Engaging Health Care Providers in
Various Settings in Routine Offer of
HIV Testing
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Engaging Health Care Providers in Various Settings
• Has been one of our greatest challenges … with the greatest reward
• Previously HIV tests were offered to individuals “at risk” for HIV
• Now HIV tests are offered to everyone at all health care encounters
Rationale
• We do not know who is at risk
• There is stigma in recommending a test to only at risk groups
• A routine offer of an HIV test reduces stigma, is well accepted and
results in increased, earlier diagnoses
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Engaging Health Care Providers in Various Settings
So how do we make this happen? Recognize that changing practice is
one of the hardest things you will do and requires that you:
Establish a visible, committed leadership
Communicate vision and rationale over and over
Identify and engage champions
Understand current processes and workflows
Build on existing processes
Educate and support – shoulder to shoulder support
Provide tools to support practice change
Anticipate arguments and have answers
Collect and share data regularly
Reinforce good practice and celebrate successes
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HIV Testing: CHANGING HIVSTORY
Rationale and Evidence
for Routine Testing
Dr. Réka Gustafson
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Clinical Rationale for
Early Diagnosis and
Treatment
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Estimates of Benefits of Early
Treatment
Life expectancy as a function of disease stage
at start of treatment:
Disease stage at start of
Treatment
Can expect to live to
(years)
CD4 < 100 57.9
CD4 100 - 199 61.0
CD4 200 - 350 73.4
Modified from May M et al. BMJ 2011;343:d6016 6
Life expectancy from age 20-65 by CD4 count at start of
antiretroviral therapy compared with UK population
May M et al. BMJ 2011;343:d6016 ©©2011 by British Medical Journal Publishing Group
2000-2006
2000-2008
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Public Health Rationale
for Early Diagnosis and
Treatment
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Evidence: HIV Prevention
Trials Network 052 Study 1,763 serodiscordant couples
HIV positive partner with CD4 350-550 97% heterosexual
N=886 Immediate ART
1 linked transmission
N=877 Delayed ART
CD4 of 250
27 linked transmissions
Cohen MS, et al. HPTN052 Study Team Prevention of HIV-1 Infection with
Early Antiretroviral Therapy. N Engl J Med 2011 Aug 11; 365(6):493-505
p < 0.001
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CD4 350-500
CD4 200-349
CD4 < 200
CD4 > 500
December
Early diagnosis is the goal
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Multiple missed opportunities for
earlier diagnosis Percent & proportion of new HIV diagnoses with ≥
1 prior Outpatient, Lab, ER or Inpatient encounter,
by CD4 count
•Only 57.5% (291/506) of new HIV Dx had a CD4 count on
* Only 57.5% (291/506) of new HIV Dx had a CD4 count on
record at time of Dx
CD4 Count* ≥ 1 prior encounter
< 200 58% (30/52)
< 350 60% (64/107)
< 500 55% (97/177)
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Cost effective Conservative threshold for cost
effectiveness is estimated to be
1/1000 new diagnoses*
or 2/1000 diagnosed prevalence
Paltiel AD, et al. Expanded screening for HIV in the United States - an analysis of
cost-effectiveness. N Engl J Med 2005; 352(6):586-595.
Paltiel AD, et al. Expanded HIV screening in the United States: effect on clinical
outcomes, HIV transmission, and costs. Ann Intern Med 2006; 145: 797–806.
Sanders GD, Bayoumi AM, Sundaram V, Bilir SP, Neukermans CP, Rydzak CE et
al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral
therapy. N Engl J Med 2005; 352(6):570- 585.
*Walensky RP, et al. Routine human immunodeficiency virus testing: an economic
evaluation of current guidelines. Am J Med 2005; 118(3):292-300.
Yazdanpanah Y et al. Routine HIV Screening in France: Clinical Impact and Cost-
Effectiveness. PLoS One. 2010;5(10):e13132.
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Guidelines US:
• Centers for Disease Control and Prevention. Revised
Recommendations for HIV Testing of Adults,
Adolescents, and Pregnant Women in Health-Care
Settings. MMWR 2006;55(No. RR-14).
UK:
• UK national guidelines for HIV testing 2008. London
(UK): British HIV Association, British Association for
Sexual Health and HIV, British Infection Society; 2008.
