Analysis of a High Volume Rapid HIV Testing Multimedia Model Project B.R.I.E.F. Yvette Calderon, M.D., M.S. Associate Professor of Clinical Emergency Medicine Albert Einstein College of Medicine Jacobi Medical Center, NY Jason Leider, M.D., Ph.D. Associate Professor of Internal Medicine

USA Stats At the end of 2003, an estimated 1.1 million persons in the United States were living with HIV/AIDS 21% are undiagnosed and unaware of their HIV infection CDC estimated that approximately 56,300 people were newly infected with HIV in 2006

Bronx Demographics 3rd most densely populated county in US >80% Hispanic and African American 1/3 households headed by a single parent 2003 Bronx Median income = $27,331 Manhattan = $47,415, Brooklyn = $35,168) 1/3 of the population is below the poverty line 40% of Bronx adults lack a high school diploma Highest unemployment rate in NYC 4

HIV/AIDS in New York Region HIV/AIDS Prevalence Rate African-Am HIV/AIDS Prevalence Hispanic HIV/AIDS Prevalence New York State 0.58% 1.74% 1.18% New York City 1.04% 1.97% 1.30% Bronx Borough 1.57% 2.18% 1.56% NYSDOH 2005 Surveillance Report, including cases reported and confirmed through 2006

Functionally illiterate Adult Literacy in NYC Region Functionally illiterate Marginally literate NYC 36% 27% Bronx borough 46% 33% Brooklyn borough 41% 32% Manhattan borough 31% 19% Queens borough 30% Staten Is borough 18% 28% New York State 24% 26% www.casas.org/lit/litcode/search.cfm

Why test in the ED? A significant percentage of patients presenting to inner-city EDs have unrecognized HIV-1 infection. (Alpert 1996, Kelen 1995, Schoenbaum 1993, et al.) Inner city EDs serve disadvantaged patient populations who continue to bear a disproportionate burden of the health disparities in our country. These patients utilize the ED for their primary care and have limited or no access to ongoing regular health care with a provider. The CDC recommends that diagnostic HIV testing and HIV screening be a part of routine clinical care in all health-care settings (CDC 2006 Revised Recommendations) WHY TEST IN THE ED?

Barriers to ED HIV Testing Responsibility Time Cost

Increase Access to HIV Counseling/Testing Project B.R.I.E.F Behavior intervention Rapid HIV test Innovative video Efficient cost and health care savings Facilitated seamless linkage to outpatient HIV care Public Health Advocate Educational Videos Rapid HIV Testing One possible solution to identifying patients with unrecognized HIV disease and offering testing (rapid testing) in the ED and UCA could be to develop model that used a video that could provide the information acquired in C&T sessions. While there may be multiple solutions one can offer to increase access to testing in the ED : : Optimal Solution: HIV counselors around the clock Increase Access to HIV Counseling/Testing in the ED

BRIEF POC LAB Bathroom Trauma Work Station Trauma Bathroom Bathroom Exam rm Exam rm Exam rm Bathroom Registration Trauma Work Station Trauma Triage Let’s peel off the layer of the ED Bathroom Bathroom BRIEF POC LAB Exam rm Exam rm Exam rm

Project BRIEF HIV testing Registration desk: pts are informed that HIV testing is offered to all pts at Jacobi and NCB in the ER and given BRIEF brochures Project BRIEF HIV testing

DOH HIV testing posters in English and Spanish help inform pts and give ambience of routinization of testing

Pt in room w/ doctor -> PHA comes to rm w/ tablet PC -> pt does DCI -> pt watches pre-test video-> tablet signals PHA’s pager to rerurn to pt -> PHA returns to pt for consent for rapid testing

PHA does oral rapid HV test -> PHA brings rapid test to ER lab -> Pt watches post-test counseling video -> pager signals PHA that 20 min have passed & need to check oral rapid result -> PHA returns to give pt results & do focussed post-test counseling -> pt did it orally

Protocol for People Testing Positive Daytime Hours: Patient are walked to ACS clinic and seen by a provider Evening Hours: Patients are given an appointment to return on next open visit at the ACS clinic

Project BRIEF Results 10/05-1/09 28,365 patients approached 25,871 (91%) eligible 24,495 pts (95%) tested 1,376 pts (5%) refused Numbers for JMC and NCB and tremont through April JMC – started 10/05 NCB – started 7/06 Tremont – started 3/08 116 (0.47% tested HIV+) 17

B.R.I.E.F. n=23,894 responded Self-identified race Hispanic 52.9% Black/ African-American 33.6% White 5.9% Multiracial 5.0% Asian 1.4% American Indian 0.6% Native Hawaiian/ Pacific Islander 0.1%

Age, Gender, Language of Patients Tested via BRIEF Mean age 35 % male 43% Preferred Language English Spanish Other 84% 15% 1% Remove bottom two? 19

