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Slideset: HIV Testing Rates in VHA 2009-2010

for Health Care Providers

HIV Testing Rates in VHA CY 2010

This slideset reviews the current scientific and policy issues related to HIV testing and presents data on rates of testing for HIV across the VA in 2009-2010.

HIV Testing Rates in VHA CY 2010

Notes to the Slides

Slide 1: HIV Testing Rates in VA 2009-2010

Title Slide

Slide 2: Background

This slide presentation reviews the current scientific and policy issues related to testing for infection with Human Immunodeficiency Virus (HIV) and presents data on rates of testing for HIV across the VA in 2009.

Slide 3: HIV in the United States

According to the Centers for Disease Control, HIV / AIDS remains a major public health concern in the United States. More than 1.1 million people in the U.S. are living with HIV, and 21% of them are unaware that they are infected. Every year there are 50,000 to 60,000 new HIV diagnoses in the United States. Rates of transmission of HIV are higher among people who do not know that they are infected.

Slide 4: Estimated Numbers of AIDS Cases, Deaths, and Persons Living with AIDS, 1985-2007--United States and Dependent Areas

This graph depicts changes in HIV epidemiology over time. The number of deaths has decreased dramatically since the introduction of potent combination antiretroviral therapy in the mid-1990's. New diagnoses of AIDS have decreased but because people with AIDS are living longer, the prevalence continues to increase.

Slide 5: HIV in VA

VHA is the largest single provider of HIV care in the United States. As of 2008 almost 64,000 veterans have received HIV care through VHA.

In 2010, VHA clinicians saw 24,296 HIV+ Veterans.

All VISNs provide care to Veterans with HIV.

However, as of 2009, only 9.2% of Veterans in VA care had ever been tested for HIV.

Slide 6: Rationale for Routine HIV Testing

The rationale for HIV testing includes the fact that early treatment improves health outcomes as well as the demonstrated cost effectiveness of HIV testing even in health care settings with relatively low prevalence. In addition, testing can help prevent new HIV infections as patients who are aware of their status have been shown to reduce behaviors associated with transmission.

Slide 7: Justification for Routine HIV Testing in VA

Justification for routine HIV testing in VA includes the fact that within VA, the most recent (as of 12/31/2010) observed rate of HIV seropositivity in all VISNs exceeds the CDC threshold for routine testing. Also, Veterans are more likely to accept HIV testing when it is presented in the context of routine care, and routinizing HIV testing may lessen associated stigma.

Slide 8: VA HIV Testing Policy Changes August 17, 2009

In August 2009 VA policy changed to make HIV testing routine, rather than risk-based, and to remove the previous requirement for written informed consent and prescribed pre- and post- test counseling for HIV testing. Current policy requires that verbal consent be documented and written information be provided to patients. Given the time required for development and implementation of local policy and procedures aligned with this change, many VA facilities did not have updated processes until after January 2010.

Slide 9: VA HIV Testing Rates: Collection Methods

The Public Health Strategic Healthcare Group collected data on HIV testing during 2009 and 2010 from all VHA facilities. Facilities used a standardized data extract routine to assess the number of Veterans with an inpatient or outpatient visit who had ever had HIV testing and who had HIV testing in the report year. For HIV tests done in the year the rate of positive results was also determined. The vast majority of Veterans with inpatient utilization in a calendar year also have outpatient utilization in the same year, so the following assessment of HIV testing focuses on outpatients.

Slide 10: VA Outpatients Ever tested for HIV 2009-2010

This figure shows the 2009 and 2010 percentage of VA outpatients ever tested for HIV. In 2009 of 5,713,265 outpatients 524,267 or 9.2% ever had HIV testing. In 2010 the percentage increased to 13.5%, or 795,126 of 5,888,599 outpatients.

Slide 11: Increases in HIV Testing 2009-2010

This slide shows that from 2009 to 2010 the number of outpatients who had HIV testing performed in the VA during the year increased 140%, from 142,345 to 341,414. It also depicts a 52% increase in the number of outpatients who ever had HIV testing done, from 524,735 in 2009 to 795,126 in 2010.

Slide 12: Number of Outpatients Tested for HIV per 1,000 Outpatients in VA 2009-2010

This slide shows the number of HIV tests performed per 1,000 outpatients in 2009 and 2010. In 2009, the number of tests performed per 1,000 outpatients increased from 25 to 58 between 2009 and 2010 , a 132% increase.

Slide 13: Percent Outpatients EVER Tested for HIV, by VISN (Map)

This figure shows two US maps color coded to depict the increase from 2009 to 2010 in the percent of outpatients in each VISN (Veteran Integrated Service Network) who ever had HIV testing. Increased shading indicates an increase in percentage of outpatients tested. Every VISN had increased rates.

Slide 14: Percentage of Outpatients EVER Tested for HIV, by VISN 2009 vs. 2010

This graph shows the percent of outpatients ever tested for HIV in each VISN for 2009 and 2010. This percentage increased in all VISNs from 2009 to 2010 with VISNs 17 and 19 showing the greatest increase.

Slide 15: Percent Increase in Outpatients Ever Tested for HIV 2009-2010, by VISN

This graph shows the percent increase in the number of outpatients ever tested for HIV in each VISN from 2009 to 2010. The mean percent increase was 63%, with a median of 52% and a range of 11-256%. Rates increased in all VISNs, with the greatest rates of increase in VISNS 17 (256%), 19 (139%), and 23 (127%).

Slide 16: Percent Outpatients Tested for HIV in Calendar Year by VISN

This figure shows two US maps color coded to depict the increase from 2009 to 2010 in the percent of outpatients in each VISN (Veteran Integrated Service Network) who had HIV testing during the year. Increased shading indicates an increase in percentage of outpatients tested. Every VISN had increased rates.