EU:
• Poljak M, Smit E, Ross J. 2008 European Guideline on
HIV testing. Int J STD AIDS February 2009; 20:77-83;
doi:10.1258/ijsa.2008.008438
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Summary
• Early diagnosis prolongs life and prevents transmission
• Late diagnosis remains common
• Those infected with HIV are being seen in health care,
but not being tested
• Routine HIV testing of all patients is cost effective at
quite low diagnostic yields
• Countries with similar prevalence and health care
systems are incorporating HIV testing as part of routine
care for all patient
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New HIV Testing
Recommendations BCMJ, 2011, 53:49
Offer an HIV test to all adults in your practice who have not had one in the past year
in acute and community care as part of blood work for any other reason every time you test for STIs, HCV,
tuberculosis
Vancouver Coastal Health Public Health
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New HIV Testing
Recommendations BCMJ, 2011, 53:49
If aware of a specific risk, recommend an HIV test now, and more often
clinical symptoms every time you diagnose another STI every 3-6 months if you are aware of
ongoing high risk
Vancouver Coastal Health Public Health
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What routine testing is not
• Not annual testing
• Not routine testing of those at risk
• Not an abandonment of case finding
based on risk
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HIV Testing:
CHANGING HIVSTORY
Routine HIV Testing in Acute Care
Afshan Nathoo
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Why - Engage Health Care
Providers? • Late diagnosis and missed opportunities for early diagnosis
• The epidemic has changed, but our testing paradigm has remained
the same
• There is an identified gap and opportunity to improve the quality of
life for individuals and reduce HIV incidence
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Who - Are the Health Care
Providers to Engage
• Those who have been doing HIV testing for many years
• Those who provide care to recognized high risk populations
• Those who provide care in general medical settings
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How – Engaging Health Care
Providers
Establish a visible committed leadership:
• Chief MHO/VP Public Health
• SET, MAC, VP Medicine
• Operations Directors
• Department Heads
• Chief Residents
• Share both leadership and the journey with these individuals
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How – Engaging Health Care
Providers
Education
• Broad and sustainable strategy for all providers (MDs, RNs, UCs)
• Work within existing education & communication networks
• Tailor educational content to your audience (impact on work)
• Maintain the momentum
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What We Learned
Operations:
• Develop a ‘task group’ that directs implementation and evaluation,
and provides support for best practices
• Embed testing into existing workflow
• Address all concerns and don’t underestimate the magnitude of the
practice change
• Ensure a delegate follow-up pathway has been established and
communicated
• Multiple-level engagement
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What We Learned
Overall:
• Most effective strategy to increase testing is to collect, analyze and
present testing data and case based data to leadership and
physicians
• Health care providers really know their area. Listen and learn.
• The verbal offer of an HIV test is a significant barrier, however, the
acceptance rate is exceedingly high – present this and continuously
work to incorporate the offer rate into practice
• Introduce testing into departments/units where entry pathways are
simple and the process for ordering bloodwork is streamlined
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Conclusions
• In Vancouver, routine testing in acute care is acceptable to patients
and providers
• Routine testing is cost-effective
• Diagnosed individuals from late stage disease to acute infection
(expanding access to those that don’t access testing and those do
access testing)
• Implementing routine HIV testing into acute care can provide the
‘pulse’ of HIV in your community
• It will require commitment from leadership and an investment in HR
• Is effective in changing the understanding of HIV, HIV testing and
treatment among HCPs, patients and the general public
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Targeted Testing
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Be Flexible
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Build Excitement/Sense of Urgency
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Use a Real Life Story
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Explain Why Data Collection is Important
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Ask Teams for their Contribution
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Presentation by
Dr. David Hall
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BC-CfE Clinical Education Program
Dr. Silvia Guillemi
Director of Clinical Education, BC Centre for Excellence in HIV/AIDS
Clinical Associate Professor, UBC Family Practice
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BC CfE Clinical Education Model
Educational Events
Training Programs
Ongoing Support for Health
Care Providers
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BC-CfE Educational Events
• Semi-annual HIV Update (June & December)*
• Bi-weekly AIDS Care Rounds*
• IDC Journal Club Reviewed articles and summaries available at the BC-CfE website
• Forefront Lectures
*Approved by the College of Family Physicians of Canada for CME credits, and archived on the BC-CfE website
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• Online Course in HIV Diagnosis and Management
• REACH phone line to provide support for HIV treating clinicians (Vancouver: 604-681-5748; outside Vancouver 1-800-665-7677)
• BC-CfE Clinical Guidelines: HIV Primary Care
Therapeutic Guidelines for Adult and Pediatric Patients
Opportunistic Infections
Accidental Exposure
BC-CfE HIV Clinical Resources for Health Care Providers
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Online Course HIV Diagnosis and Management
• 10 learning modules
• Topics related to HIV diagnosis; BC’s HIV epidemic; initial clinical assessment of patients; treatments and side effects; opportunistic infections; hepatitis co-infections, etc.
