Opt Out HIV Testing Dr Brudney

50 %
50 %
Information about Opt Out HIV Testing Dr Brudney
Entertainment

Published on January 12, 2008

Author: Saverio

Source: authorstream.com

Opt-Out Routine HIV Testing :  Opt-Out Routine HIV Testing Karen Brudney, MD Director, Presbyterian Hospital Infectious Disease/AIDS Clinic Columbia University MMWR SEPTEMBER 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings :  MMWR SEPTEMBER 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings Slide3:  HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Persons at high risk for HIV infection should be screened for HIV at least annually. Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. For pregnant women HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women. Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women CONDITIONS APPROPRIATE FOR A SCREENING TEST: :  CONDITIONS APPROPRIATE FOR A SCREENING TEST: SERIOUS HEALTH DISORDER THAT CAN BE DXED BEFORE SYMPTOMS INFECTED PTS GAIN YEARS OF LIFE IF TREATMENT STARTED BEFORE SX TEST IS EASY, RELIABLE NON-INVASIVE COSTS OF SCREENING REASONABLE IN RELATION TO LIVES SAVED OPT OUT DOES NOT MEAN::  OPT OUT DOES NOT MEAN: Mandatory HIV testing Mandatory HIV treatment Dissemination of confidential information Reducing services for people living with HIV/AIDS HIV IS A TREATABLE CHRONIC ILLNESS:  HIV IS A TREATABLE CHRONIC ILLNESS HIV TESTING:  HIV TESTING IN THE BEGINNING…. THERE WAS NO AIDS :  THERE WAS NO AIDS FIRST PUBLISHED DESCRIPTION: MMWR 6/81 FIRST PEER-REVIEWED JOURNAL: NEJM 12/81 HOW WAS AIDS RECOGNIZED IN NYC?:  HOW WAS AIDS RECOGNIZED IN NYC? Individual cases presented in Fall 1980 Intercity ID rounds: PCP in gay men: NYH, Harlem, St.Lukes etc. EARLY REACTIONS:  EARLY REACTIONS JUST A FLUKE—LYME, LEGIONNAIRES, TOXIC SHOCK= SERIOUS ILLNESSES JUST ANOTHER GAY THING LIKE ‘GAY BOWEL’ IS IT REALLY NEW? IF SO, GRID: GAY RELATED IMMUNODEFICIENCY ETIOLOGY: NITRITES (POPPERS), SPERM ANTIBODIES, CMV??? CDC KS/OI TASK FORCE ESTABLISHED & CASE DEFINITION: CONDITIONS INDICATIVE OF UNDERLYING CELLULAR IMMNODEFICIENCY MMWR 9/24/82 EMERGING EPIDEMIOLOGY: THIS IS A BLOOD BORNE &/OR SEXUALLY SPREAD AGENT:  EMERGING EPIDEMIOLOGY: THIS IS A BLOOD BORNE &/OR SEXUALLY SPREAD AGENT MMWR 12/10/82 MMWR 9/24/82 1979-81: the epidemic takes off:  1979-81: the epidemic takes off SOME MISSTEPS, DENIAL, SELF-DELUSIONS:  SOME MISSTEPS, DENIAL, SELF-DELUSIONS Heated resistance by some activists to the idea that gay men should refrain from blood donation (‘the gas chambers are next’). Blood banks denial of the obvious risks; rejection of directed donation. Hospitals slow to respond to safety issues. Health care workers delusion of safety (‘if it’s really contagious we’d all be dead by now’). HIV EPI: GOOD NEWS, BAD NEWS:  HIV EPI: GOOD NEWS, BAD NEWS REPORTING:  REPORTING ALL COMMUNICABLE DISEASE REPORTING IS LOCAL: ALL COUNTIES REPORT TO STATE DOH SYPHILIS REPORTING MANDATED IN US 1938 DATA SENT FROM STATES TO FEDERAL GOVERNEMENT=CDC MMWR PUBLISHES COUNTS WEEKLY AIDS AND NOT HIV INITIALLY MANDATORILY REPORTED TO CDC HIV DATA WEAK BECAUSE OF HIV NOT REPORTED IN EARLY YRS & ANONYMOUS TESTING =NO NAME REPORTING The HIV Test:  The HIV Test 1985: BLOOD TEST FOR HIV DEVELOPED SENSE OF URGENCY TO SCREEN BLOOD SUPPLY: TESTING ALL BLOOD DONORS DEBATE SHIFTED TO IDENTIFICATION OF HIV INFECTED NOT YET SICK WITH AIDS SOME STATES REQUIRED REPORTING HIV POSITIVE TESTS BY NAME AS WITH OTHER DISEASES SUCH AS