Prevention Programs

It has long been a goal of state and federal governments to identify the approximately 21 percent of HIV positive persons that don’t know they are infected. In September 2007, the Centers for Disease Control and Prevention (CDC) launched the Expanded Testing Initiative (ETI). The ETI is an ambitious plan to conduct 1.5 million HIV tests and identify 20,000 new HIV-infections annually for three years, targeting disproportionately impacted populations, particularly African Americans.

The ETI is a three year program. In year one, FY2007, 18 states and five cities were funded at $35 million.1 In year two, FY2008, two more states were funded at $36 million for a total of 25 jurisdictions.2 The jurisdictions eligible for the ETI funding accounted for 95 percent of all AIDS cases among African Americans in 2005. Through the ETI, CDC directed that 80 percent of the testing occur in clinical settings, and encouraged the use of rapid HIV testing to help ensure that HIV-positive persons receive their test results and to establish routine HIV testing as a standard across health care services.

The ETI also supports counseling and referral programs, including integration of HIV testing programs with partner services programs that reach out to partners of HIV-positive persons in order to notify, counsel and test them. The ETI encourages integration of HIV program efforts with public health programs targeting viral hepatitis, sexually transmitted diseases (STDs) and tuberculosis as well. The establishment of routine HIV testing in these contexts increases the opportunities public health systems have to reach at-risk individuals.

YEAR ONE PROGRESS
Both CDC3 and NASTAD4 conducted assessments of year-one including progress and challenges faced. Following significant scale-up efforts in all jurisdictions, 21 of the funded jurisdictions conducted 446,503 tests in year one of the ETI. Nearly 4,000 new HIV infections were identified, 80 percent of which were in clinical settings.1 During the first year, 86 percent of testing occurred in clinical settings, primarily emergency departments, STD clinics, community health centers and correctional health facilities. Of the total number of tests conducted in the first year, 64 percent were administered to African Americans. Seventy percent of the newly identified infections were among African Americans.

Eighty-four percent of jurisdictions report providing routine HIV testing within clinical settings. Those jurisdictions included both “opt-in” and “opt-out” programs. The primary locations in which HIV testing is routinized are emergency departments, community health clinics, correctional facilities and STD clinics.

Sixty-four percent of jurisdictions also conducted testing in non-clinical venues such as community-based organizations, while 88 percent have used funds for the purchase of rapid tests. Other activities within the ETI include social marketing campaigns, viral hepatitis testing and partner services.

For many jurisdictions, ETI funding has significantly enhanced the reach of public health programs targeting HIV/AIDS prevention and care. Accordingly, most jurisdictions are “blending” the CDC funds with state, local and/or other federal funding to support the ETI activities. As part of the mandate for innovation and creativity, 92 percent of jurisdictions reported that ETI funding has facilitated expansion of programs into settings or venues not previously supported by the health department. Twenty jurisdictions increased the number of facilities providing routine HIV testing and 21 increased the number of facilities providing rapid testing.

Since September 2007, jurisdictions have conducted numerous activities in support of implementation of ETI programs, including streamlining of consent requirements (52%) and counseling requirements (60%). A large majority of jurisdictions have devoted health department staff time to providing technical assistance to grantees on issues including implementation of rapid testing (80%) and routine testing (76%), as well as linkages to care (76%) and partner services (72%). A significant number of jurisdictions also report efforts at developing linkages with professional organizations (e.g., medical associations), businesses and community
organizations.

There were challenges in year one, particularly on the start up time needed to establish contracts and requests for proposals; to purchase rapid-test kits and to develop program protocols. These challenges led to a staggered start for many of the sites. Data and experiences from individual jurisdictions show that significant progress was made in year one, particularly in reaching African American populations and providing routine HIV testing in clinical venues. Projected numbers for year two indicate that jurisdictions are on track to meet ETI goals.

LESSONS FOR THE FUTURE
The ETI has shown an increased need for the building and strengthening of infrastructure and capacity. The focus on testing in clinical settings requires a number of significant structural changes for clinical venues in which routine HIV testing is provided by clinical staff. Training, education and technical assistance are all necessary to assist venues in identifying and/or adding the needed staff to implement routine rapid testing.

Particularly in clinical venues such as emergency departments and primary care facilities, programs need assurances that their programs will be able to maintain funding from either grants or billing streams (e.g. Medicare, Medicaid or other insurance) as they move forward. The continued participation and buy-in of health care staff, including nurses and physicians, is vital if routine HIV testing is to become a standard of care.

REFERENCES
1. Alabama, California, Chicago, Connecticut, District of Columbia, Florida, Maryland, Georgia, Houston, Los Angeles County, Louisiana, Massachusetts, Michigan, Missouri, New Jersey, New York City, New York State, North Carolina, Ohio, Pennsylvania, Philadelphia, South Carolina, Tennessee, and Virginia.
2. Mississippi and Texas.
3. DRAFT CDC report: “Summary of Year One of CDC’s Funding Opportunity Announcement 07-768”.
4. National Alliance of State and Territorial AIDS Directors “Report on the Centers for Disease Control and Prevention (CDC) Expanded Testing Initiative: Successes and Challenges for Health Department HIV/AIDS Programs” March 2009; available at: http://www.nastad.org/Docs/highlight/200935_26632_NASTAD_Brief%20(3).pdf.

All above information was obtained from here.

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