Streamlined HIV Screening in a Municipal STI Clinic

Kees Rietmeijer, MD, PhD

Denver Public Health Department

2006 National STD Prevention Conference

Jacksonville, Florida

Denver Metro Health Clinic• Largest STI clinic and HIV testing facility in

Rocky Mountain region• Provides:

– Comprehensive STI services– confidential HIV testing in the STI clinic– confidential and anonymous testing in the HIV

counseling and testing site integrated in the clinic

• Every year – 14,000 “new problem” visits – >10,000 HIV tests– >100 HIV diagnoses: 50% of new HIV infections in the

Denver Metro area; 30% in Colorado.

Background

• DMHC was prompted to review its HIV testing policies due to:– Shifting prevention paradigm heralded in

CDC’s Advancing HIV Prevention initiative

– Availability of HIV rapid test

– Only 66% of persons with a positive HIV test received results

• Rapid testing introduced in November, 2003

HIV Testing at Denver STI ClinicBefore November 2003

• General consent for all procedures and testing, except HIV testing, obtained at registration

• HIV testing offered by clinician during the clinic visit, based on risk assessment

• Blood drawn for syphilis and HIV (if accepted) testing during the clinic visit

• HIV test used: standard EIA

HIV Testing at Denver STI Clinic

• November 1, 2003:Rapid HIV testing (OraQuick) offered as optional alternative to standard EIA– After 6 weeks, >95% of clients in CTS

preferred the rapid HIV test

– Adoption in STD clinic significantly slower due to increased length of visit

• July 1, 2004: Standard testing discontinued

HIV Testing at Denver STI ClinicChange in Testing Logistics

• To avoid adding another 20 minutes to the visit, prior to clinic encounter:– Draw RPR blood before clinician sees patient

– Offer HIV testing routinely

– Obtain additional consent

– Use RPR blood draw to collect extra tube for rapid HIV test

• Implemented in May, 2004

Transfer to Electronic Medical Record System

Opt-Out Consent for HIV Testing

• Prompted by the change-over to the electronic medical record in March, 2005

Impacts of Rapid TestingDenver Metro Health Clinic

Percentage of patients who received their positive test results:

Before: After:

66% 100%

HIV Testing Acceptance

60

65

70

75

80

85

90

95

100

2002 2003 2004 2005 2006

%

Rapid test

Logistical Adjustments

Opt-out Consent

HIV Testing Acceptance

60

65

70

75

80

85

90

95

100

2002 2003 2004 2005 2006

MSMNon-MSM

%

HIV Positivity

00.5

11.5

22.5

33.5

44.5

5

MSM Non-MSM

20022003200420052006

%

• Data suggest that increased testing uptake may have resulted in:– Inclusion of lower-risk MSM– Inclusion of higher-risk non-MSM

• Denying risk behaviors (e.g. male same-sex encounters) at intake

• Separate analysis:– Comparing over time the proportion of newly-

diagnosed HIV infections who did not report high-risk behaviors at the time tested for HIV

New HIV Infections and Initial Versus Subsequent NIR Status

Year # HIV+ NIR

Initial Subsequent*

2003 39 3 (7.6%) 3 (7.6%)

2004 48 6 (12.5%) 5 (10.4%)

2005 55 11(20.0%) 6 (10.9%)

2006** 13 3 (23.1%) 2 (15.3%)

*After interview with DIS or PCM**Through March 16, 2006

Opt-Out Analysis

• During the first 3 months of 2006– 800/4,000 (20%) opted out

• Of those opting out:– 18% were HIV tested after further counseling– 39% were recently tested– 10% were follow-up visits– 3% were known to be HIV+– 30% were not tested for unknown reasons

Opt-Out Analysis

• Those opting out for unknown reasons:– 50% were low-risk MSW

– 9% were low-risk women

– 13% were MSM• Not known to the clinic to be HIV+

– 2% left before being seen/tested

Conclusions

• Enhancing HIV testing uptake at DMHC appeared to be principally a matter of logistics and convenience:– Rapid HIV Testing– Change in clinic logistics to avoid lengthier

visits– Offer HIV testing on a routine basis rather than

as part of risk assessment– Switch to opt-out consenting

Acknowledgements

• Christie Mettenbrink

• Brandy Mitchell

• Dean McEwen