1. Yvette Calderon, M.D., M.S. Professor of Clinical Emergency Medicine Albert Einstein College of Medicine Jacobi Medical Center, NY Project B.R.I.E.F. An innovative multimedia HIV testing system

2. Overview Project BRIEF Development of an integrated HIV testing model Data summary Linkage to care Description of model Treatment outcomes HIV Testing in Special Populations HIV Testing in Community Pharmacies Teen-targeted HIV Education and Testing Tailored HIV Education for African Immigrants

3. HIV/AIDS in New York NYSDOH 2010 Surveillance Report, including cases reported and confirmed through 2008

4. Bronx Demographics U.S.A.New YorkBronx Population 1 (millions) 30719.51.4 % Hispanic 1 15.816.852.0 % Black 1 12.917.243.0 Median Household Income 2 $52,029$55,980$35,108 % Below Poverty Line 2 13.213.727.3 Data from U.S. Census Bureau 1. 2009; 2. 2008

5. RegionFunctionally illiterateMarginally literate New York State24%26% NYC36%27% Bronx46%33% Brooklyn41%32% Manhattan31%19% Queens33%30% Staten Island18%28% www.casas.org/lit/litcode/search.cfm Adult Literacy in NYC

6. Awareness of HIV Status Among Persons with HIV and Estimates of Transmission - US AMA Jour of Ethics, Dec 2009, Vol 11, Num 12: 974-979 ~21% Unaware of Infection ~79% Aware of Infection ~50-70% of New Infections ~30-50% of New Infections People living with HIV/AIDS ~1.1 millionNew infections per year ~56,300

7. The Bronx Knows: est. June 2008 NYC Department of Health Initiative –HIV testing for Bronx residents aged 18-64 –Communities engaged in testing Colleges Community-based organizations, Community health centers Correctional facilities NYC Department of Health STD clinics, Faith-based organizations Hospitals

8. Testing by Agency and Agency Type January 2008 – December 2009 N=175,742 total tests

9. Why test in the ED? Inner city EDs serve disadvantaged patient populations, which continue to bear a disproportionate burden of U.S. health disparities. (Alpert 1996, Kelen 1995, Schoenbaum 1993, et al.) These patients utilize the ED for their primary care and have limited or no access to ongoing regular health care. 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) As of September 2010, it is New York State law that Emergency Departments, as well as other clinical settings, must offer HIV testing to all patients.

10. Educational Videos Increased Access to HIV Counseling/Testing in the ED Rapid HIV Testing Public Health Advocate 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

14. 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 Protocol for People Testing Positive

15. 80,392 patients approached 66,416 pts (92.9%) tested 258 pts (0.4% tested HIV+) Project BRIEF Results: Oct. 2005- July 2011 71,514 pts (89.0%) eligible 5,098 pts (7.1%) refused 208 pts (81%) linked to care

16. Patients tested through Project BRIEF Demographics(n=63,122) % Male42.3% Mean Age36.1 ± 14.5 years Race/Ethnicity Hispanic Non-Hispanic Black Non-Hispanic White Asian Other American Indian/ Alaska Native Native Hawaiian/ Pacific Islander 56.8% 34.2% 5.5% 1.5% 1.4% 0.5% 0.1%

17. Risk Factors by Gender Male n=24,137 Female n=32,534 Vaginal sex past 3 mo86.5%89.0% Sex without a condom86.9%91.8% Previous STI dx12.2%12.7% >3 drinks before sex50.9%33.8% Non-IV drugs before sex25.4%11.8%

18. 99.2% felt HIV testing in the ED is helpful. 96.0% felt the video answered their questions regarding HIV testing. 86.5% learned a moderate to large amount of new information BRIEF model Satisfaction with BRIEF model

19. Linkage to Care Data October 2005 – July 2011

20. Linkage to Care (10/05 – 07/11) # of patients diagnosed as HIV-positive n=258 214 pts are newly diagnosed # of patients linked to outpatient care n=208 (82%) # of pts linked to care @ NBHN n=191 (92% of all linked patients)

