for Health Care Providers
HIV Testing Rates in VHA 2009
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.
Notes to the Slides
Slide 1: HIV Testing Rates in VHA 2009
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 2: Background
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. Rates of transmission of HIV are higher among people who do not know that they are infected.
Slide 3: Background
Antiretroviral therapy decreases HIV-related morbidity and mortality and reduces the chance of perinatal transmission, but persons unaware of their infection are unable to benefit from such care. HIV testing is often not done until late in the disease process. In its 2007 HIV/AIDS Surveillance report the CDC cited the fact that 36% of people testing positive for HIV were diagnosed with AIDS within one year of that diagnosis. In addition to identifying infection earlier, routine testing for HIV can help to reduce stigma associated with HIV infection
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: American College of Physicians
The American College of Physicians issued guidance in the 2009 Annals of Internal Medicine (volume 150, pages 125 to 131) making the following points about testing for HIV:
- HIV screening should not be contingent upon an assessment of patients' behavioral risk
- More patients accept HIV testing when it is offered routinely, without a risk assessment
- Early diagnosis of HIV has been shown to reduce morbidity and mortality
- Patients aware of their HIV infection substantially reduce behaviors that put them at risk of transmitting HIV
- HIV screening is cost-effective even in health-care setting with low HIV prevalence
Slide 6: VHA Informed Consent Handbook 1004.01: August 17, 2009
According to the VHA Informed Consent handbook, Section 1004.01 dated August 17, 2009, written informed consent and prescribed pre- and post-test counseling are no longer required for HIV testing in VA. Verbal consent must be obtained and documented in the medical record, and written educational materials about HIV testing must be provided to patients.
Slide 7: VHA Directive - HIV Screening
VHA Directive 2009-036, dated August 17, 2009, establishes policy on HIV testing in VHA. Current VHA policy includes the following principles and practices:
- HIV testing is a part of routine medical care.
- Providers routinely provide HIV testing to all Veterans who give verbal consent.
- Veterans who test positive for HIV infection are referred for state-of-the-art HIV treatment as soon as possible after diagnosis.
Slide 8: HIV Care in VHA
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 2008, VHA clinicians saw 23,463 HIV+ Veterans. All VISNs provide care to Veterans with HIV.
Slide 9: Percentage of persons 18-64 who reported ever being tested for HIV and those who were tested in preceding 12 months
Percentage of persons 18-64 who reported ever being tested for HIV and those who were tested in preceding 12 months. National Health Interview Survey data from 1987 through 2007 reveal that less than 10% of people were tested for HIV in the previous twelve months and about 40% were ever tested for HIV.
So who gets tested in VHA?
Slide 11: HIV Testing in VHA - 2009
The Public Health Strategic Healthcare Group collected data on HIV testing during calendar year 2009 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 2009. For HIV tests done in 2009 the rate of positive results was also determined.
Slide 12: VHA CY 2009 HIV Testing n= 5,713,265 Veterans w/ OP visit
This figure shows that of 5,713,265 outpatients seen in VHA during 2009, 524,735 or 9.2% ever had HIV testing and 141,337 or 2.5% had HIV testing during calendar year 2009.
Slide 13: Percent Veterans in Care in 2009 Ever Tested For HIV, by VISN
This figure shows a US map, which is color coded to show, the percent of veterans with outpatient visits in 2009 who ever had HIV testing in each VISN (Veteran Integrated Service Network). Rates were highest in VISN 22 and ranged from 5.6% to 20%, with a median of 8.3%.
Slide 14: Percentage of Veterans in Care in CY 2009 EVER tested for HIV, by VISN
This bar graph displays the percentage of Veterans in care during 2009 in each VISN who ever had an HIV test. The range across VISNs was 5.6% to 20%, with a mean of 9.2% and a median of 8.4%.
Slide 15: Percent Veterans in Care in 2009 Tested For HIV in 2009, by VISN
This US map is color coded to show the percent of veterans with outpatient visits in 2009 who had HIV testing in 2009 in each VISN (Veteran Integrated Service Network). Rates were highest in VISN 22 and ranged from 0.3% - 5.7% with a median of 2.0%.
Slide 16: Percentage of Veterans in care in CY 2009 with an HIV Test in 2009, by VISN
This bar graph displays the percentage of Veterans in care during 2009 in each VISN who had an HIV test during 2009. The range across VISNs was 1.4% to 5.7%, with a mean of 2.5% and a median of 2.0%.
Slide 17: Percent Veterans in Care in 2009 With Positive HIV Test in 2009, by VISN
This US map is color coded to show the percent of Veteran outpatients tested in each VISN during 2009 who had a positive HIV result. Rates of positivity, by VISN, ranged from 0.4% to 1.9% with a median of 1.1%.
Slide 18: Percentage of HIV Positive Tests in CY 2009, by VISN
This figure displays the percentage in each VISN of Veterans with a positive result on an HIV test performed in 2009. The range across VISNs was 0.4% to 2.3%, with a mean of 1.2% and a median of 1.1%. All VISNs reported rates of positive HIV tests above CDC's threshold for routine HIV screening, which is 0.1%.
Slide 19: Screening for HIV Infection
If the yield is less than 1 per 1,000 continued routine HIV screening is not warranted. But to ensure a 95% confidence interval that prevalence is less than 0.1% at least 4,000 patients need to have been screened with no confirmed positives. As of 1/1/2010, no VHA facilities meet this criterion to discontinue routine HIV testing.
Slide 20: Percent HIV Positive on 2009 Tests, by facility
This figure displays rates of positivity on HIV tests performed in 2009 for all reporting facilities. 114 or 88% reported rates above the CDC suggested threshold for routine HIV testing of 0.1%. In the 15 facilities with 2009 positivity rates below this threshold, none had tested more than 500 patients.
Slide 21: Online Resources for Providers and Patients
VHA provides online access to extensive HIV related information and resources for both providers and patients on the VA HIV portal at www.hiv.va.gov.