NC HIV/STD Screening Initiatives:HIV in the ER

Brooke Hoots, MSPHFall 2008 HIV/STD Update

September 25, 2008

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

Presentation Outline

Rationale and CDC recommendations for HIV screening in Emergency Departments

HIV in North Carolina UNC ED WakeMed ED Future directions

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

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

Source of HIV Tests

Private doctor/HMOHospital/ED/OutpatientCommunity clinic (public)HIV counseling/testingCorrectional facilitySTD clinicDrug 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

Reasons for Testing: Early v. Late

0%

20%

40%

60%

80%

100%

Illness Self/partnerat risk

Wanted toknow

Routinecheck up

Required Other

Late (Tested < 1 yr before AIDS dx)

Early (Tested >5 yrs before AIDS dx)

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in

Health-Care Settings

MMWR 2006;55(No. RR-14):1-17Published September 22, 2006

http://www.cdc.gov/mmwr/pdf/rr/rr5514.pdf

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

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

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

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

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

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.

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

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

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

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

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

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

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.

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

Testing Recommendations for Providers

REMEMBER SAASSORDER HIV TEST WHEN ≥18 years old & any signs of

STDAIDS

Acute InfectionSubstance 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:

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: __________

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

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

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

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

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

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

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%)

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

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

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)