21. Male* (n = 168) Female (n =90) Total (n=258) Average Age40 (range: 19-82) 39 (range: 13-70) 40 (range: 13-82) # of pts newly dx’d HIV+ 14272214 # NBHN Visits prior to Dx 5.014.28.2 # NBHN Visits 1 year prior to Dx 1.62.31.8 Median Initial CD4 Count (cells/mm 3 ) 282308284 Median Initial Viral Load (c/mL) 31,70040,06333,118 BRIEF (10/05-07/11) HIV dx’d Patient Characteristics * 1 pt is transgender (M -> F)

22. HIV Testing on Inpatient Wards ED-based HIV testing does not reach all patients –especially those whose disease processes are acute enough that they require hospital admission. When patients become stable enough for transfer to an inpatient ward (IP), they may meet inclusion criteria. –However, HIV testing is oftentimes not offered.

23. HIV Testing on Inpatient Wards June 2010 to June 2011 Inpatients approached for HIV testing 2,819 Previously approached for testing in ED 46.1% (831/1,804) Already tested in ED 69.7% (579/831) Refused testing in ED 30.3% (252/831) Accepted testing In IP 48.4% (122/252) Not previously approached in ED 53.9% (973/1,804) Accepted testing in IP 72.5% (705/973) Refused testing In IP 27.5% (268/973) Could not consent to testing in IP 36.0% (1,015/2,819)

24. Demographics of Patients tested in IP vs. ED Patients Tested in IP (n=827) Patients Tested in ED (n=9210) p-value Age 52.8 ± 18.335.9 ± 14.3<0.01 Male 49.1% (406/827)43.5% (4003/9210)<0.01 Hispanic 48.2% (391/811)52.4% (4812/9187)0.02 Black, Non-Hispanic 28.2% (229/811)35.6% (3294/9187)<0.01 Prior HIV Test 63.8% (526/825)77.8% (7104/9128)<0.01 June 2010-July 2011

25. BRIEF Concurrent AIDS dx: Newly dx’d pts Note: 33 pts with missing baseline CD4 data 67% 38%61% 47% 42% 57% 13% Total patients tested

26. HIV Testing in Pharmacies Phase 1: testing at one pharmacy site to assess feasibility Phase 2: expansion to multiple sites Phase 3: addition of multimedia tool for efficient data acquisition and video messaging in different languages

27. BRIEF: HIV+ Oct ’07-Oct ’08 (all patients except for 1 pt from Philadelphia) H H Congress Pharmacy De Franco Pharmacy Bioscrip Pharmacy Leroy Pharmacy: E. 204th Leroy Pharmacy: Gun Hill

28. HIV Testing in Pharmacies Evaluated 12 different pharmacies for: –Location –foot traffic –staff acceptance –private area for testing Selected five highest-ranked pharmacies Obtained a Limited Testing Laboratory certificate from New York State for each pharmacy site Established a hospital-based medical record documentation protocol

29. 4,177 patients approached 2,010 pts (73.0%) tested 6 pts (0.3% tested HIV+) Pharmacy Testing Results 2,755 pts (66.0%) eligible 745 pts (27.0%) refused -Data from 10/26/09 to 06/07/11 -289 Days of Testing

30. Community Pharmacy Testing: Demographics BioscripDe FrancoCongressLeroy Mean Age (range) 32.7 (13-86)31.9 (13-82)33.7 (15-88)36.0 (16-75) Male 40.1% (400/998) 42.0% (261/622) 43.3% (101/233) 32.9% (46/140) Hispanic 54.7% (546/998) 63.7% (387/608) 60.3% (147/234) 59.0% (82/139) Non-Hisp. Black 34.9% (348/998) 33.0% (205/622) 33.8% (79/234) 30.2% (42/139) Language English Spanish Other (n=987) 74.0% (730) 24.1% (238) 1.9% (19) (n=618) 70.7% (441) 25.3% (158) 3.1% (19) (n=231) 68.8% (159) 26.8% (62) 4.4% (10) (n=141) 73.0% (103) 27.0% (38) 0% (0) Uninsured 34.9% (344/985) 33.4% (207/619) 33.2% (79/238) 29.6% (42/142)

