1. Expanding HIV Screening in the
Veterans Administration
Matthew B. Goetz, MD
Chief, Infectious Diseases, VA Greater Los Angeles HCS
Clinical Coordinator, QUERI-HIV/HCV
Professor of Clinical Medicine, David Geffen School of
Medicine at UCLA

2. What should be done for this patient?
54 yo male new dx HCV+; abnormal LFTs and chronic pruritis
PMH: Depression, viral pericarditis, GSW to thorax 1977
SHx: denies tobacco and ETOH, admits MJ; denies IDU
PE: Folliculitis 2 to pruritis, otherwise unremarkable
Lab: Hg 15.4 WBC 3.8 (47 P, 32 L, 12 M, 9 E), Platelets 105K,
ALT 59, AST 91, Alk P 55, bili 1.1, HCV Ab+, HCV VL 6,030,000

3. What should be done for this patient?
54 yo male new diagnosis HCV+; abnormal LFTs and chronic pruritis
PMH: Depression, viral pericarditis, GSW to thorax 1977
SHx: denies tobacco and ETOH, admits MJ; denies IDU
PE: Folliculitis 2 to pruritis, otherwise unremarkable
Lab: Hg 15.4 WBC 3.8 (47 P, 32 L, 12 M, 9 E), Platelets 105K
ALT 59, AST 91, Alk P 55, T bili 1.1, HCV Ab+, HCV VL 6,030,000
One month later: Admitted with 2 weeks  SOB, cough
ABG: pH 7.48, PCO2 28, pO2 58;
CXR: diffuse reticulonodular opacities
HIV+, CD4 74, VL 37,000. Bronchoscopy  PCP.
Despite Rx, died of progressive respiratory failure

5. Audit of 397 death in UK 2005:
Scenario leading to AIDS-related deaths
% of AIDS
deaths
Diagnosed too late for effective Rx 40%
Under care with untreatable complication 29%
Treatment ineffective due to poor adherence 12%
Chose not to receive treatment 8%
Known positive, not under regular care 6%
MDR HIV, ran out of options 5%
BHIVA Audit – Johnson et al 2006

6. Benefit of HIV Therapy vs Diagnostic Delay
 Antiretroviral therapy reduces HIV-related morbidity
and mortality, and reduces perinatal transmission,
but 21% of US HIV+ persons do not know their status
 50% of newly diagnosed patients have < 200 CD4 cells
• High risk of AIDS-related complications
• Many patients have multiple, missed opportunities for early
testing
MMWR: Vol 57(39), 2008. Campsmith ML et al. JAIDS. 2010; 5:619-624.

7. Epidemiology
 1.2 million HIV cases in US
• Heterosexual transmission increasing most rapidly
• Women and minorities are disproportionately affected
1000 HIV Cases per 100,000 People
800
600
Equal Case rate in
400 AI/NA & Caucasians
200
0
African Hispanic Multiple Native Caucasian Amer Indian Asian
American races Hawaiian Alaska Nat
2005 2006 2007 2008 2009
MMWR: Vol 57(39), 2008. Campsmith ML et al. JAIDS. 2010; 5:619-624. CDC HIV Surveillance Reports.

8. American Indian

9. CDC and ACP Guidelines for HIV Testing
 Early diagnosis of HIV reduces morbidity and mortality
 HIV screening should not be contingent on an assessment of
patients' behavioral risk
 Opt-out HIV screening recommended for all patients
• CDC recommends age range from 13 – 64; ACP has no upper bound
• Exception if HIV prevalence known to be < 0.1% of patients screened
 At least yearly testing for people at high risk for infection
MMWR. 2006; 55(RR-14). Qaseem A, et al. Ann Intern Med. 2009; 150:125-131.

10. Screening and Testing for HIV is Cost Effective
CDC recommends routine offer of HIV testing if prevalence
of undiagnosed infection is > 0.1%
140,000
Incremental Cost Effectiveness
120,000
100,000 QALY without consideration of HIV transmission
($/QALY)
80,000
60,000
40,000 Testing in VA is cost effective
even at very low HIV prevalence
20,000
QALY with consideration of HIV transmission
0 $50,000/QALY
0 0.1 0.2 0.4 0.6 0.8 1
Prevalence (%)
Sanders GD, et al. NEJM. 2005; 352:570.