Slide 17: Percent of Outpatients Tested for HIV in the CY, by VISN 2009 vs 2010

This graph shows the percent of outpatients with an HIV test in the calendar year for 2009 and 2010. Every VISN saw an increase in testing.

Slide 18: Percent Increases in Outpatients Tested for HIV in CY 2009-2010, by VISN

This graph shows the percent increase from 2009 to 2010 for the number of outpatients tested in the calendar year. The mean percent increase among VISNs was 174% with a median of 137% and a range of 25-538%. Highest rates of increase were in VISN 17 (538%), VISN 19 (513%) and VISN 23 (483%) .

Slide 19: Percent Outpatients with HIV Positive Test in CY 2010, by VISN

This US map is color coded to show the percent of outpatients tested in each VISN during 2010 who had a positive HIV result. Rates of positivity by VISN ranged from 0.4% to 1.9% with a median of 1.1%. This geographic distribution is similar to non-VA national data, with higher concentrations in the Southeastern and Gulf coast areas.

Slide 20: Percentage of HIV Positive Tests in CY 2010, by VISN

This figure displays the percentage in each VISN of outpatients with a positive result on an HIV test performed at the VA during 2010. The range across VISNs was 0.14% to 1.58%, with a mean of .65% and a median of 0.58%. All VISNs reported rates of positive HIV tests above CDC's threshold for routine HIV screening, which is 0.1%.

Slide 21: Percentage of HIV Positive Tests in CY 2010, by Facility

This slide displays the rate of positivity on 2010 HIV tests at the facility level. Of the ten facilities that reported rates below the CDC 0.1% threshold for routine testing, two had performed a sufficient number of tests (>4,000) to establish that the positivity rate was less than 0.1% at the 95% confidence level.

Slide 22: HIV Positives Identified vs. Number of Tests Performed at Facilities

This slide displays the rate of positivity on 2010 HIV tests at the facility level. Of the ten facilities that reported rates below the CDC 0.1% threshold for routine testing, two had performed a sufficient number of tests (>4,000) to establish that the positivity rate was less than 0.1% at the 95% confidence level.

Slide 23: Data Summary 2009-2010

This table shows that from 2009 to 2010 rates of HIV testing have increased across the VA. Rates of observed seropositivity decreased in 2010, as would be expected with a shift from risk-based to routine testing. However, the overall seropositivity rate for VA remains above the 0.1% threshold. Work remains to be done in order to achieve the goal of every Veteran being tested at least once. Despite a 140% increase in testing since VA's HIV testing policy change, only 13.5% of VA outpatients had ever been tested as of 2010.

Slide 24: VA Initiatives to Improve HIV Testing Rates 2009-2010

VA has employed multiple strategies to increase HIV testing, including changes in policy to shift from risk-based to routine testing, to allow verbal consent rather than require written consent, development of a model clinical reminder to prompt routine HIV testing, provision of grant funding for laboratory and clinical practice initiatives and a social marketing campaign targeting both providers and patients.

Slide 25: VHA HIV Testing Policy Change

While national policy related to HIV testing changed in August 2009 additional time was required to allow for the process of changing official policy processed at the local level. By January 2010, 46 VA medical centers (VAMC) had completed the process of changing local policy. Local policy change alone was not associated with increases in HIV testing rates, though such policy change is required in order to implement effective operational changes such as clinical reminders.

Slide 26: Routine HIV Test Clinical Reminder: Impact on Percentage of Outpatients tested in CY

This slide shows that at VA facilities using a clinical reminder to prompt routine HIV testing for at least one quarter in 2010, increases in HIV testing rates were greater than at locations where such a clinical reminder was not used.

Slide 27: 2010 Laboratory Grant Recipients: Impact on Outpatients tested for HIV in CY

The graph shows the increase in percent of outpatients with an HIV test in the CY among facilities that received grant funding to support laboratories. Increases were seen at all these facilities, with a mean increase of 315% and a range of 5% to 1,170%.

Slide 28: 2010 Clinical Grant Recipients: Impact on Outpatients tested for HIV in CY

The graph shows the increase in percent of outpatients with an HIV test in the CY among facilities that received clinical grant funding to increase HIV testing. Increases were seen at all these facilities, with a mean increase of 314% and a range of 15% to 1,768%.

Slide 29: Social Marketing Campaign

PHSHG has employed multiple strategies to support increased HIV testing, including VA's first HIV Testing Week campaign in mid-2010 and activities around World AIDS Day in December, 2010. Supporting materials were produced for use by the field and will be expanded and enhanced when a new Social Marketing campaign employing multiple strategies to increase HIV testing is started, with a scheduled launch date of World AIDS Day 2011.

Slide 30: Conclusions

PHSHG has employed multiple strategies to support increased HIV testing, including VA's first HIV Testing Week campaign in mid-2010 and activities around World AIDS Day in December, 2010. Supporting materials were produced for use by the field and will be expanded and enhanced when a new Social Marketing campaign employing multiple strategies to increase HIV testing is started, with a scheduled launch date of World AIDS Day 2011.

Slide 31: Summary

In Summary:

VA is the largest provider of HIV care in the US.

Routine HIV testing warranted in VA.

HIV testing is now much simpler.

Many Veterans in VA care have still not been tested for HIV.

Progress made in all VISNs; continued progress will require local champions, leadership support, and use of tools such as clinical reminders

Slide 32: Public Health Strategic Health Care Group

VHA provides online access to extensive HIV related information and resources for both providers and patients on the VA HIV portal at http://www.hiv.va.gov