1. CDC’s Expanded HIV Testing Program:
Successes, Best Practices and Lessons
Learned
Kristina Cesa, MPH
ORISE fellow, Division of HIV/AIDS Prevention
Office of the Director
National HIV Prevention Conference
Atlanta, GA
August 14-17th, 2011
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention
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2. Advancing HIV Prevention: New Strategies for
a Changing Epidemic, 2003
Strategy 1
• Make HIV testing a routine part of medical care
Strategy 2
• Implement new models for diagnosing HIV infections outside
medical settings
Strategy 3
• Prevent new infections by working with persons diagnosed with HIV
and their partners
Strategy 4
• Further decrease perinatal HIV transmission
MMWR 2003;52:329-32
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3. Revised Recommendations for HIV Testing of
Adults, Adolescents, and Pregnant Women in
Health-Care Settings
HIV screening in all health-care settings for adults ages 13-64
years
• Opt-out testing strategy
Persons at high risk for HIV infection should be screened
annually
General consent for medical care should 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
HIV screening should be included in the routine panel of prenatal
screening tests for all pregnant women
MMWR 2006;55 (No.RR-14)
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4. PS07-768: Expanded and Integrated Human
Immunodeficiency Virus (HIV) Testing for Populations
Disproportionately Affected by HIV, Primarily African
Americans
Purpose:
1. Increase testing opportunities for populations disproportionately
affected by HIV, primarily African Americans
2. Increase the proportion of HIV-infected persons in these
populations who are aware of their infection and are linked to
medical care
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5. PS07-768: Expanded HIV Testing Program
Annual Goals:
1. Test 1.5 million persons
2. Identify 20,000 previously undiagnosed HIV infections
Project length: 3 years (Oct 2007 – Sept 2010)
Total Funding: $111,211,614
Venues: Clinical settings (at least 80%)
Non-clinical settings (no more than 20%)
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6. PS07-768: Funded Jurisdictions¹
Eligibility: At least 140 AIDS cases (estimated) among African Americans in 2005
VT NYC
Chicago ME
WA NH
MT ND MN MA
OR NY RI
SD WI
ID MI NJ
WY CT
PA Philadelphia.
IA DE
NE OH MD
NV IL IN
UT WV VA Washington, D.C.
CO KS
Los Angeles MO KY
County CA NC
TN
OK SC
NM AR Funded in Years 1-3
AZ MS AL GA Funded in Years 2-3
TX LA
FL
Houston
1Represents 95% of AIDS cases among African Americans in the United States in 2005
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7. Number of HIV Tests, Positive Tests, and
Positive Test Rates
October 2007 – September 2010
Total Clinical Settings Non-Clinical
Settings
Tests Done 2,786,739 2,519,917 (90%) 266,822 (10%)
Confirmed HIV+ 29,503 23,546 (80%) 5,957 (20%)
New HIV+ 18,432 15,478 (84%) 2,954 (16%)
Previous HIV+ 11,071 8,068 (73%) 3,003 (27%)
New HIV+ Rate 0.7 0.6 1.1
Data Source: APR Year 1–3
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8. Number of HIV Tests, New Positive Tests and
New Positive Rate in Years 1 – 3
Year 1 Year 2 Year 3
HIV Tests 458,014 1,021,181 1,307,544
New Positive Tests 4,029 6,821 7,582
New Positive Rate 0.9% 0.7% 0.6%
Data Source: APR Year 1–3
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9. Proportion of HIV Tests and New HIV Positives
by Race/Ethnicity
October 2007 – September 2010
80% HIV Tests
70% New HIV Positives
60% New Positive Rate, %
60%
Percent
40%
18% 16%
20% 14% 12%
5% 5%
0.8 0.5 0.5
0%
Black/AA White Hispanic Other/Unknown*
Race/Ethnicity
* Includes American Indian/ Alaskan Native, Asian, Native Hawaiian/ Pacific Islanders, multiple race and unknown
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10. Proportion of HIV Tests and New HIV Positives
by Gender
October 2007 – September 2010
80%
72%
60% HIV Tests
55%
New HIV Positives
New Positive Rate, %
45%
Percent
40%
27%
20%
0.9 0.4 <1% 1%
0%
Male Female Other*
Gender
* Includes transgender and unknown categories
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11. Venues Funded Under PS07-768
Year 3 (October 2009 – September 2010)*
30%
315
281 270
20%
183
10% 108 98
76
0%
Emergency STD Clinics Correctional Substance Community Community Other**
Departments Health Abuse Health Based
Facilities Treatment Centers Organizations
Centers
* (n=1,331)
** Includes Inpatient Medical Units, Urgent Care Clinics, Substance Abuse Treatment Centers, TB Clinics, and
miscellaneous
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12. Distribution of HIV Tests and New Positive Tests
by Venue Type
October 2007 – September 2010*
40%
HIV Tests
32% HIV Positives
30% New Positive Rate, %
30%
20% 20%
20% 17%
15% 14%
12% 11% 11% 11%
10%
6%
0.7 0.6 0.5 0.6 1.2 0.6