11. Survival Gains of ART Compared With Other
Disease Interventions
200
Survival Gains (months)
180
160
140
120
100
80
60
40
20
0
Node + Node – 2 vessel 3 vessel BMT OI Proph ART
Chemo/breast CABG/PTCA Lymph- AIDS Care
cancer oma
Walensky R et al. JID 2006;194:11-19

12. Frequency and Delayed HIV Diagnosis
& Types of Missed Opportunites
HIV Diagnosis with < 200  Public facility: 1994 – 2001
CD4 Cells (%)
• 6 visits before HIV diagnosis
USA (1998)
• 40% of visits were to either the
USA (2003) ED or to an urgent care clinic
Italy (2004)  VA data: 1998 – 2002
Canada (2004)
• 6 visits before HIV diagnosis
Scotland (2004)
• Visits prior to diagnosis
USA (2004)
- Primary care clinic: 56%
UK & Ireland (2005)
- Subspecialty clinic: 50%
USA (VA) (2007)
- Psychiatry clinic 31%
0% 20% 40% 60% - Substance abuse clinic: 16%
Girardi DE et al. (J Acquir Immune Defic Syndr 2007; 46: S3–S8. Gandhi NR et al. Med Care. 2007; 45:1105-1109. Samet J et al. Arch
Intern Med. 1998; 158:734. Liddicoat R, et al. J Gen Intern Med. 2004; 19:349.

13. 2005: Status of HIV Testing in the VA
 No HIV testing in 50 – 70% of patients with known
risk factors
 50% of newly diagnosed patients had < 200 CD4 cells
How were these problems addressed?

14. Identified Impediments to HIV Testing
 Organizational barriers
• Written informed consent & pre-test counseling requirements
• Constraints on provider time
• Uncertain capacity to manage newly diagnosed patients
 Provider behaviors
• Lack of recognition of HIV risk factors
• Discomfort with HIV counseling and discussion of risky behaviors
• Lack of prioritization of HIV testing
 Patient behaviors
• Fear of stigma

15. Interventions
 Organizational changes
• Streamlined, scripted & nurse-based consent process; verbal consent
• Telephonic notification of negative test results
• Assure assistance in counseling & HIV clinic f/u for new HIV+ pts
 Provider behavior
• Education through academic detailing & social marketing
• Regular clinic level feedback regarding HIV testing rates
• Electronic clinical reminder to identify previously untested patients
 Patient fear of stigma
• Substitution of routine, non-risk based testing

16. How did the Electronic Medical Record
(EMR) help the HIV testing program?
 100% access to records
 Able to identify patients not previously tested and
avoid repeatedly offering tests the previously tested
 Able to identify patients at higher risk of disease
through lab results and ICD-9 codes
 Able to use data to create reports, provide feedback
 Decision support tools at point of care including
clinical reminders to providers

17. What does the VA Computerized
Patient Record System (CPRS) look
like?

18. Cover Sheet

19. Problem List

20. Medications

21. Laboratory Results

22. Reports tab
– imaging
report

23. Progress Note Tab

24. Using CPRS-Based Decision Support
(Clinical Reminders)
 Used for a wide variety of purposes in the VA
• Screening for depression, traumatic brain injury
• Screening for Tobacco & alcohol use
• Hypertension identification and management
• Diabetes monitoring
• Vaccination rates
• Etc.
 Contribute to attainment of performance standards
 HIV testing Clinical Reminder is among the simplest
and best accepted

25. Electronic prompt for identification and testing of patients at-risk for HIV infection

28. Implementation Plan
In-Person Launch Meeting
 Met with facility leadership, e.g., COS and leadership of
nursing, laboratory, ambulatory care and primary care
 Promoted program at primary care team meetings
• Consent process
• Emphasize that HIV testing is not a performance measure
• Tips for proposing HIV testing
 Provide educational materials
 Emphasized use of site-wide rather than provider-
specific feedback

29. Handout package
Pocket card
Overview Sheet Poster & Pamphlet

30. Tips for Proposing HIV Testing
 Would you like a free HIV test?
 As a veteran, you’re entitled to an HIV test.
 In addition to doing some tests to check for
cholesterol, diabetes, etc., we’re now offering HIV
testing. Would you like us to check for HIV
infection?

31.  Quarterly feedback
• HIV testing rate
• Rate of clinical
reminder resolution

32. VISN 22: Pre- vs Post Incident HIV Testing Rate
VA facilities in Southern California & Nevada
2 – 3 fold Increased Testing Rate, which is Sustainable
80%
HIV testing HIV evaluation without testing
Reminder Resolution (%)
70%
60%
50%
40%
30%
20%
10%
0%
-1 1 2 -1 1 2 -1 1 -1 1 2 -1 1
Intervention Year
Control
Site A Site B Site C Site D Site E

33. Post vs Pre Odds Ratio of HIV Testing
Analysis of Patient Level Factors
18 – 30 years
Age 31-50 years
51-64 years
> 64 years
Income Low
High
Caucasian
Ethnicity African American
Hispanic
Other
Missing
Marital status Single
Married
Other
Homeless No
Yes
HCV Risk Fx No
Yes
HCV Infection No
Yes
HBV Infection No
Yes
Prior STD No
Yes
No
Illicit Drug Use Yes
0 1 2 3 4
Goetz MB et al. J Gen Intern Med. 2008; 23:1200-1207. Post vs Pre Odds Ratio