31. Pharmacy HIV+ pts PatientRisk factor CD4VLComments 61 yo AA FHP6221658DM, HTN, amb care pt 29 yo HMIDU27314725Prev dx’d, never linked prev 34 yo HMMSM71889369RPR 1: 512 33 yo AAMMSM11805453Mentally challenged, exchanging sex for $ 23 yo black HMMSM494964820 yo M (MR#  ) partner tested HIV neg  both linked: 1 for HIV care, 1 for nPEP

32. Special Populations: Adolescents Project Control Post-HIV Test Video Intervention Series

34. Special Populations: Adolescents Effects of Video and Counselor on Teenagers’ Intentions for Condom Use Condom Use measure Video Mean improvement Counselor Mean improvement Mean difference (video vs. counselor) p-value 95% CI Condom Use Intention Score 0.98-0.041.020.01(0.24, 2.30) Condom Self-Efficacy 0.31 0.050.260.03(0.03, 0.50) Male Condom Outcome Expectancy 0.19 0.040.150.03(0.02, 0.28) Female Condom Outcome Expectancy 0.16-0.040.200.06(-0.01, 0.40)

35. Special Populations: Black African Immigrants We conducted focus groups with black African immigrants to identify: -barriers to HIV testing -methods to increase voluntary HIV testing -receptivity to media/video based interventions

36. Special Populations: Black African Immigrants Key Messages Barriers to HIV Testing Stigma Immigration Status Hospital Setting Confidentiality Methods to Increase Testing Collaborate with Community Leaders Provide Culturally-relevant Education General Health Approach Receptivity to Video Messaging Comprehension Cultural Relevancy Persuasiveness Receptiveness

37. Special Populations: Black African Immigrants Preliminary qualitative research revealed 3 key messages: –Culturally-relevant HIV education must be incorporated into messages of general health and wellness –HIV testing must exist in venues located outside of traditional medical care facilities –Use of video to provide tailored messages is acceptable to this community

38. "Now this is not the end. It’s not even the beginning of the end. But it is, perhaps, the end of the beginning.” -Sir Winston Churchill (Second Battle of El Alamein)

39. BioscripDe FrancoCongressLeroy Start Date 10/26/200901/06/201009/16/201011/15/2010 Days of testing 161875231 Patients Approached 21231299513241 Eligible Pts 66.2% (1406/2123) 65.1% (846/1299) 63.5% (326/513) 71.8% (173/241) Eligible Pts tested 71.0% (998/1406) 73.8% (624/846) 74.2% (242/326) 84.4% (146/173) Mean tests per day (range) 7.5 (3-18) 7.2 (1-12) 5.0 (2-10) 4.0 (1-9) # Positive Pts 5010 Community Pharmacy Testing

40. Community Pharmacy Testing: Demographics BioscripDe FrancoCongressLeroy Mean Age (range) 32.7 (13-86)31.9 (13-82)33.7 (15-88)36.0 (16-75) Male 40.1% (400/998) 42.0% (261/622) 43.3% (101/233) 32.9% (46/140) Hispanic 54.7% (546/998) 63.7% (387/608) 60.3% (147/234) 59.0% (82/139) Non-Hisp. Black 34.9% (348/998) 33.0% (205/622) 33.8% (79/234) 30.2% (42/139) Language English Spanish Other (n=987) 74.0% (730) 24.1% (238) 1.9% (19) (n=618) 70.7% (441) 25.3% (158) 3.1% (19) (n=231) 68.8% (159) 26.8% (62) 4.4% (10) (n=141) 73.0% (103) 27.0% (38) 0% (0) Uninsured 34.9% (344/985) 33.4% (207/619) 33.2% (79/238) 29.6% (42/142)

41. Community Pharmacy testing: Risk Factors of Patients Tested BioscripDe FrancoCongressLeroy Condom use described as never, almost never, or sometimes 47.6% (444//933) 48.5% (283/584) 50.7% (109/215) 62.2% (79/127) Previously had an STD 10.8% (105/973) 11.8% (73/620) 12.1% (28/231) 14.5% (12/137) Sex with partner with HIV 2.0% (19/949) 3.8% (23/611) 2.6% (6/231) 1.4% (2/138) Sex with known MSM 3.1% (29/950) 0.7% (4/613) 3.0% (7/2313) 4.7% (6/127)

42. Recruitment Methods Participants were recruited using a social network strategy that involved leaders of black African community organizations within the Bronx.

