregnant women
• Include in routine panel of prenatal screening
  tests
• Opt-out screening

CDC. MMWR 200655(RR-14). http//www.cdc.gov/mmwr/
preview/mmwrhtml/rr5514a1.htm
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Watson and the Shark John Singleton Copley 1778