1. HIV Counseling, Testing and Referral (CTR) Services at Boston Medical Center Vanessa J. Sasso, MSW Manager, HIV CTR Program Center for HIV/AIDS Care and Research (CHACR)

2. Background Over 1 million people are living with HIV in the US Approximately 25% dont know it Approximately 40K new cases of HIV per year 40 - 50% of all new HIV cases develop AIDS within 1 year of first testing HIV positive CDC

3. Major Objectives of our CTR Program Find all HIV+ patients Link all HIV+ patients to care Prevent new cases of HIV

4. Testing Sites at BMC Urgent Care Center / ED Hierarchical routine screening/ Patients typically dont utilize PCPs Inpatient Medical Service Hierarchical routine screening/ Some physician referrals Public Health STD Clinic All patients receiving STD screens offered HIV CTR Adult Primary Care Clinic Patients mostly referred by physicians/ Some routine testing Project TRUST Drop-in Center Harm reduction center/ Clients acknowledge risk Other: Community venues i.e. Dimock Detox, BPHC Needle Exchange Van, MALE Center

5. Program Data (2006) Location# Tested# PositivePrevalence UCC 1018141.38% Drop-In 2063251.21% Primary Care 99580.80% Inpatient 1345241.78% STD 1736301.73%

6. Overview One of the first CTR sites in the nation Largest case reporter in MA High volume testing program Originally only drop in testing; now fully integrated into medical system Pioneered routine hospital based testing Piloted Urgent Care/Emergency Room testing Piloted rapid testing for MDPH

7. Testing Technologies Offered Traditional Venipuncture OMT (OraSure) Rapid Testing (OraQuick Advance)

8. Rapid vs. Traditional With Traditional Tests: Pre-test Counseling Session (Visit #1) 2 weeks for result to come back HIV counselor can prepare for positive results and plan for linkage to care Post-test Counseling Session (Visit #2) Loss to follow-up: ~85% overall return rate within our program, CDC reports a national average of ~30%

9. Rapid vs. Traditional With Rapid Tests: Same day test results No preparation time for HIV Counselor Explanation of test result meaning Negative Preliminary positive and/or Reactive Essentially 100% of negatives get results Immediate linkage to care

10. Pre-test Counseling Changes It is now one visit (pre- and post-test counseling in one visit) Patient acceptance and competency for testing assessed initially Consent form must specify need for confirmatory serum sample (Patient needs to understand RT is a screening tool) Risk/demographic data collected while test is running If reactive/preliminary positive, immediate blood draw and linkage to care occurs

11. Rapid vs. Traditional Monthly we are doing ~100% rapid testing Linkage to care for HIV+ increased from 85% to ~100% Community satisfaction!

12. Implementation of Rapid Testing Specialized staff training Coordination with BMCs Department of Laboratory Medicine and MDPH

13. Rapid Testing Roll-Out Rapid Test Trainings: Massachusetts Department of Public Health (MDPH) BMCs Department of Laboratory Medicine Counselors now wear two hats: Counselor and Lab Tech! Staff Training

14. Laboratory Medicine Buy-in and support from Laboratory Director CLIA Point of Care Coordinator Monitors QA/QC Trains and evaluates Counselors; Approves competency and ongoing proficiency Approves paperwork and documentation Enters results into BMC medical records

15. Logistics Designed special rolling mobile testing carts proper lighting, temperature and work space Lid on the cart can be closed while test is running so counselor and/or patient is not distracted Counselors are now delivering a preliminary diagnosis to the client More staff time is dedicated to paperwork and performing the test Storage and cost of kits and controls

16. Conclusion Dedicated staff instrumental Major institutional commitment required Laboratory support and involvement crucial Actual supply costs high Inpatient and outpatient clinical areas well suited for hierarchical routine testing Routine testing facilitates testing and improves case identification Linkage to care for HIV+ patients is crucial and rapid testing helps facilitate immediate linkage to care

17. Acknowledgements Paul Skolnik Jon Hall Jeff Greenwald Kim Gregory Joann Crain All of the 11 HIV Counselors MDPH CDC BMC Collaborators Funding