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In the early 2000s, fewer than 10 percent of VA patients had ever been screened for HIV, the virus that causes AIDS. Today, the figure stands at about 20 percent, says Henry Anaya, PhD, an expert on HIV screening in VA.
Screening is crucial because up to a quarter of people with HIV don't know they have it. As a result, not only do they themselves not get the care they need, but they also risk infecting others.
According to Anaya, there have been two major drivers of higher HIV screening rates for Veterans who use VA health care. One was the advent of rapid tests that return results in minutes instead of days. The other was a VA policy change that streamlined the consent process for administering HIV screens to patients.
VA Research Currents spoke with Anaya, a health science researcher at the VA Greater Los Angeles Healthcare System, about these changes and what they mean for Veterans. We also asked about efforts to further expand HIV screening in VA.
When did rapid tests come into use?
There have been a few rapid tests available since around 2004. Some use blood, others use oral fluid [a mixture of saliva and other fluids in the mouth]. The Centers for Disease Control and Prevention put out new guidelines in 2006 recommending routine HIV screening in health care settings for all adults in the U.S., so that led to further expansion of HIV testing in VA. The rapid test that has had the biggest impact on screening rates in VA is the oral test.
How does the rapid oral HIV test work?
The person rubs a plastic collection swab on the gums to collect oral fluid, and then the swab is inserted into a specially prepared chemical solution. The results appear in 20 minutes. The test detects HIV antibodies, not the virus itself.
Why is rapid testing, the oral test in particular, so important in VA?
Research has shown that a significant number of people who receive conventional HIV screening don't come back for their results. They go in and get a test, but then for whatever reason don't come back a week later to get their results. So some of them are walking around with HIV and not knowing it. With the rapid test, you get your results in 20 minutes. And if necessary, you can be linked to care immediately.
Also, compared with the general population, there is a larger proportion of VA patients who are homeless and living in shelters. And a lot of VA patients have problems with substance use disorders [SUDs]. The rapid oral test can be administered in non-traditional settings where there isn't blood testing available—such as homeless shelters or SUD clinics. In a shelter, you could give someone a test while they are waiting for a meal, and then give them their results 20 minutes later. In fact, the test can be done almost anywhere. There is also a version that has just been FDA-approved for use by people at home.
Don't the oral test results still need to be confirmed with a blood test? How do you get people to come back for that?
In a hospital or clinic setting, we try to link the patient immediately to the confirmatory blood test. Outside these settings—in shelters, for
example—it's more problematic. Among other issues, homeless people have transportation problems. To help address this, we devised a taxi voucher system. Whenever we render a preliminary positive result, we give the person a taxi voucher for two-way transportation to a hospital or clinic where they can get the blood test and linkage to care, if needed.
What was the significance of VA's policy change in 2009 regarding HIV testing?
It did away with the need for written informed consent. All you need now is specific verbal informed consent for an HIV test. The provider asks the patient if he or she would like to have the test and discusses the risks and benefits of the test and any other information about it that a person would reasonably want to know. If the patient agrees to have the test, the provider documents the consent in the patient's electronic health record.
The policy change also eliminated the need for pre- and post-test counseling for HIV testing. The new requirement is to provide written educational materials to the patient, in place of the routine counseling. This further streamlined the process.
Compared with the general population, are VA patients at higher risk for HIV?
We know from research that VA patients on the whole tend to engage in risky behaviors, such as drug use or unsafe sexual habits, more so than the general U.S. population. By the very nature of that, they are more likely to contract HIV. There is also a large percentage of VA patients who are minorities, and we know that compared with the general population, minorities—especially African Americans and Native Americans—contract HIV at greater rates. So overall, HIV impacts VA patients much more than it does the general population.
How has the outlook for HIV patients changed in recent years?
Back in the 1980s, when HIV first reared its head, it was essentially a death sentence for anyone who was infected. There was no effective treatment. In the 1990s and beyond, drug companies and researchers came up with antiviral medications that changed that prognosis. Magic Johnson became the personification of living with HIV. It's now considered a chronic but manageable disease, like diabetes. It's better to not have HIV, of course, but if you do get it, and you're fortunate enough to live in a society that has access to these drug cocktails, you're most likely going to live a pretty long life—almost as long as if you didn't have it. Third-world countries are a different story. People don't have access to the same drugs,. In these places, unfortunately, HIV can still be a death sentence.
How does early detection help?
With early detection, antiviral treatment can start sooner. That can prevent HIV from progressing to AIDS, which is the most advanced stage of HIV
infection. Once a person has AIDS, the immune system is severely damaged and very weak. The person becomes susceptible to any number of "opportunistic— infections that can be deadly. From an economic perspective, once a person has AIDS, the health care costs go up exponentially. So it's always better to have screening initiatives in place.
As an implementation researcher with the Quality Enhancement Research Initiative on HIV and Hepatitis C, you are involved in efforts to further increase HIV screening rates in VA. Could you talk a bit about that?
One of our main initiatives has been training nurses and other providers in VA to administer the rapid oral test. We've done this throughout Los Angeles County, as well as in Northern California, Washington DC, Houston, Pittsburgh, and other locations. We've trained VA providers in primary care settings, SUD clinics, and emergency departments. We've also reached out to Veterans in homeless shelters. Now, we're leading a rapid testing initiative in one of the hardest hit places in country, the southeastern U.S. We've got 11 SUD clinics that will take part. In partnership with VA's Office of Public Health, the QUERI has also developed a lot of other tools and programs to help educate and train VA providers.
Has VA's experience with HIV testing had an impact in the broader community?
We are the largest single provider of HIV care in the U.S.—we cared for more than 25,000 Veterans with HIV in 2011. We are also the largest health care system overall. Other health care systems look to us as a model. We've disseminated the research findings we've been able to gather during all our HIV testing interventions and initiatives, and this information has helped guide other providers in their efforts to engage more Americans in HIV screening.
To learn more about VA care for HIV-AIDS, visit www.hiv.va.gov. For more on VA's Quality Enhancement Research Initiative on HIV and Hepatitis C, go to http://www.queri.research.va.gov/hiv/.