Colorado passed the first HIV reporting law NO STATE W/ LARGE 3S OF AIDS CASES REQUIRED NAMED HIV REPORTING ONLY REASON TO TEST AND REPORT WOULD BE TO TRACK AND TREAT BUT THERE WAS NO TREATMENT INITIAL FEARS:  INITIAL FEARS QUESTIONS RAISED ABOUT SPREAD TO OTHERS Pressure to fire gay waiters and hair dressers Claims of housing discrimination against persons with AIDS These claims were difficult to substantiate CIVIL LIBERTARIANS AND GAY RIGHTS ADVOCATES PUSHED TO KEEP DIAGNOSIS SECRET Anonymous Testing:  Anonymous Testing ONLY FOR HIV HEALTH DEPARTMENTS ALWAYS HAD FEW PEOPLE GIVE FALSE NAMES IN STD CLINICS SYPHILIS CONTACT TRACING IN NYC ALWAYS HIGHLY SUCCESSFUL ANONYMOUS TESTING BLOCKED ABILITY TO TRACK EPIDEMIC OR CONTACT TRACE GAY RIGHTS GROUPS LOBBIED CONGRESS TO REQUIRE ANONYMOUS TESTING SITES AS CONDITION OF FEDERAL STATES W/ NAMED REPORTING HAD TO ALSO ALLOW ANONYMOUS TESTING ACTG 076 CHANGES EVERYTHING:  ACTG 076 CHANGES EVERYTHING AZT STARTING AT 14-34 WEEKS GESTATION AZT INTRAVENOUSLY DURING LABOR & DELIVERY AZT ORALLY TO BABIES FIRST 6 WEEKS ALL 3 TOGETHER DECREASED TRANSMISSION BY TWO THIRDS RESULTS PUBLISHED IN NEJM 1994 POST 076 ERA:BABY AIDS LAW:  POST 076 ERA:BABY AIDS LAW 1996 PATAKI SIGNS LAW MANDATING NEWBORN SCREENING FOR HIV PRENATAL TESTING IS NOT MANDATORY IN NYS BUT IS IN 8 OTHER STATES 1999: IOM RECOMMENDED UNIVERSAL HIV TESTING OF PREGNANT WOMEN AS ROUTINE PART OF PRENATAL CARE RATES OF PRENATAL HIV SCREENING SIGNIFICANTLY HIGHER WHERE ROUTINIZED (OPT OUT) VAST MAJORITY OF HIV TESTING IN NYC=PRENATAL SCREENING=SIMPLIFIED COUNSELING Change in MTCT Over a Decade in the U.S.: Effectiveness of Implementing Clinical Trial Results:  Change in MTCT Over a Decade in the U.S.: Effectiveness of Implementing Clinical Trial Results 1993: 1994: 1997: 1999: 2001: 2002: 2003: WITS PACTG PACTG WITS PACTG PACTG WITS 076 185 247 316 % Transmission AZT Era Combination ARV Era MMWR JUNE 27, 2003:  MMWR JUNE 27, 2003 Compared with 1,573 early testers, 1,877 late testers significantly more likely to be younger (aged 18--29 years), to be black or Hispanic, to have been exposed to HIV through heterosexual contact, to have a high school or less education Majority of late testers received HIV testing because of illness (65%), and the majority of early testers were tested because of self-perceived risk (29%) or because they wanted to know their HIV status (19%) 87% of late testers had first positive HIV test at an acute or referral medical care setting Death Rates from AIDS By Gender and Race/Ethnicity, NYC, 2004:  Death Rates from AIDS By Gender and Race/Ethnicity, NYC, 2004 Data from DOHMH Vital Statistics; age-adjusted 6x higher 9x higher Increasing Proportion of NYC’s AIDS Cases Result from Heterosexual Transmission to Women 15-Fold Increase from 1981 to 2003:  Increasing Proportion of NYC’s AIDS Cases Result from Heterosexual Transmission to Women 15-Fold Increase from 1981 to 2003 Among all cases with a known and reported transmission risk factor, 1981-2003. CASE 1: 33 YEAR OLD AFRICAN AMERICAN WOMAN WITH NO RISK FACTORS:  CASE 1: 33 YEAR OLD AFRICAN AMERICAN WOMAN WITH NO RISK FACTORS 33 YEAR OLD AA WOMAN W/HX ASTHMA PRESENTED TO THE CUMC ER WITH 2 WEEKS SOB & COUGH; TREATED FOR ASTHMA 1 WK EARLIER AND SENT HOME; SOB WORSENED FOLLOWED REGULARLY IN HOSPITAL BASED MEDICAL CLINIC SOCIAL HX-NO CIGS; NO ETOH; NO DRUGS EVER; LIVES W/12 YEAR OLD SON; WORKS IN DEPARTMENT STORE AS CLERK CASE 1 CONTINUED:  CASE 1 CONTINUED