NC HIV

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

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

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

6. Source of HIV Tests Private doctor/HMO Hospital/ED/Outpatient Community clinic (public) HIV counseling/testing Correctional facility STD clinic Drug treatment facility

7. Reasons for Testing: Early v. Late

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

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

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

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

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

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

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

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

23. Testing Recommendations for Providers

24. ID Clinic Referral Card

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

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)