1. NC HIV/STD Screening Initiatives: HIV in the ER Brooke Hoots, MSPH Fall 2008 HIV/STD Update September 25, 2008

2. Acknowledgements  NC HIV/STD Branch Pete Moore Jan Scott  UNC Peter Leone, MD Cynthia Gay, MD, MPH Theresa Patrick, RN Byrd Quinlivan, MD James Larson, MD  WakeMed Jennifer Raley, MD Janice Frohman, RN Susan Harris, RN  CDC Bernard Branson, MD

3. Presentation Outline  Rationale and CDC recommendations for HIV screening in Emergency Departments  HIV in North Carolina  UNC ED  WakeMed ED  Future directions

4. Awareness of HIV Status, US Number HIV infected Number unaware of their HIV infection Estimated new infections annually Those with unrecognized infection account for ~51% of new infections 1,039,000 – 1,185,000 252,000 – 312,000 (24-27%) 56,000 ~29,000 Glynn M, Rhodes P. 2005 HIV Prevention Conference

5. Late HIV Testing is Common  Among 4,127 persons with AIDS, 45% were first diagnosed HIV-positive within 12 months of AIDS diagnosis  Late testers, compared to those tested early (>5 years before AIDS diagnosis) were more likely to be: Younger (18-29 years) Less educated African American or Hispanic Slide courtesy of Bernard Branson, MD; MMWR June 27, 2003

6. Source of HIV Tests Private doctor/HMO Hospital/ED/Outpatient Community clinic (public) HIV counseling/testing Correctional facility STD clinic Drug treatment facility 44% 22% 9% 5% 0.6% 0.1% 0.7% 17% 27% 21% 9% 5% 6% 2% HIV tests* HIV + tests** *National Health Interview Survey, 2002 **Supplement to HIV/AIDS surveillance, 2000-2003

7. Reasons for Testing: Early v. Late 0% 20% 40% 60% 80% 100% IllnessSelf/partner at risk Wanted to know Routine check up RequiredOther Late (Tested < 1 yr before AIDS dx) Early (Tested >5 yrs before AIDS dx)

8. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings MMWR 2006;55(No. RR-14):1-17 Published September 22, 2006 http://www.cdc.gov/mmwr/pdf/rr/rr5514.pdf

9. CDC Revised Recommendations - I  Routine, voluntary HIV screening for all persons 13-64 in health care settings, not based on risk  All patients with TB or seeking treatment for STDs should be screened for HIV  Repeat HIV screening of person with known risk at least annually Slide courtesy of Bernard Branson, MD

10. CDC Revised Recommendations - II  When acute retroviral infection is a possibility, use an RNA test in conjunction with an HIV antibody test  Settings with low or unknown prevalence: Initiate screening If yield from screening is less than 1 per 1,000 (0.1%), continued screening is not warranted Slide courtesy of Bernard Branson, MD

11. CDC Revised Recommendations – III  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 health care settings should not be required Slide courtesy of Bernard Branson, MD

12. Rationale for CDC Revisions  Many HIV-infected persons access health care but are not tested for HIV until symptomatic (late stage)  Effective treatment available  Awareness of HIV infection leads to substantial reductions in high-risk sexual behavior  Inconclusive evidence about prevention benefits of “typical” counseling for persons who test negative  Great deal of experience with HIV testing Slide courtesy of Bernard Branson, MD

13. HIV in North Carolina  ~31,000 living with HIV (1,700 new cases per year)  ~18,000 aware of HIV infection (30-40% unaware of HIV status)  ~12,000-13,000 in care Slide courtesy of Peter Leone, MD

14. EDs and the Uninsured  EDs serve as the source of primary care for many patients with limited access to medical care  In NC, ~17.9% of non-elderly residents were uninsured in 2004  Uninsured rates were highest among Hispanics, blacks, and female heads of household families Stern RS, Weissman JS, Epstein AM. JAMA 1991;266(16):2238-43. Sun BC, Burstin HR, Brennan TA. Acad Emerg Med 2003;10(4):320-8. DHHS NC. North Carolina 2005 HIV/STD surveillance report. 2006. Available at www.epi.state.nc.us/epi/hiv.www.epi.state.nc.us/epi/hiv

15. People living with HIV/AIDS in NC  Epidemic of disparity 62% Black 8% Hispanic  Women and HIV 29% of all cases are female 78% Black, 6% Hispanic Slide courtesy of Peter Leone, MD

16. Late Testing in North Carolina  Study of patients initiating HIV care at the UNC ID clinic found that the median CD4 count was 202 68% initiated care within one year of AIDS diagnosis  True story: Patient presented to local ED stating that he thought he had acute HIV infection and was referred to a local HD

17. Missed Opportunities for Testing  Review of 37 individuals diagnosed with acute HIV infection in NC ( unpublished data ). 28 (76%) initially presented to an ED or urgent care clinic with symptoms Only 7 (19%) were diagnosed with HIV on initial presentation to care If they had not presented again for medical care, the diagnosis would likely have been missed