PE: WDWN BP140/90; P 110; T101.1 RR24 O2 SAT 90% ORAL THRUSH; CLEAR LUNGS CXR SHOWS DIFFUSE INTERSTITIAL INFILTRATE ADMIT TO MEDICINE; PRESUMPTIVE DX PCP; RX IV TMP-SX &PREDNISONE RESPIRATORY STATUS WORSENS INTUBATED TO MICU X 5 DAYS; CD4=11 Late Diagnosis of HIV Increases Risk of Death from AIDS by Two Thirds:  Late Diagnosis of HIV Increases Risk of Death from AIDS by Two Thirds DOHMH HIV Surveillance & Epidemiology, 2005 Today in NYC…:  Today in NYC… 12 people will be diagnosed with AIDS 10 will be black or Hispanic 3 will be women 3 people will first learn they are HIV-positive when they are already sick from AIDS 4 people will die from AIDS 3 will be black or Hispanic Large Disparities in HIV Rates in NYC:  Large Disparities in HIV Rates in NYC Note: Data include estimates of undiagnosed cases, rounded to nearest 0.5% Case 2: 44 Y/O AFRICAN AMERICAN MAN W/NO SIGNIFICANT MEDICAL HX:  Case 2: 44 Y/O AFRICAN AMERICAN MAN W/NO SIGNIFICANT MEDICAL HX IN USUAL STATE OF GOOD HEALTH; AM OF ADMISSION SEVERE EPIGASTRIC PAIN S N, V D; NO HX GB DISEASE ; NO FEVERS, CHILLS TO ER 2 WKS PTA W/ SOB & DRY COUGH: NEG CXR, NEG V/Q SCAN; D/C HOME BP 118/76, P 116, T 97.4 RR 18. O2 sat 96% RA PE: LUQ & EPIGAST TENDERNESS; VOL GUARDING; ADM MEDICINE: PRESUMPTIVE DX PANCREATITIS PAST MEDICAL/SURGICAL HISTORY: SUBLUXATION OF R CLAVICLE 3 YEARS AGO RXED IN ER OF NYC HOSPITAL SOCIAL HX: LIVES ALONE & WORKS IN FACTORY ETOH 4-5 BEERS/d X 10 YEARS LAST DRINK 10d AGO; NO HX CIGS, CRACK, COCAINE OR IVDU; +UNPROTECTED SEX W/MULTIPLE PARTNERS CASE 2 Continued:  CASE 2 Continued ADMISSION LABS: H&H 14.3/42.6, WBC 4.5, PLT 264,000. LFTs WNL; AMY 492, LIPASE 1530 CXR: SLIGHTLY INCREASED DENSITY DIFFUSELY ABDOMINAL CT: PERIPANCREATIC FLUID. NO PSEUDOCYST CHEST CT: BILATERAL CENTRAL GROUND GLASS OPACITIES C/W PCP &/OR NON-CARDIOGENIC PULMONARY EDEMA PHYSICAL EXAMINATION: VS: BP 124/76, T 97.5, P 92 and RR 20. O2 sat 91% ON RA; DESATURATION TO 68-71% WITH MINIMAL WALKING HIV COUNSELED AND TESTED; CD4 22 IN 2006 HIV SHOULD NOT = AIDS:  IN 2006 HIV SHOULD NOT = AIDS 1,038 New Yorkers – nearly 3 people every day – first learned they had HIV when they were already sick with AIDS These people were infected on average for 10 years, often with multiple contacts with the health care and social services systems. MANY MISSED OPPORTUNITIES TO BE TESTED IT’S ALL THE FAULT OF THE LAZY DOCS WHO DON’T WANT TO BE BOTHERED COUNSELING:  IT’S ALL THE FAULT OF THE LAZY DOCS WHO DON’T WANT TO BE BOTHERED COUNSELING EUROPEAN ARGUMENT: TESTING WITHOUT EXTENSIVE COUNSELING= EXCUSE FOR MD NOT TO SPEND TIME NEEDED TO EXPLAIN COMPLICATED ISSUE HIV COUNSELING REQUIRES 20-30 MINUTES IF DONE PROPERLY PHYSICIANS ACTUALLY DO NOT WISH TO BREAK THE LAW AND DO COUNSELING IN 3 MINUTES DO NOT BLAME THE PHYSICIAN:  DO NOT BLAME THE PHYSICIAN US HEALTH CARE SYSTEM IS BROKEN: NO REIMBURSEMENT FOR COUNSELING 15-20 MINUTES PER PATIENT IN CLINIC SETTING BUSY CLINICIANS IN URBAN MEDICAL CLINICS TRYING TO ADDRESS ALL “MEDICAL” ILLNESSES: FOCUS ON CHRONIC DISEASES: DIABETES, ASTHMA, HTN BUT HIV IS A CHRONIC DISEASE WHY NOT USE RISK ASSESSMENT?:  WHY NOT USE RISK ASSESSMENT? MULTIPLE STUDIES SHOW RISK ASSESSMENT DOES NOT WORK MANY PATIENTS DO NOT PERCEIVE THEMSELVES TO BE “AT RISK”: HETEROSEXUAL & MONOGAMOUS ALWAYS HETEROSEXUAL & MONOGAMOUS FOR>10 YEARS MANY PHYSICANS DO NOT PERCEIVE THEIR PATIENTS TO BE AT RISK MANY PHYSICIANS CONTINUE TO STIGMATIZE HIV: THEY DO NOT WANT TO THINK OF THEIR