0%
Emergency STD Clinics Community Correctional Community Based Other **
Departments Health Centers Health Facilities Organizations
* (n=2,562,124)
** Includes Inpatient Medical Units, Urgent Care Clinics, Substance Abuse Treatment Centers,
TB Clinics, and miscellaneous
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13. New HIV-Positives by Selected Outcome
October 2007 – September 2010
Total Clinical Non-Clinical
Settings Settings
New HIV-Positives 18,432 15,478 2,954
New HIV+ Receiving 91% 93% 84%
Test Results
New HIV+ Linked to 75% 78% 63%
Medical Care
New HIV+ Referred 83% 83% 82%
to Partner Services
Data Source: APR Year 1–3
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14. CDC Cost per Test and New HIV Diagnosis
October 2007 – September 2010
Year 1 Year 2 Year 3
Tests 458,014 1,021,181 1,307,544
Cost/Test $58 $36 $30
New Positives 4,029 6,821 7,582
Cost/New $6,634 $5,346 $5,163
Positive
Data Source: APR and grantee financial status reports year 1 – 3
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15. PS07-768: Barriers & Challenges
Start-up delays
New partnerships
Provider resistance
Laws and policies
Operational issues
Technical assistance/training
Data management
Reimbursement
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16. PS07-768: Lessons Learned
Testing Strategy: Opt-out vs. Opt-in
Difficult to identify a profile to capture all those at risk/unaware of
infection
Opt-out screening reaches clients who otherwise would not have been
tested
Opt-out HIV screening in high prevalence areas maximizes case finding
value
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17. PS07-768: Lessons Learned
Test Technology: Rapid vs. Conventional
Rapid Testing Models:
• Increase receipt of preliminary results
• Decrease the number of clients lost to follow up
• More feasible in settings with dedicated testing staff
Conventional Testing:
• Reduces disruptions to clinic flow associated with point-of-care
testing
• Feasible in clinical settings where routine blood tests are ordered as
a standard of care
• Reduces the overall costs of testing
• Using multi-platform analyzers increases the volume of tests and
decreases the turn around time for results
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18. PS07-768: Lessons Learned
Staffing Model: Integrated vs. Parallel
Parallel Models:
• Minimum effect on the clinic flow
• Better acceptance from staff
• More expensive and require additional space
Integrated Models:
• More difficult to initiate due to:
o Perceived burden on clinic flow
o Extensive training requirements
• Requires getting buy-in from staff
• More cost effective and increase sustainability
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19. PS07-768: Lessons Learned
Sustainability
Identifying and maximizing all possible sources of funding
Building community support and cultivating program champions
Implementing innovative strategies
• Cost effective staffing models
• Low cost testing models
Develop a “business case” for routine testing
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20. PS 07-768: Lessons Learned
Bottom Line:
Routine HIV screening in healthcare settings
WORKS!
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21. PS10-10138/ PS12-1201: Expanded HIV Testing
for Disproportionately Affected Populations
Purpose:
To sustain progress made under announcement PS07-768
To expand routine testing services to new clinical venues to
reach a broader array of at-risk populations.
Target Population:
African American and Hispanic men and women
MSM and IDUs, regardless of race or ethnicity
Grantees:
Expanded to 30 state, territorial and local health departments
under PS10-10138
Eligibility further extended to 36 jurisdictions under PS12-1201
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22. PS10-10138/ PS12-1201: Expanded HIV Testing
for Disproportionately Affected Populations
Objectives: (when fully implemented)
1. Conduct ≥ 1.3 million tests
2. Identify ≥ 6,500 undiagnosed HIV infections
3. Receipt of test results (≥ 85% of positives)
4. Linkage to medical care (≥ 80% of positives)
5. Linkage to partner services (≥ 80% of positives)
6. Receipt of prevention counseling and/or referral to prevention
services (≥ 80% of positives)
7. Sustainability
8. Service Integration
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23. Acknowledgments:
Co-authors: Additional Acknowledgments:
Christopher Brown Nadia Duffy
Sam Dooley Abigail Viall
Erica Dunbar PS 07-768 Grantees
Benny Ferro
Priya Jakhmola
Marlene McNeese-Ward
Kimberly Thomas
Cathy Yanda
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24. Kristina Cesa
404-639-6418
Kcesa@cdc.gov
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
National Center for HIV/AIDS, Viral Hepatitis, STD & TB Prevention
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