Self-reported Risk Factors % population answering affirmatively Have had sex without using a condom 83% Have more than 3 drinks before sex 38% Previous non-IV drug use 22% Previously had an STD 18% Currently use non-IV drugs 10.30% Sex with drug user 9.20% Previously used street drugs before sex Mention: data here is collected via tablets/kiosks

Condom Use Reported by BRIEF ED Patients Males Females Never/Almost Never/Sometimes 69.2% 78.2% Almost/Every time 30.0% 21.1% Hispanic females had the highest risk behaviors: 53.2% said they “never” use condoms (the highest of any race/gender group) and only 9.3% said they use condoms “every time” (the lowest of any race/gender group). *of patients who stated they were sexually active in the past 3 months

Patient Satisfaction with BRIEF 99.3% felt HIV testing in the ED was helpful 96.0% felt the PHAs made getting tested in the ED easier 94.3% felt the video answered their question regarding HIV testing

Patient Satisfaction with BRIEF 86.4% learned a moderate to large amount of new information 80.8% felt the video gave them new information to influence their sexual practice

Previously tested for HIV Under 21 Cohort Acceptance (3660/3774) = 96% Male 40% (n=1457) Hispanic 54% (n=1974) African American 32% (n=1178) Mean age 19.5 ± 1.4 years Previously tested for HIV 62% (n=2274) HIV Prevalence 0.16% (6/3660)

Under 21 Cohort: Risk Factors Unprotected Sex Anal Vaginal Multiple Partners STI Male n=1457 75% n=918 15% n=202 84% n=1139 59% n=866 8% n=120 Female n=2183 84% n=1582 13% n=260 89% n=1830 43% n=927 21% n=458 Total n=3640 81% n=2500 n=462 87% n=2969 49% n=1793 16% n=578 20 patients had age data, but were missing the gender variable, which is why the total in this table is not 3660 9.0% of males were MSM

Linkage to Care Data October 2005 – August 2008

Building Linkage: Coordination of ED testing with HIV clinical care Pt tests HIV+ in UCA/ED Communication from PHA to HIV care team about pt Pt unstable Pt stable Pt admitted to inpt ACS HIV team Pt escorted to ACS clinic Pt stabilized & d/c’d Open access ACS HIV clinic Pt d/c’d home w/ f/u at ACS clinic Pt d/c’d to NH (etc)

HIV dx’d Patient Characteristics BRIEF (10/05-1/09) HIV dx’d Patient Characteristics Male* (n = 81) Female (n = 35) Total (n=116) Average Age 40 (range: 21–71) 38 (range: 13-56) (range: 13-71) # NBHN Visits prior to Dx 4.3 13.5 7.1 # of pts newly dx’d HIV+ 67 26 93 # NBHN Visits 1 year prior to Dx 1.8 2.8 2.1 Initial CD4 Count (cells/mm3) 291 374 316 Median Initial Viral Load (c/mL) 68,350 90,700 74,450 * 1 pt is transgender (M -> F) 28

# of pts linked to outpt care # of pts linked to care @ NBHN Linkage to Care (10/05 – 1/09) # of pts dx’d HIV+ n= 116 93 pts are newly dx’d # of pts linked to outpt care n= 97 (84%) # of pts linked to care @ NBHN n= 86

Pts with with AIDS < 12 months after HIV dx # of Patients 49% of all pts with baseine CD4 have and AIDS dx < 12 months after HIV testing (40 pts have CD4<200 and 1 pt has AIDS by hx in clinical progress notes).

Mean (+SE) Rate of Heterosexual Transmission of HIV-1 among 415 Couples, According to the Sex and the Serum HIV-1 RNA Level of the HIV-1-Positive Partner Figure 1. Mean (+SE) Rate of Heterosexual Transmission of HIV-1 among 415 Couples, According to the Sex and the Serum HIV-1 RNA Level of the HIV-1-Positive Partner. At base line, among the 415 couples, 228 male partners and 187 female partners were HIV-1-positive. The limit of detection of the assay was 400 HIV-1 RNA copies per milliliter. For partners with fewer than 400 HIV-1 RNA copies per milliliter, there were zero transmissions. Quinn T et al. N Engl J Med 2000;342:921-929

Disparities in Receipt of HHART Related to Racial Concordance HCSUS study Examined time to HAART for 1241 patients cared for by 287 providers African American patients with white providers received PIs significantly later than patients with concordant providers (p<.001) Low percentage of minority HIV providers and variable cultural competence among white HIV providers may contribute to disparities in receipt of HAART and outcome by race King WD et al. J Gen Intern Med. 2004; 19: 1146-1153.