PATIENTS AS AT RISK ie DOING “BAD” THINGS HIV-Related Stigma:  HIV-Related Stigma The stigma of an HIV diagnosis can be devastating – and is an important barrier to testing and treatment The alternative – not getting care, spreading infection to others, and dying prematurely of AIDS – is even worse Societal change will be required to successfully address stigma 25 years of struggling has not fixed society WE CANNOT WAIT FOR BROAD SOCIAL CHANGES WHEN LIVES CAN BE SAVED NOW:  WE CANNOT WAIT FOR BROAD SOCIAL CHANGES WHEN LIVES CAN BE SAVED NOW WE NEED NAT’L HEALTH INSURANCE, BETTER PRIMARY CARE WE NEED A NON-RACIST & NON-HOMOPHOBIC SOCIETY BUT: AIDS EXCEPTIONALISM MAINTAINS THE STIGMA FOCUSES ATTENTION ON THOSE ALLEGEDLY “AT RISK” RATHER THAN ON THE COMMUNITY AT LARGE COMMUNITY BASED ORGANIZATIONS:  COMMUNITY BASED ORGANIZATIONS SENSITIVE TO NEEDS AND FEARS OF “THEIR COMMUNITY” FUNDED TO PROVIDE COUNSELING AND TESTING; PROVIDE OTHER SERVICES TO PLWAS HAS THEIR MAIN FOCUS BECOME KEEPING FUNDED? IS THEIR NEED FOR EMPLOYMENT BLOCKING EARLY DIAGNOSIS & LIFE SAVING INTERVENTIONS IN THE VERY COMMUNITIES THEY SERVE? IS THERE A PRECEDENT? POLIO:  IS THERE A PRECEDENT? POLIO The National Foundation for Infantile Paralysis Established 1938 Grew out of huge success of Birthday Balls for President Franklin Roosevelt. Balls & the foundation both Roosevelt’s ideas NAME CHANGE: MARCH OF DIMES:  NAME CHANGE: MARCH OF DIMES The organization’s name came from comedian Eddie Cantor’s comment that the donation of dimes from across the country could become a “march of dimes,” a reference to the popular March of Time newsreels of the era. AN EARLY CBO:  AN EARLY CBO The March of Dimes was a grassroots campaign run primarily by volunteers Over the years, millions of people gave small amounts of money to support both the care of treatment of people who got polio and research into prevention and treatment The advent of the polio vaccine was NOT a cause for them to try to block its use REINVENTION & REFOCUS:  REINVENTION & REFOCUS GOAL OF MARCH OF DIMES:  GOAL OF MARCH OF DIMES TO PREVENT BIRTH DEFECTS & INFANT MORTALITY THROUGH EDUCATION, RESEARCH, COMMUNITY PROGRAMS, ADVOCACY DURING ITS 32-YEAR HISTORY, WALKAMERICA HAS RAISED MORE THAN $1 BILLION Death Rates from AIDS By Gender and Race/Ethnicity, NYC, 2004:  Death Rates from AIDS By Gender and Race/Ethnicity, NYC, 2004 Data from DOHMH Vital Statistics; age-adjusted 6x higher 9x higher CASE 3: 74 YEAR OLD DOMINICAN MAN W/ HX HYPERTENSION:  CASE 3: 74 YEAR OLD DOMINICAN MAN W/ HX HYPERTENSION ADMITTED 9/18/06 W/ L FLANK PAIN & FEVERS ADMISSION PE: T104; ABD PELVIC CT: NONOBSTRUCTING RENAL STONES URINE CX + COAG NEG STAPH PT RECEIVED ZOSYN & AUGMENTIN W/RESOLUTION OF FEVERS PT C/O SOB: TTE SHOWED GLOBAL HYPOKINESIS W/ EF 25-30% & RV ANTERIOR WALL MASS 6x4cm, C/W TUMOR PET SCAN 10/3: MASS IN R HEART INVOLVING RA, RV, SEPTUM, PERICARDIUM; CERVICAL, AXILLARY, MEDIASTINAL & PLEURAL INVOLVEMENT C/W METASTATIC DISEASE; CASE 3 CONTINUED:  CASE 3 CONTINUED BX REVEALS NON-HODGKINS B CELL LYMPHOMA HIV TEST POSITIVE; CD4 90; 10/31/06: 71 YEAR OLD WIFE TESTED HIV POSITIVE W/ CD4 131 11/5/06: PATIENT DIES HIV Testing – Then and Now:  HIV Testing – Then and Now 1985 2006 RISK RISK BENEFIT BENEFIT Risks and benefits not clear; benefits slightly outweigh risks Benefits clearly outweigh risks ? IN 2006 NO ONE IN THE US SHOULD ENTER A HOSPITAL LIKE THIS:  IN 2006 NO ONE IN THE US SHOULD ENTER A HOSPITAL LIKE THIS

