Post on 22-Feb-2016
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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).