Routine HIV testing at the VA: Podcast interview with Dr. Henry Anaya (transcript)

This is the transcript of my podcast interview with Dr. Henry Anaya of the Veterans Health Administration.

David Williams: This is David E. Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Dr. Henry Anaya from the Veterans Health Administration.  He works as a research scientist in the area of HIV.  Dr. Anaya, thanks for being with me today.

Dr. Henry Anaya: Thank you Mr. Williams.  I appreciate this opportunity.

Williams: I understand that the VA has made a policy change regarding HIV testing.  Can you tell me what change has been made?

Anaya: As of August 17th of this year, the VA eliminated the requirement for written informed consent for HIV testing.  All that is required now is verbal assent from a patient.  It just eliminates a lot of bureaucracy that was previously involved in HIV testing.  Prior to this change there had to be a significant amount of paperwork that an HIV counselor or provider had to go through with a patient in order to walk them through the process for HIV testing and discuss HIV risk behaviors. That’s no longer required.  All that’s required is a brief overview of HIV related risk behaviors and then a verbal assent; no longer is this long cumbersome written policy and written consent required.

Williams: What was the purpose of having all that extra consent in the first place and why is a change being made now?

Anaya: If you think about it the VA policy was adopted decades ago when HIV/AIDS was considered a death sentence, 30 or so years ago at the advent of the epidemic.  If people contracted HIV, that was not a good condition to be in.  A lot of times people ended up dying from the disease, but that’s no longer the case.  HIV is considered a chronic disease now where it’s manageable with a variety of antiretroviral treatments.

So the policy didn’t really catch up to the treatment. The policy was written back when it was far more worse a disease. The VA finally caught up with that and said patients don’t really need to go over a very cumbersome amount of paperwork to go over some of the issues related to HIV risk behaviors because the disease is now a chronic disease. We can go through the one page educational type of counseling, which gives an overview, so this written consent was waived because of that.  The VA has basically caught up with where the HIV disease is today.

Williams: Who should be tested for HIV?  Is it something that everyone should get a test for or are there some people who should really not be tested or don’t need to be tested?

Anaya: The CDC has put forth their recommendations.  The VA’s policy basically mirrors that of the CDC.  The CDC policy is that everyone between the ages of 18 and 64 should have at least one HIV test within their lifetime.  Obviously if you’re not sexually active or don’t engage in other types of HIV related risk behaviors like sharing needles or any other types of risk behaviors then there probably really isn’t any need for you to have an HIV test. But if you do fall within the age bracket where you are sexually active, then the requirement is that you should have at least one test per lifetime. If you do engage in risky behaviors such as those that I just laid out, then the requirement is that you should have a test at least once every year.

Williams: What is the testing procedure?  Is this a blood test or a urine test?  What kind of test is it?

Anaya: Traditionally it had been a blood test. It’s a typical venipuncture where they draw blood and the laboratory would send the blood out for analysis and it would come back with your HIV results a week or so later. But recently there has been a new device on the market where you don’t have to have a needle stuck into your arm. It’s basically an oral swab. It’s an FDA approved test. It’s basically a swab of the gum area of your mouth, and then you dip the device in a solution.

Twenty or so minutes later you have your results and they’re either positive or negative. If it’s a positive test then you do have to go in for confirmatory blood testing.  You still would have to have a blood test, but if you’re negative then there is a 99.6% accuracy that indeed you are negative.

So traditionally it has been blood testing, but if people prefer rapid testing because they’re needle phobic or for any other reason, there is that option available to people across the country now.

Williams: It’s probably more comfortable to have the mouth swab as opposed to the needle stick, but are there any advantages from a clinical perspective of having your results sooner as opposed to a few days later?

Anaya: There is a big advantage and that is especially pronounced in hard to reach populations such as homeless people and people that are very transient. The reason is obvious.  If you have a blood-based HIV test, you have to come back to the hospital or your doctor or clinic later.  If you’re someone who is transitory and you have trouble with transportation issues, etc., you might not come back.

The CDC estimates that up to 20% to 25% of people who have HIV in this country don’t know because they don’t come back for their results.  With a rapid oral test you can get your results in 20 minutes while a patient waits to see his or her doctor, so that eliminates a lot of the gap in care that currently exists with the blood based testing.

Williams: What is the expected impact of this policy across the VA in terms of the number of infections you expect to pick up? In other words what’s the number you expect to find or the number of infections that you hope to prevent by having a better knowledge of somebody’s HIV status?

Anaya: I don’t have any hard figures on that, but it just stands to reason that if you’re now able to offer someone a test and they don’t have to come back for their results, then you’re going to be able to identify a lot of people who normally would be walking the streets with HIV who don’t know it.  It just makes sense to me. I think that some point in the future when people are able to step back and collect some of this data you will be able to see evidence that points to the success rate that rapid testing has in terms of identifying previously unknown people with HIV and then ultimately linking them to care.

Williams: What sort of reaction have you seen among patients who perhaps have not been getting HIV tests in the past or among the staff?  Is this a major change or is it being taken in stride?

Anaya: I think for a lot of people it is a major change. For patients I’ve read estimates that about 10% of the population is needle phobic. So just off the top, you might have 10 percent of the people out there who won’t have an HIV test because they don’t want to go through a needle stick.  So right there it seems just from the face of it that you might be adding 10 percent more to the pool of people that want to get tested.

We have some anecdotal evidence that people like HIV rapid testing.  They like to get their results in 20 minutes as opposed to waiting for a week with all that anxiety that that could lead to. As far as staff, one of the things that we were concerned with was that staff would feel that this is just another task that you’re having to do attached to an already busy work day, but we have found that staff like the rapid test.  They’re able to integrate it into their normal workflow without undue burden on them. It seems like all around people have really taken to this device and like it.

Williams: I’ve been speaking today with Dr. Henry Anaya from the Veterans Health Administration where he is a research scientist working on HIV.  Dr. Anaya, thank you very much for your time today.

Anaya: Thank you Mr. Williams.  I’ve appreciated it.

November 12, 2009

4 thoughts on “Routine HIV testing at the VA: Podcast interview with Dr. Henry Anaya (transcript)”

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