• Self-evaluation with quizzes
• CME credits from the College of Family Physicians
• Registration on the BC-CfE website
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• VCH Intensive Preceptorship for family physicians and NPs
• Preceptorship program for NPs
• UBC Enhanced Skills program for family physicians
• Interdisciplinary UBC Course — IHHS 402
• Elective rotations for UBC family practice, community
medicine and other residency programs fellow
BC-CfE Clinical Training Program
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BC-CfE Clinical Training Program
Clinical Sites
Immunodeficiency clinic (IDC)
• Primary care site
• HIV and other specialist clinic
AIDS ward
External sites
• Oak Tree Clinic
• Downtown Eastside Clinics
• Others
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Primary Care Providers Trained in Last 8 Years: 61 (2004 - Jan 2013)
Family Physicians Total: 46
• UBC Enhanced Skills Program
(1-3 months of training) : 15
• Community physicians sponsored by Health Authorities (1-8 weeks average) : 11
• VCH Intensive Preceptorship Program: 20
Nurse Practitioners Total: 15
• Community NPs sponsored by
Health Authorities: 9
• VCH Intensive Preceptorship Program: 6
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VCH Intensive HIV Preceptorship for FPs and NPs - Program Structure -
MODULE 3: CLINICAL MENTORSHIP
One-to-one support for 3 to 6 months after completion of clinical rotations
MODULE 2: ONE WEEK ON-SITE CLINICAL PRECEPTORSHIP
To achieve clinical competency in primary care management of
HIV-positive patients
MODULE 1: ONLINE COURSE IN HIV DIAGNOSIS AND MANAGEMENT
The foundations of HIV/AIDS
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VCH Intensive Preceptorship Outcome
• 26 family physicians and NPs were trained from September 2011 to September 2012
• Out of the 21 survey responses received, 11 (52.4%) were highly satisfied, and 10 (47.6%) trainees were very satisfied or satisfied with the program
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VCH Intensive Preceptorship Outcome
• Data from BC-CfE DTP was reviewed in January 2013 to assess changes in antiretroviral (ARV) prescribing patterns in the 26 trainees.
• Only one trainee had prescribed ARVs to 2 patients before participating in the preceptorship.
• After the preceptorship 12 FPs initiated 45 patients on ARTs and 13 (3 NPs and 10 FPs) had refilled 162 ART prescriptions.
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Future Clinical Education and Support Initiatives
• Webinar sessions for health care providers and community workers in remote and/or underserved areas
• On-line/ telemedicine consultations with the BC-CfE HIV experts for community family physicians.
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• BC-CfE website: www.cfenet.ubc.ca
• Training program information: e-mail
• REACH line: 604-681-5748 and 1-800-665-7677
• Dr. Silvia Guillemi: [email protected]
Contact Information
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Thank you
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MOBILE PRIMARY CARE GUIDELINES
Marianne Harris, MD, CCFP
AIDS Research Program, St. Paul’s Hospital
Dept. of Family Practice, Faculty of Medicine, UBC
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Objectives
• To support the expansion of HIV care and treatment throughout the province
• To provide consensus guidelines for the management of HIV-infected individuals in the primary care setting
• To provide this information in a concise, accessible, and user-friendly format
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Primary Care Guidelines for the Management of HIV/AIDS in B.C.: Expert Panel
• Rolando Barrios, MD
• Linda Akagi, BSc Pharm
• Silvia Guillemi, MD
• Marianne Harris, MD
• Paul Kerston, Positive Living Society of BC
• Martin Payne, NP (F), MScN, Dr. Peter AIDS Foundation
• Peter Phillips, MD
• Neora Pick, MD, Oak Tree Clinic
• Aida Sadr, MD, Vancouver Native Health Clinic
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Primary Care Guidelines for the Management of HIV/AIDS in B.C.: History
• March 2011: original pdf version completed
http://cfenet.ubc.ca/therapeutic-guidelines/primary-care
• November 2012: Updated and converted to
mobile-accessible format
• Launched November 23, 2012
http://www.cfenet.ubc.ca/guidelines/
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Supported devices
Mobile devices
• iPhone and iPad
• Android 2.1+
• Windows Phone 7
• Blackberry 5+
• Blackberry Playbook
Desktop web browsers
• Firefox 4+
• Safari 4+
• Google Chrome 11+
• Internet Explorer 7+
• Opera 10+
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Topics
• Assessment of the HIV+ individual
History, physical exam, HIV-specific testing
Screening for infectious and non-infectious comorbidities
• Management of the HIV+ individual
Immunizations
Monitoring
Prophylaxis for opportunistic infections
Lifestyle and psychosocial issues
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Topics
• Optimizing adherence to ARV therapy
• Acute HIV Infection
• Special issues in women with HIV
• Special issues in addictions
• HIV Patient Care Flow Sheets
• Contact List for referrals and information
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Future Plans
• Increase awareness and improve accessibility of
guidelines e.g. by links on other websites
– Clinical Practice Guidelines and Protocols in BC
(www.bcguidelines.ca)- BC Ministry of Health
• Update and convert other CfE guidelines
– Accidental Exposure Guidelines
– Therapeutic Guidelines for ARV Treatment of Adult
HIV Infection
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Thank you
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