43. Data Analysis Digital recordings were transcribed Four researchers coded themes using Nvivo –Attitudes towards use of video –Barriers to HIV testing –Strategies to improve HIV testing

44. Mean Annual Per-Patient Cost by CD4 Strata Chen RY, et al. Clin Infect Dis. 2006;42:1003-1010.

45. Lifetime Per-Person Costs by Initial CD4 Count Hutchinson, et al. J Acquir Defic Syndr. 2006;43:451-457. Lifetime Medical Costs ($, in thousands) Life Expectancy (y) Initial CD4 Count (cells/μL) 0 5 10 15 20 25 0 50 100 150 200 250 <199 200-349 >500 192.3 195.3 230 8.5 15.4 24.4 Lifetime Medical Costs ($, in thousands) Life Expectancy (y)

46. Quinn T et al. N Engl J Med 2000;342:921-929 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

47. Cost-Effectiveness of Screening for Other Chronic Diseases C-E RATIO Screening program$/QALYReference HYPERTENSION Asymptomatic men >20 y/o $29,300 1 Littenberg. Ann Intern Med. 1990. BREAST CANCER Annual mammogram, women 50-69 y/o $46,500 4 Salzmann. Ann Intern Med. 1997 HIV Routine, rapid testing in health settings $50,000 5 Paltiel. Ann Intern Med. 2006 DIABETES MELLITUS Type 2 fasting plasma glucose, adults >25 y/o $57,000 2 CDC C-E Study. JAMA. 1998. COLON CANCER FOBT + SIG q5y, Adults 50-85 y/o $92,900 3 Frazier. JAMA. 2000.

48. Does HIV testing and initiation of HAART impact COST? Cost:

49. Governor Paterson Signs into Law Landmark HIV Testing Legislation! (July 30, 2010) http://open.nysenate.gov/legislation/bill/S8227 The new legislation (S08227/A11487) will institute significant advances in making HIV testing routine, such as: Requiring the offering of an HIV test in all public (Article 28) and private health care settings thereby establishing the offer of an HIV test as the standard of care; Extending required offering of HIV screening to individuals ages 13-64 years old; Requiring that informed consent be obtained prior to performing an HIV test; Facilitating routine testing by permitting flexibility in how informed consent is documented where rapid technology is used; Providing durable consent where written consent is part of the general consent to medical care with an opt-out for HIV testing. Durable unless patient changes providers or revokes the consent; Requiring that when an HIV test is positive, with the patients’ consent, the person ordering the test must provide or arrange for follow-up medical care.

50. Governor Paterson Signs into Law Landmark HIV Testing Legislation! (July 30, 2010) Responsiblity Requiring the offering of an HIV test in all public (Article 28) and private health care settings thereby establishing the offer of an HIV test as the standard of care; –including hospitals, emergency rooms, hospital outpatient departments, and primary care settings including physician, physician assistant, nurse practitioner and midwife offices

51. NY HIV Testing Legislation! Counseling The new legislation (S08227/A11487) will institute significant advances in making HIV testing routine, such as: Section 1 also provides that HIV counseling messages shall be tailored based on whether the HIV test indicates infection. Counseling with respect to positive tests will remain consistent with existing law. In the case of negative results, counseling will emphasize risks associated with participating in high risk behavior and may be accomplished by oral or written reference to information previously provided.

53. Informed Consent vs Assent Informed consent: Explanation of the risks, benefits and alternatives to testing, and some attempt to ensure that these are understood Opt-out assent: “The patient will be notified that the test will be performed, and consent is inferred unless the patient declines.”