Treatment Outcomes: Pts @ NBHN (n=69) # of days: HIV dx to 1st med clinic visit (range) Mean = 32 Median = 14 (0-696) # of clinic pts eligible for HAART (DHHS definition) 44 # of days: HIV dx to HAART start (mean, median, range) (n = 36) Mean = 52 Median = 38 (1 – 238) # of pts started on HAART (% of eligible pts) 35/44 (80%) # patients with viral load < 400 c/mL 28 # patients with viral load < 50 c/mL 16 35/44 (80%) OF NBHN PTS ELIGIBLE BY DHHS GUIDELINES (CD < 350 AND/OR VL > 100,000 c/ML and/or symptomatic HIV and/or AIDS) are on HAART. Note that AMONG PTS NOT ON HAART: 4 PTS ARE NO LONGER IN CARE AT NBHN (LAST VISIT > 6 MONTHS AGO) Slide 1: consort total #1: # tested, # linked, # linked to NBHN Slide 2: NBHN pts: # of days dx to clinic visit, # of days starting HAART for those needing HAART Note stating our experience for HAART vs lit Slide 3: NBHN pts: # eligible for HAART, # started on HAART, VL < 400 (some notation of <50) 33

ED Testing Systems System Pros Cons Counselor in ED (Queens, Bx Leb) Can do individualized counseling session Rate-limiting (can only see pts serially) Inefficient Nurses doing testing (Alameda, Metropolitan Physicians (not done yet) May have more contact with pts Limited buy-in by staff More QI on testing practices Limited by staff availability Limited counseling Responsibility for linkage Public Health Advocate with video and technology support Able to efficiently offer high quality counseling High volume testing Data collection Linkage Start-up costs Requires cont’d oversight and program evaluation by expert leadership

ED HIV Screening Programs NY (1/05 – 3/06) LA Oakland Chicago (1/03 – 4/04) GW (9/06 – 12/06) BRIEF (10/05-12/07) Total Patients 72,948 47,736 65,731 154,479 14,986 65,214 Offered and Eligible 1,543 (2%) 1,742 (4%) 31,342 (48%) 5285 (3.42%) 4,187 (27.94%) 7,109 (10.93 %) Accepted 1,296 (84%) 1,713 (98%) 16,547 (52%) 3285 (62.16%) 2,486 (59.37%) 6,214 (87.41%) Tested 1,288 (99.38%) 1,709 (99.77%) 6,368 (38.48%) 3238 (98.57%) (100%) Positive 19 (1.5%) 13 (0.8%) 65 (1%) 83 (2.56%) 26 (1.04%) 57 (0.92%) L to Care 15 (78.95%) 11 (84.61%) 59 (90.77%) (78.31%) 8 (30.77%) 49 (84.21%) 3 of the studies conducted parallel testing = BRIEF, the study at GW and the study in Oakland. The rest tested in series. All the studies delivered pre-test counseling except GW and Oakland – these sites provided written information to their pts. None of the studies provided true post-test counseling except for BRIEF. In the Chicago study, pts could make an appt to come back for post-test counseling in 2 wks. Linkage to care was defined as: NY/LA/Oakland = at least 1 follow-up visit for medical care Chicago = seen at HIV clinic within 4 mo of testing positive GW = seen by ID specialist FTEs: NY/LA = offered by additional HIV counselors. No FTE specified Oakland = offered by triage nurse, tested by exisiting staff. No FTE specified Chicago = 2 FTE, testing offered 9am – 8pm on weekdays GW = testing offered b/t 8am and midnight daily, with 2 screeners assigned during periods of peak activity (no specific # FTEs), screeners were undergraduates who received 8-hr orientation BRIEF = 1.5 – 2 FTEs NY/LA/Oakland = total pts calculated as # of pt visits to ED during study period Chicago = total pts calculated as # of pt visits to ED during study period GW = total pts calculated as # of pts seen in ED druing study period BRIEF = total pts calculated as # of pts available to approach during hours when PHAs were present - MMWR June, 2007

Financial view of BRIEF Re-imbursement for testing 10/05 – 1/09 Estimated Operating Cost of BRIEF = $453,000 24,495 pts tested in ED For NY Medicaid*: $108 re-imbursement for pre-/post test HIV counseling, Approx 25% of pts in JMC ER have Medicaid, 33% have re-imbursable insurance for HIV T&C 24495 pts x 0.68 w/ Medicaid x $108/HIV C&T + 53 SNP> $1,798,913 + $1,060,000* 24495 116 1/09 *Note: 116 pts tested HIV+, 70% of pt come to care @ NBHN (35 pts join SNP, 1.3 x rate for Medicare about 25% of ED pts are uninsured

BRIEF: HIV+ Oct ’07-Oct ’08 (all patients except for 1 pt from Philadelphia) Bronx County is outlined 1 pt lives in Manhattan, 1 pt in Mt Vernon; not shown is pt from Philadelphia Each thumb tack represents a pt