1. 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

2. 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

4. 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

5. 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

6. 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%

7. 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?

8. Barriers to ED HIV Testing
Responsibility
Time
Cost

9. 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

10. 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

11. 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

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

13. 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

14. 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

16. 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

17. 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

18. 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%

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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)

25. 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

26. Linkage to Care Data October 2005 – August 2008

27. 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)

28. 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

29. # 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 NBHN
n= 86

30. 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).

31. 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:

32. 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 ; 19:

33. 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

34. 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

35. ED HIV Screening ProgramsNY
(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

36. 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*
/09
*Note:
116 pts tested HIV+, 70% of pt come to NBHN (35 pts join SNP, 1.3 x rate for Medicare
about 25% of ED pts are uninsured

37. 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