54. Revised Recommendations Adults and Adolescents Routine, voluntary HIV screening for all persons 13-64 years in healthcare settings Opt-out HIV screening with the opportunity to ask questions and the option to decline testing Separate signed informed consent should not be required Prevention counseling in conjunction with HIV screening in healthcare settings should not be required

57. Qualitative Research The videos were made with input from focus groups and semi-structured individual interviews The material was tailored to meet the needs of urban youth

58. Adolescent-Specific Multimedia Program Project Control is a theory-based program designed for teens by teens

59. Adolescent-Specific Multimedia Program This study compared a youth-friendly HIV education video to in-person HIV counseling to determine the most effective way to convey HIV knowledge and improve HIV testing rates

60. Adolescent-Specific Multimedia Program Results Of 333 eligible patients, 200 (60%) agreed to participate and were randomized Counselor (n=100) Video (n=100) p- value Age17.5 ± 1.918.1 ± 2.00.04 Male53%52%0.89 Hispanic52%41%0.12 Prior HIV test40%30%0.14 Avg pre-test score57.6%58.5%0.18

61. Adolescent-Specific Multimedia Program - Results VideoCounselor Average score78.5%66.3% p-value<0.01 95% C.I.76.2 to 80.163.6 to 69.0 Post-test HIV knowledge scores

62. Adolescent-Specific Multimedia Program Conclusions 51% of adolescents who watched the video consented for HIV testing – only 22% of adolescents who received in- person counseling consented (p<0.01) A youth-friendly HIV education video improved HIV knowledge and increased rates of testing

65. RCT 2: Effect of a theory-based, post-HIV test counseling video designed with feedback from adolescents Goal of the investigation –determine if focused, teen-specific videos change intended risk behavior compared to standard HIV testing and counseling Participant eligibility –Between 15 and 21 years old –Sexually active

66. Stages of Change Model Behavior change is the result of change that occurs in smaller stages. –Precontemplation: not thinking seriously about changing behavior –Contemplation: aware of the problems caused by a specific behavior –Preparation: make a commitment to change –Action: take steps to change behavior –Maintenance: take steps to avoid relapse in behavior

67. Stages of Change for Condom Use

68. Theory-based videos Stages of Change Model for Condom Use 5 Stages of Change 1.Pre-contemplator 2.Contemplator 3.Preparation for action 4.Action 5.Maintenance  “Negative consequences” video  “Positive consequences” video

69. Theory of Reasoned Action A person’s attitude toward a behavior, combined with subjective norms, forms one’s behavioral intentions. Validated measures to determine behavioral intention –Self-Efficacy: attitude of one’s ability to perform a behavior –Outcome Expectancy: beliefs on the likely consequences for a behavior

70. Measures Self-Efficacy: 12 Questions Ex: On a scale of 1 (not sure at all) to 7 (completely sure): You can put a condom on yourself so that it will not slip or break? Outcome Expectancy: 9 questions Ex: On a scale of 1 (strongly disagree) to 5 (strongly agree): If you use condoms, your relationship with your partner will be better

71. RCT 2: Design and Demographics Counselor (n=101) Video (n=102) p-value Age18.7 ± 1.618.8 ± 1.50.58 Male45%39%0.44 Hispanic57%60%0.73 Prior HIV test69%66%0.69 - 2 study arms: counselor group (control) and video group (experimental) - Participants completed pre- and post-intervention measures on: condom intention, condom outcome expectancy, and condom self-efficacy. Both arms offered HIV testing. - 203 (94%) agreed to participate and were randomized.

72. Participant Flow Diagram

73. RCT 2: Results Stages of Change for Condom Intention Measure –Mean difference in both arms for change over time: 1.02, CI(.24,1.80) SD=2.87. Through immediate change in condom intention score, the intervention: 1. helped people progress to the next level of readiness 2. maintained participants’ positive behavior

74. B.R.I.E.F. validation study Validate the effectiveness of B.R.I.E.F. in a community hospital ED acceptability patient satisfaction linkage to care

75. Validation study- results *n=11565;5350 5123 patients were tested in the community ED % of Patients

76. Conclusions This model’s effectiveness in two distinct venues suggest more widespread applicability CommunityUrbanDifference;95% CI HIV+0.35% (18/5123)0.35% (39/11038)0%; [-0.2 to 0.2] Linked to care77.8% (14/18)84.6% (33/39)-6.8%; [ -31 to 13] Newly dx’d77.8% (14/18)79.5% (31/39)-1.7%; [-27 to 18] AIDS at dx35.7% (5/14)51.4% (18/35)-16%; [-41 to 14] Initial CD4 (mean)419 ± 316342 ± 36977; [-156 to 309] Outcomes for Positive Patients