18. NC HIV Rule Changes  November 1, 2007  Requirement for pre-test counseling removed  Requirement for post-test counseling of HIV- negative patients removed  HIV testing may be included in general consent for treatment

19. Barriers to HIV Testing in EDs  Surveys consistently indicate time is biggest obstacle  Concern for lack of patient acceptance of testing  Concern for ensuring adequate follow-up  Lack of privacy and space for counseling

20. Removing Barriers at UNC  UNC Hospitals incorporated HIV consent into general consent for treatment signed at entry to ED Verbal notification and consent still required  Follow-up of positive HIV results ID Clinic assumes full responsibility for follow-up of patients

21. Program Goals in UNC ED  To create an acceptable and sustainable HIV testing program in the UNC ED with post-test counseling and linkage to care provided by the UNC ID Clinic.  To prospectively characterize the patients targeted by ED providers for HIV testing and determine the proportion testing positive and successfully linked into HIV care.

22. HIV Testing Process at UNC ED Patient presents to ED and signs general consent for care Provider decides to test patient for HIV, informs patient about test Patient does not opt out, blood drawn for HIV1/2 Antibody Test* Patient opts out and test is not done Patient given referral card to Infectious Disease Clinic to receive test results Provider documents consent and test in patient’s record *HIV-antibody negative samples are pooled for RNA testing by the UNC Hospitals lab

23. Testing Recommendations for Providers REMEMBER SAASS ORDER HIV TEST WHEN ≥18 years old & any signs of STD AIDS Acute Infection Substance Abuse (every 6m) Sexual Risk Behavior (every 6m) Mono-like illness (fever, LAD, pharyngitis) Gastrointestinal illness (n/v, fever, diarrhea) Aseptic meningitis Fever, rash Above with any of the following: oral ulcers, fatigue, myalgias/ arthralgias, wt loss Think about Acute HIV with:

24. ID Clinic Referral Card EMERGENCY ROOM TEST FOLLOW-UP Please bring this card to the UNC Infectious Diseases Clinic (directions on back) to receive the results of your ER lab test. You may walk in to the clinic on Fridays any time between 9:00 am and 12:00 pm at least one week after the date of your ER visit. If you cannot come to the clinic on Friday between 9:00 am and 12:00 pm, you may schedule an appointment by calling 919-966-7198 or 1-800-241-7586 ER entrance Manning Drive Enter the NC Memorial Hospital lobby (#1) and go to the Information Desk. You will be directed to the Infectious Diseases Clinic. Parking is available in the Dogwood Deck (#6). Today’s date: __________

25. Follow-Up by UNC ID Clinic  Automated report of all HIV results from ED printed in ED clinic twice weekly at specified time  Reviewed by program staff  HIV positive results are flagged and given to clinic staff for follow-up

26. Post-test Counseling  Clients with negative results who come to the ID clinic receive full post-test counseling  HIV-positive patients are seen by counselor and medical provider Offered on-site new patient assessment Access to financial counselor/assistance Follow-up in ID clinic within 7-14 days

27. Loss to Follow-Up  HIV-negative patients – No follow-up  HIV-positive patients Clinic provider contacts patient and schedules appointment to receive results If unable to reach, or patient declines walk-in or scheduled appointment, regional DIS will be notified

28. UNC Data  Tests between 5/11/08 and 9/11/08: 264  New positives: 4 (1.5%) Acute: 19-year old white male (homosexual, substance abuse) 50-year old white male (thrush, bacterial pneumonia, AIDS dx) 19-year old black female (pregnant) 26-year old black male (cough, fever)  Previously known positives: 7 All not in care at time of ED visit

29. HIV Testing at WakeMed ED  Goals Higher numbers of high-risk clients tested More new cases identified Quick referrals into care for newly diagnosed positives

30. WakeMed Program  Separate HIV consent still required by hospital  Blood draws sent to hospital lab, which reports HIV test results back to ED nurse  DIS handle follow-up and referral to care

31. WakeMed Data  Population to test: Physician suspicion of infection Concurrent treatment for STDs Drug abuse Homeless New pregnancy  Tests between 2/4/08 and 9/15/08: 130  New positives: 4 (3.1%)

32. Strategic Planning Workshop  June 18-19, 2008  13 North Carolina hospitals  Collaborations between medical staff, laboratory, nursing management, hospital administration, and infection control needed  SWOT analysis  Focused on rapid testing

33. Future Directions  UNC Encourage ED personnel to expand testing to all patients meeting risk-based criteria Routine screening of all patients during particular shifts Start rapid testing during particular shifts, with all preliminary positives referred to ID clinic

34. Future Directions cont.  WakeMed In process of hiring bridge counselor who will work with WakeMed and Wake County Human Services Provide students for particular shifts to administer consent forms  Follow-up with other North Carolina hospitals Incremental approaches (diagnostic testing to targeted testing to screening)