34. Pre- vs Post-Intervention Risk-Based HIV Testing
VA facilities in North-East and South-Central US
35% Increase in Testing
30% 12% 78% 158%
HIV Testing Rate
25%
20%
15%
10%
5%
0%
1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3
Control Sites Local Implementation
Control Sites Local Central
National Implementation
No Implementation Implementation Implementation
Pre-Intervention Post-Intervention

35. 2009 Changes in VA HIV Testing Policy

36. VHA Directive – HIV Screening
 Current VHA policy: HIV testing is a part of routine
medical care
 Providers should routinely provide HIV testing to all
Veterans who give verbal consent
 Veterans who test positive for HIV infection are to be
referred for state-of-the-art HIV treatment as soon as
possible after diagnosis
VHA Directive 2009-036, August 17, 2009

37. 2009 Changes in VA HIV Testing Policy
 Organizational barriers
• Informed consent & pre-test counseling requirements
• Constraints on provider time
• Limited opportunity for timely, in-person post-test notification
• Uncertain capacity to manage newly diagnosed patients
 Provider behaviors
• Incomplete recognition of HIV risk factors
• Reliance on trained counselors to order HIV tests
• Discomfort with HIV counseling
• Lack of prioritization of HIV testing
Use of verbal consent and routine testing removes only two barriers

38. Pre- vs Post-Intervention Routine HIV Testing
Multi- VISN QI Project
30% Increase in Testing
25% 50% 390% 556%
HIV Testing Rate
20%
15%
10%
5%
0%
1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 8
HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
Control Sites Local Central
No Implementation HHH
Implementation Implementation
Pre-Intervention Post-Intervention

39. Veterans Ever Tested for HIV by Year
2009-2011
9.2% Ever Tested 13.5% Ever Tested n= 20% Ever Tested
n=524,267 795,126 n= 1,221,328
2009 2010 2011
Outpatient Visits n= Outpatient Visits n= Outpatient Visits n=
5,713,265 5,888,599 6,114,034
VETERANS HEALTH ADMINISTRATION

40. Changes in HIV Testing vs
Use of HIV Testing Clinical Reminder
Sites without Clinical Reminder Sites with Clinical Reminder
16
14
HIV Tests (thousands)
12
10
8
6
4
2
0
2009 2010

41. Percentage of HIV Positive Tests in
CY 2011, by VISN
% HIV Tests Performed in 2010 that were Positive
0.7%
Mean: 0.38% *CDC Threshold for routine HIV testing
0.6% Median: 0.35%
Range: 0.14-0.64%
0.5%
0.4%
0.3%
0.2%
0.1%
0.0%
*
19 23 11 2 17 6 21 18 12 10 20 1 4 15 3 9 7 8 5 16 22
VISN
VETERANS HEALTH ADMINISTRATION

42. Increased Testing Results in Earlier Diagnosis
VA Atlanta & VA Greater Los Angeles
CD4 Count < 200 Cells/µL Mean CD4 Cells/µL
60% 500
50% 400
40%
300
30%
200
20%
10% 100
0% 0
Los Angeles Atlanta
Los Angeles Atlanta
Goetz MB, Rimland D. J AIDS. 2011. 57:e23-e25.

43. Summary of Results
 Routine HIV testing is feasible in primary care clinics
 Routine testing increased by 390 – 556%
 Clinical reminders based technology to promote HIV
testing is widely effective and may not require a
specialized intervention
 Promotion of routine HIV testing in primary care clinics
supports the CDC goal that every American aged 13 –
64 know their HIV status

44. Summary of Justification for Promoting
HIV Testing in VHA
 HIV care is most effective with early diagnosis
 US HIV prevalence generally exceeds CDC testing
threshold
 HIV Testing is not cost-free but is an excellent use of
healthcare dollars
 ACP recommends offering HIV testing to all adults
 Effective interventions have been developed

45. HIV Consensus
 Early diagnosis and treatment improves outcomes
 Undiagnosed & infected persons cannot benefit from
HAART
 Early stage patients are asymptomatic
 Antiretroviral therapy decreases risk of disease
transmission
 Patients who know their status reduce their to others
 HIV Testing is cost-effective & allows patients to get
treatment

46. Acknowledgements
 VA HSR&D funding: QUERI cord funds, SDP 06-
001, SDP 08-002
 VA Office of Public Health: moral, financial and
logistical support
 Local leaders, clinical champions, primary care
providers, facility leadership in VISNs 1, 3, 16 and 22
 QUERI-HIV/HEP colleagues: Steve Asch, Allen
Gifford, Jane Burgess, Tuyen Hoang, Hersch
Knapp, Henry Anaya and many, many others