77. Analysis of patients who refuse testing Characteristics and risk factors of patients who decline HIV testing

78. Refusal Analysis - Results 44% of patients refused testing because they felt they were “not at risk for HIV infection.”  59.2% had vaginal sex in the past 3 months  49.2% described condom use as “never”  10.9% had a previous STI diagnosis  37.1% had more than one current sexual partner AcceptedRefused Male46.5% (6919/14849)47.2% (515/1090) Hispanic50.4% (7492/14860)13.5% (147/1090) Black34.5% (5128/14860)40.2% (438/1090) Married14.6% (2175/14860)18.1% (197/1090) Age ≤ 2945.9% (6810/14843)27.6% (300/1087)

79. Cost: Chen et al, CID 2006;42-1003-1010

80. HIV Testing Expansion: Earlier Diagnosis, Higher CD4 Counts Program to expand testing in medical and jail settings in Washington, DC began in 2006 Since program began, patients diagnosed with higher CD4 counts at initial testing During first 18 months of program, increase in median CD4+ count at diagnosis to 332 cells/mm 3 Median CD4+ Count at Time of Testing 215 187 198 220 262 332 183 0 50 100 150 200 250 300 350 2001200220032004200520062007 Year of HIV Diagnosis Median CD4 Count Hader S, et al. 16th CROI; 2009; Montreal. Abstract 57.

81. Qualitative Research Study: African-born Immigrants Population Data African immigrants to the USA increased from 109,733 between 1961 and 1980 to 531,832 between 1981 and 2000. The Bronx’s sub-Saharan African population ballooned from 12,063 in 1990, to 36,361 in 2000, to 54,932 in 2007.

82. African-born Immigrants: HIV data African-born individuals in the USA had a disproportionately high prevalence of HIV – although they comprised only 0.6% of the study population, almost 4% of HIV diagnoses were amongst African-born individuals. –up to 41% of diagnoses in F’s (mean: 8.4%, range: 4%-41%) & up to 50% of diagnoses in blacks (mean: 8.0%, range: 2%-50%) occurred among African-born individuals. –Data collated and analyzed aggregate data on persons dx’d with HIV in 2003-2004 and reported to HIV surveillance units in California, Georgia, Massachusetts, Minnesota, and NJ and in King County, Washington; NYC; and the portion of Virginia included in the DC, metropolitan area There is a “hidden epidemic” of HIV amongst African migrants living in the USA. JAIDS Journal of Acquired Immune Deficiency Syndromes. 49(1):102-106, 1 September 2008.

83. Qualitative Research Study: African-born Immigrants Community-based Participatory Research –Engage African-born immigrant community Small, gender-divided focus groups –Produce culturally-sensitive educational media Tailor HIV educational messages to a specific community –Modify videos according to community feedback

84. Adolescent Cohort CDC estimates indicate that HIV seroincidence rates among individuals 13- 29 are increasing B.R.I.E.F. patients under 21 were analyzed to assess the efficacy of the intervention on this high risk group

85. Conclusions Despite the challenges to engage and test teens: High acceptability of an integrated, ED-based HIV testing program The computer program helped to elicit a behavior profile which showed significant HIV risk This model could be an important way to expose a hard-to-reach and high risk population to HIV prevention messages

86. Conclusions- RCT2 Young people are engaging in behavior which puts them at high risk for contracting HIV Innovations in HIV prevention need to be utilized to influence those most at risk Interventions should be tailored to meet the needs of the community and formulated with input from teens

87. Qualitative Research Study: African-born Immigrants Community-based Participatory Research –Work with African-born immigrant communities to share videos in key community settings Expansion to other sites across the world –Dublin, Ireland

88. Total: 33 million (30 – 36 million) Western & Central Europe 730 000 [580 000 – 1.0 million] Middle East & North Africa 380 000 [280 000 – 510 000] Sub-Saharan Africa 22.0 million [20.5 – 23.6 million] Eastern Europe & Central Asia 1.5 million [1.1 – 1.9 million] South & South-East Asia 4.2 million [3.5 – 5.3 million] Oceania 74 000 [66 000 – 93 000] North America 1.2 million [760 000 – 2.0 million] Latin America 1.7 million [1.5 – 2.1 million] East Asia 740 000 [480 000 – 1.1 million] Caribbean 230 000 [210 000 – 270 000] Adults and children estimated to be living with HIV, 2007

