NC HIV/STD Screening Initiatives: HIV in the ER

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NC HIV/STD Screening InitiativesHIV in the ER

• Brooke Hoots, MSPH
• Fall 2008 HIV/STD Update
• September 25, 2008

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Acknowledgements

• WakeMed
• Jennifer Raley, MD
• Janice Frohman, RN
• Susan Harris, RN
• CDC
• Bernard Branson, MD

• 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

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Presentation Outline

• Rationale and CDC recommendations for HIV
  screening in Emergency Departments
• HIV in North Carolina
• UNC ED
• WakeMed ED
• Future directions

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Awareness of HIV Status, US
1,039,000 1,185,000 252,000
312,000(24-27) 56,000 29,000

• Number HIV infected
• Number unaware of their HIV infection
• Estimated new infections annually
• Those with unrecognized infection account for
  51 of new infections

Glynn M, Rhodes P. 2005 HIV Prevention Conference
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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 (gt5
  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
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Source of HIV Tests
HIV tests
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
National Health Interview Survey,
2002 Supplement to HIV/AIDS surveillance,
2000-2003
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Reasons for Testing Early v. Late
100
Late (Tested lt 1 yr before AIDS dx)
80
Early (Tested gt5 yrs before AIDS dx)
60
40
20
0
Illness
Self/partner
Wanted to
Routine
Required
Other
at risk
know
check up
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• Revised Recommendations for HIV Testing of
  Adults, Adolescents, and Pregnant Women in
  Health-Care Settings
• MMWR 200655(No. RR-14)1-17
• Published September 22, 2006
• http//www.cdc.gov/mmwr/pdf/rr/rr5514.pdf

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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
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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
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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
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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
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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
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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
1991266(16)2238-43. Sun BC, Burstin HR, Brennan
TA. Acad Emerg Med 200310(4)320-8. DHHS NC.
North Carolina 2005 HIV/STD surveillance report.
2006. Available at www.epi.state.nc.us/epi/hiv.
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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
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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

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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

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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

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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

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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

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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.

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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
Provider documents consent and test in patients
record
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
HIV-antibody negative samples are pooled for RNA
testing by the UNC Hospitals lab
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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)
Think about Acute HIV with

• 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

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ID Clinic Referral Card
Todays date __________
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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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)