Project B.R.I.E.F. An innovative multimedia HIV testing system Yvette Calderon, M.D., M.S. Professor of Clinical Emergency Medicine Albert Einstein College of Medicine Jacobi Medical Center, NY
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
HIV/AIDS in New York NYSDOH 2010 Surveillance Report, including cases reported and confirmed through 2008
Bronx Demographics Data from U.S. Census Bureau 1. 2009; 2. 2008
Adult Literacy in NYC www.casas.org/lit/litcode/search.cfm
Awareness of HIV Status Among Persons with HIV and Estimates of Transmission - US ~21% Unaware of Infection ~50-70% of New Infections ~79% Aware of Infection ~30-50% of New Infections People living with HIV/AIDS ~1.1 million New infections per year ~56,300 AMA Jour of Ethics, Dec 2009, Vol 11, Num 12: 974-979
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
Testing by Agency and Agency TypeJanuary 2008 – December 2009 N=175,742 total tests
Why test in the ED? • Inner city EDs servedisadvantaged patient populations,which continue to bear a disproportionate burden of U.S. health disparities. (Alpert 1996, Kelen 1995, Schoenbaum 1993, et al.) • These patientsutilize 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 ofroutine 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.
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 Public Health Advocate Rapid HIV Testing Educational Videos Increased Access to HIV Counseling/Testing in the ED
Protocol for People Testing Positive 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
Project BRIEF Results:Oct. 2005- July 2011 80,392patients approached 71,514pts (89.0%) eligible 66,416pts(92.9%) tested 5,098pts (7.1%) refused 208pts (81%) linked to care 258 pts (0.4% tested HIV+)
Satisfaction with BRIEF model • 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
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)
BRIEF (10/05-07/11) HIV dx’d Patient Characteristics * 1 pt is transgender (M -> F)
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.
HIV Testing on Inpatient Wards June 2010 to June 2011
Demographics of Patients tested in IP vs. ED June 2010-July 2011
BRIEF Concurrent AIDS dx: Newly dx’d pts 42% 47% 57% 38% 61% 13% Total patients tested 67% Note: 33 pts with missing baseline CD4 data
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
BRIEF: HIV+ Oct ’07-Oct ’08(all patients except for 1 pt from Philadelphia) Leroy Pharmacy: E. 204th Bioscrip Pharmacy H Leroy Pharmacy: Gun Hill H Congress Pharmacy De Franco Pharmacy
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
Pharmacy Testing Results 4,177patients approached 2,755pts (66.0%) eligible 2,010pts(73.0%) tested 745pts(27.0%) refused -Data from 10/26/09 to 06/07/11 -289 Days of Testing 6 pts (0.3% tested HIV+)
Special Populations: Adolescents Project Control Post-HIV Test Video Intervention Series
Special Populations: Adolescents Effects of Video and Counselor on Teenagers’ Intentions for Condom Use
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
Special Populations: Black African Immigrants Key Messages
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
"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)
Recruitment Methods • Participants were recruited using a social network strategy that involved leaders of black African community organizations within the Bronx.
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
Mean Annual Per-Patient Costby CD4 Strata Chen RY, et al. Clin Infect Dis. 2006;42:1003-1010.
Lifetime Per-Person Costsby Initial CD4 Count Lifetime Medical Costs ($, in thousands) Life Expectancy (y) 250 25 24.4 230 200 20 195.3 192.3 150 15 15.4 Lifetime Medical Costs ($, in thousands) Life Expectancy (y) 100 10 8.5 50 5 0 0 <199 >500 200-349 Initial CD4 Count (cells/μL) Hutchinson, et al. J Acquir Defic Syndr. 2006;43:451-457.
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 Quinn T et al. N Engl J Med 2000;342:921-929
Cost: Does HIV testing and initiation of HAART impactCOST?
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.
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