89. USA Statistics 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

90. 3,948 patients approached 1,940 pts (73.8%) tested 6 pts (0.3% tested HIV+) Pharmacy Testing Results 2,627 pts (66.5%) eligible 687 pts (26.2%) refused -Data from 10/26/09 to 05/01/11

91. BioscripDe FrancoCongress Start Date10/26/200901/06/201009/16/2010 Days of testing1028722 Patients Approached15201299266 Eligible patients 68.0% (1033/1520) 65.1% (846/1299) 64.7% (172/266) Eligible Patients tested 74.4% (769/1033) 73.8% (624/846) 76.7% (132/172) Mean tests per day (range) 7.5 (3-18) 7.2 (1-12) 6.0 (2-10) Community Pharmacy Testing Two patients have tested positive

92. Community Pharmacy Testing: Demographics BioscripDe FrancoCongress Mean Age (range) 33.6 (13-86)31.9 (13-82)32.9 (15-74) Male 39.6% (305/769) 42.0% (261/622) 44.3% (58/131) Hispanic 55.4% (426/769) 63.7% (387/608) 60.3% (79/131) Non-Hisp. Black 33.9% (261/769) 33.0% (205/622) 34.4% (45/131) Language English Spanish Other (n=764) 71.3% (545) 26.7% (204) 2.0% (15) (n=618) 70.7% (441) 25.3% (158) 3.1% (19) (n=130) 71.5% (93) 23.8% (31) 4.6% (6) Uninsured 38.5% (294/764) 33.4% (207/619) 35.9% (47/131) Prior HIV Test 74.3% (567/763) 76.4% (476/623) 86.3% (113/131)

93. Community Pharmacy Testing: Demographics BioscripDe FrancoCongress Mean Age (range) 33.6 (13-86)31.9 (13-82)32.9 (15-74) Male 39.6% (305/769) 42.0% (261/622) 44.3% (58/131) Hispanic 55.4% (426/769) 63.7% (387/608) 60.3% (79/131) Non-Hisp. Black 33.9% (261/769) 33.0% (205/622) 34.4% (45/131) Language English Spanish Other (n=764) 71.3% (545) 26.7% (204) 2.0% (15) (n=618) 70.7% (441) 25.3% (158) 3.1% (19) (n=130) 71.5% (93) 23.8% (31) 4.6% (6) Uninsured 38.5% (294/764) 33.4% (207/619) 35.9% (47/131) Prior HIV Test 74.3% (567/763) 76.4% (476/623) 86.3% (113/131)

94. Community Pharmacy testing: Risk Factors of Patients Tested BioscripDe FrancoCongress Condom use described as never, almost never, or sometimes 46.5% (342/718) 48.5% (283/584) 51.6% (64/124) Sex with multiple partners 40.2% (309/769) 38.0% (237/624) 43.2% (57/132) Previously had an STD 9.4% (72/761) 11.8% (73/620) 14.5% (19/131) Sex with partner with HIV 1.8% (13/737) 3.8% (23/611) 3.1% (4/131) Sex with known MSM 3.0% (22/738) 0.7% (4/613) 1.5% (2/131)

95. Special Populations: Black African Immigrants Female (n=6) Male (n=8) Age Range (years) 25-5025-45 Country of Origin Nigeria (6/6) Côte d'Ivoire (6/8) Mali (2/8) Length of stay in U.S. > 1year 100% Regularly engaged in health care 2/6 0/8

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

97. Special Populations: Black African Immigrants Collaborate with Community Leaders “You can also…try to contact the imam, try to contact the head of the different communities. Try those people to involve those people, probably they're going to help.” Cultural Relevance “I think it's going to be important to have an African—somebody from Africa (physician)… and he's working over here, I think that is very important. That [is] going to encourage people to come get tested. General Health Approach “In order to make more Africans engage in testing, I think you don't have to focus only on HIV, but focus on other diseases like high blood pressure, many things.” “[If you are testing] for just HIV you won't see nobody.” Strategies to Increase HIV Testing Special Populations: Black African Immigrants