HIV Testing in Acute Care Settings Rich Rothman, MD, PhD, FACEP [e-mail] CDC, DHHS, OraSure Technologies, Abbott

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HIV Testing in Acute Care SettingsRich
Rothman, MD, PhD, FACEPrrothman_at_jhmi.edu CDC,
DHHS, OraSure Technologies, Abbott

• Historical Perspective
• Recent Urgent Care and Emergency Department
  Programs Using Rapid Test

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U.S. Emergency Departments

• 115 million visits/year
• 24/7
• Safety net
• Minority populations
• Underinsured
• Foreign born
• Substance abusers (IDU)
• High risk sexual behavior

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JHU Emergency Department

• Maryland 19th population 3rd AIDS incidence
• Baltimore 50 HIV patients live in Baltimore
  City
• 55,000 visits/year
• gt 75 African American
• 40 uninsured individuals
• 15 injecting drug use
• 14 unrecognized STDs in patients 18-31 years
• Kelen G., et al. Ann Emerg Med 2002 9368-9
  Rothman RE. 2004 (unpublished data) Mehta S.,
• et al. Clin Infect Dis 2001 32655-9

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Historical Trends in HIV Prevalence at JHU ED
11.8
11.4
10.9
8.9
6.0
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Overall Rates of Unrecognized HIV Seropositivity
in JHU ED(as of ED population
negative/untested)
3.8
3.6
2.8
Percent of ED patients with newly identified
HIV
2.3 (UCC)
1.8
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National Perspective

• USPHTF
• HIV screening recommended for all person at high
  risk for infection
• Beneficial effects associated with HIV CTR lead
  to early disease detection
• Improve prognosis for those treated with HAART
• Reduce OI
• Reduce high risk behaviors
• Reduce HIV transmission
• Emergency Medicine (SAEM) PHTF
• Similar evidence based evaluations for ED
  Applicability

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ED Testing for HIV

• Significant Disease Burden exists in many centers
• Baltimore, Maryland 11.4-14
• Bronx, New York 7.8
• Atlanta, Georgia 2.0
• Testing for HIV is EDs is feasible
• Consent 50
• Follow-up 70
• Rapid testing Increased turn around time and
  reporting of results (80)
• Cost analysis suggests that testing in EDs is
  comparable to that spent in publicly funded
  health care clinics

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Late 90s - 2000

• National Survey (95 Academic EDs)
• Routine HIV testing not routinely performed
• CDC Qualitative Survey
• Majority physicians supported concept of
  preventive services
• Lack of time major obstacle

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Developments

• Availability of rapid bedside test
• Revision of CDC HIV CTR guidelines
• Streamline counseling
• Rationale for routine testing
• Many patients dont fully disclose risk
• Targeted testing may introduce stigma
• Increased rates of acceptance with routine
  testing

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Rapid TestingTesting Integrated into Routine
Care in UCCProvider driven15 different staff
members

• Department of Emergency Medicine and Pathology
• The Johns Hopkins University School of Medicine

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Characteristics of 687 Participants of Rapid
Point-of-Care HIV Testing
Characteristics Number ()
African American 617 (89.8)
No Primary Care Physician 499 (72.6)
Uninsured 346 (50.4)
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Detection of Unrecognized HIV Infection Among 687
Participants
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Previous HIV Testing in 16 HIV () Participants
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Follow-up of Referral on 15 HIV Positive
Patients Identified by Rapid HIV Testing
1 HIV positive patient who died was excluded
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Stage of Disease in Newly Identified HIV
Patients (N 15)

• 33 of newly diagnosed HIV patients had a CD4
  Count lt 200 (cells/mm3)
• 60 of newly diagnosed HIV patients had a viral
  load of gt 10,000 (copies/ml)

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4 Month Validation Study for JHU for OraQuick
Advance Rapid HIV1/2 Antibody Test (oral fluid)
N Sensitivity Specificity Positive Predictive Value Negative Predictive Value
204 100.00 99.02 99.07 100.00

• 100 of patients received test results during
  visit
• 4 out of 5 new HIV patients entered long term
  care

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Routine ED Testing at Bedside

• Early Pilot Data
• 230 tested
• 10 (4.3) positive
• 8 (80) entered into care

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Conclusions

• Significant disease burden remains in US
• Need innovative approaches (ED testing) to access
  population
• ED stream-lined rapid testing
• Easy to administer
• Easy to interpret
• Well accepted

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Challenges/Barriers to ED based HIV testing

• ED cultural issues
• Time (provider)
• Resources
• Education of providers
• Logistics of testing provider or laboratory
• Arranging follow-up
• State regulations
• QA/QC reporting and time requirements
• Programmatic costs