Keeping Prevention Standard During a Pandemic: Provider Resources for Routine HIV Testing

By: 

• RAPID Resource Program – University of Miami

The Centers for Disease Control and Prevention (CDC) estimate that there are approximately 160,000 people living in the United States who are unaware that they are living with HIV. The CDC recommends that all individuals between the ages of 13 to 64 get tested for HIV at least once and that those with risk factors get tested more frequently. In the state of Florida, individuals who are younger that 18 but who are at least 13 years of age do not need parental consent to obtain an HIV test.

Routine HIV testing increases early diagnoses of HIV and the number of persons who are aware of their HIV status. Early diagnosis can reduce HIV transmission to others, HIV-related morbidity and mortality, and may even reduce the risk of acquiring other serious non-AIDS-related diseases.

To reduce HIV infections in the state of Florida, the Florida Department of Health has assigned Routine HIV testing in health care settings as one of four key components in their “Ending the Epidemic” strategy. There is a substantial opportunity to increase widespread implementation of HIV testing throughout Florida.

Early diagnosis and immediate treatment for HIV is paramount to ending the epidemic in the U.S. Routine testing is an important first step in the early detection of HIV and can help facilitate an immediate linkage to HIV care and antiretroviral therapy (ART).

Effective treatment with antiretroviral medications can lower the amount of virus in the body until the patient achieves viral suppression. People living with HIV who adhere to ART as prescribed can achieve an undetectable viral load (<200 copies/mL) and have effectively no risk of sexually transmitting HIV. Starting ART immediately after diagnosis improves health outcomes by preventing disease progression and reducing viral load, making transmission highly unlikely.

Florida law does not require written informed consent for HIV testing in health care settings (section 381.004, Florida Statutes). As such, the implementation of routine opt-out HIV testing is encouraged.

With prior notification of routine testing authorized facilities can test any patient who does not explicitly opt-out of testing for HIV. Florida legislation describes facilities that are authorized to implement the “opt-out” strategy as any hospital, urgent care clinic, substance abuse treatment center, primary care clinic, community clinic, blood bank, mobile medical clinic, or correctional health care facility.

The COVID-19 pandemic has introduced a new set of challenges for HIV prevention that are unprecedented. These challenges require unique and innovative approaches to enable continued HIV testing while maintaining social distancing and stay at home orders.

The COVID-19 pandemic response has scaled-back, in-person contact in health care settings where traditional testing typically takes place. To maintain the health and safety of patients and healthcare professionals while continuing to provide the essential health service of routine HIV testing and PrEP care, the use of telehealth, home specimen collection kits for STI testing, and HIV self-test kits, are encouraged when laboratory testing services are not available.

Self-administered at-home HIV testing options are available to patients. Providers are encouraged to provide patients with the option of having a self-test kit mailed to their home, and to provide education and linkage to care if a test kit returns a positive result.

Many payors will cover the cost of these kits. The Florida Department of Health provides free at home testing kits to Florida residents who are seeking an HIV test. Test kits can be ordered at https://knowyourhivstatus.com/get-afree-home-testing-kit/. Clients can also contact their local health department for information on how to request kits as well as HIV counseling and prevention services.

HIV testing is the first step in the consideration of pre-exposure prophylaxis (PrEP) for those who are HIV negative and have an increased risk of acquiring infection.

When a patient receives a negative HIV test result, it is important to evaluate appropriateness for and interest in available prevention strategies, such as PrEP. This begins with an open discussion of sexual practices and other risk behaviors. For patients with increased risk of HIV, a risk reduction plan should be considered. Strategies in such a plan may include routine retesting for HIV and other sexually transmitted infections (STIs), condom use, and PrEP.

PrEP initiation and continuation of care can be achieved through remote management and telehealth.

Home specimen collection kits are a recommended alternative when in-person lab-visits are not feasible. These kits allow collection of samples to test for HIV and sexually transmitted infections (STIs) including gonorrhea, chlamydia, and syphilis. The kits can be ordered by physicians and delivered by mail directly to patients’ homes. Testing kits may be covered by commercial payors and can contain the appropriate panel of tests needed to start or continue PrEP care. Our program can help to establish protocols and plans for implementing PrEP care, both in-person and remote, within your practice setting.