Add a comment

Related presentations

Related pages

routine HIV testing - Centers for Disease Control and ...

CDC Releases Revised HIV Testing Recommendations in Healthcare Settings ... declines (opt-out screening). HIV testing of people at high risk for HIV
Read more

HIV Post Test Results - aids.gov

... follow-up testing is performed. HIV tests are generally ... Frequency Confidential & Anonymous Testing Understanding Your Test Results Opt-Out Testing.
Read more

How New York State's New HIV Testing Law Affects Consumers

How New York State's New HIV Testing Law Affects Consumers ... you can decline testing by signing the opt-out section on the form. If I refuse an HIV ...
Read more

Opt-Out HIV Testing: Making HIV Tests Routine In the ...

• Opt out testing in peri-natal care now legal. * ... Awareness of Serostatus Among People with HIV and Estimates of Transmission Author: momoreno
Read more

Routine Emergency Department HIV Screening - Medscape

Routine Emergency Department HIV ... actively opt out of screening or otherwise be tested," Dr ... for rapid HIV testing. During the opt-out ...
Read more

The Role of Public Health in HIV Opt-out Testing: An ...

... What have turned out to be the greatest barriers to implementation of opt-out testing? Dr ... in HIV Opt-out Testing: An Expert Interview With Dr ...
Read more

Opt-Out Screening Can Improve Acceptance of HIV Testing

Opt-Out Screening Can Improve Acceptance of HIV Testing. ... Compared with active choice testing, opt-out screening ... Dr Montoy and colleagues ...
Read more

Implementing Opt-out HIV Screening in Today's ED: An ...

Implementing Opt-out HIV Screening in Today's ED: ... How did you, an ED physician, become an advocate and champion for HIV testing? Dr. White: ...
Read more

Guidelines for HIV Counselling and Testing in Ethiopia - WHO

for HIV Counselling and Testing in Ethiopia Federal HIV/AIDS Prevention and Control Office Federal Ministry of Health ... Dr. Ayele Belachew WHO
Read more