The United States Preventive Services Task Force (USPSTF) has given Grade “A” recommendations to the use of PrEP and routine HIV testing as effective strategies for early diagnosis of HIV infection and prevention for persons who are at increased risk of acquiring HIV.

Florida HIV Testing Law Basics

Prevention counseling is not required before HIV testing in health care settings. Patients must be notified that HIV testing is planned and have the opportunity to opt-out of testing. This notification may occur in a number of ways including verbally or by the distribution of written materials. A facility may include a notification of HIV testing in general consent to medical treatment. If testing is declined, this decision should be documented, and providers are encouraged to address the reasons for declining. Minors who are 13 years or older do not need parental consent to get an HIV test.

Why Conduct/Get Testing?

From a provider’s perspective, the testing laws remove time spent acquiring written consent, conducting prevention counseling, and conducting HIV risk assessments. HIV can be reliably detected with rapid tests, which are inexpensive, and noninvasive. Testing can also be incorporated into routine blood work planned as part of a health care visit. Although not required, HIV counseling and risk assessment are billable actions during an office visit, and thus can be a source of revenue. Under the Affordable Care Act (ACA), Medicare, Medicaid, and private insurance are required to cover or incentivize “A” and “B” grade services. HIV screening has an “A” rating from the USPSTF and should be a covered service by Medicare, Medicaid, and ACA-qualified health plans. Although most HIV testing services will be covered, it is important to refer to each individual health plan to verify reimbursement coverage.

Who should be tested for HIV?

The CDC recommends that everyone between the ages of 13 and 64 is tested for HIV at least once in their lifetime. This recommendation is similar to screening guidelines for other treatable conditions. However, the frequency of testing should increase with level of risk. For those at higher or ongoing risk for HIV, testing should be repeated at least annually. More frequent testing may be indicated for some individuals at highest risk.

Patients who have increased or ongoing risk for HIV include:

• Sexual partners of people living with HIV
• Those starting a new sexual relationship
• Those with recent sexually transmitted infections
• Those with multiple sexual partners
• Those who report inconsistent condom use

It is important to remember that although there is no cure, HIV is a manageable infection. Current medicines are extremely effective and help people live longer healthier lives.

What is PrEP and Where is it Available?

Pre-exposure prophylaxis (PrEP), is when people who do not have HIV and are at substantial risk of acquiring infection take medication to prevent HIV. PrEP can decrease risk of sexually acquired HIV infection by more than 99% when taken as directed. PrEP, in combination with HIV testing, testing for sexually transmitted infections, and provision of condoms, should be discussed with all people who are at increased risk for HIV infection after receipt of a negative HIV test.

Currently, there are two FDA-approved medications for PrEP: they are both single tablet combinations of two antiretroviral medications (tenofovir and emtricitabine) with the brand names Truvada® and Descovy®, as well as a generic formulation. Descovy® is not currently recommended for individuals who have receptive vaginal sex and are at risk of HIV. Provision of PrEP requires baseline testing for HIV, sexually transmitted infections, viral hepatitis, and monitoring of serum creatinine. PrEP can be provided through a number of venues including primary care, sexually transmitted infection clinics, family planning clinics, and other venues.

Who should take PrEP?

CDC guidelines suggest that PrEP be discussed with individuals who are HIV-negative and are at an increased risk of infection from sex or injection drug use. Federal guidelines recommend that PrEP is considered for people who are HIV negative and who are:

• Sexual partners of people living with HIV
• Engaging in sex with multiple sexual partners
• Recent diagnosis of bacterial STI (gonorrhea, chlamydia, or syphilis)
• Exchanging sex for drugs money or other items
• Using condoms inconsistently
• Injection drug users who share injection equipment or have sexual risk for HIV

Please see below a list of resources which further explain/assist with the implementation of HIV testing, PrEP programs, linkage to HIV care, and HIV prevention in general.

Our program is designed to increase information and provide resources to Florida providers regarding HIV prevention. For more information regarding our services and for testing & PrEP resources for your practice, please contact us at 305-243-2584 or [email protected].