Rapid HIV Testing in the ED: A Local Perspective

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Rapid HIV Testing in the EDA Local Perspective

• Andy Ruffner, MA, LSW
• Early Intervention Program

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To Get your CMEs

• After viewing this eLearning Seminar, please go
  to our website, www.stdptc.uc.edu
• Sign in, look for the title of this seminar
• Follow directions to register
• Complete the evaluation
• Print out your CEU certificate!

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Objectives

• Describe how an emergency department HIV testing
  program increases HIV case finding and access to
  HIV care.
• Describe how rapid testing facilitates the
  adoption of HIV testing in the ED setting.

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Topics Covered

• Background/rationale of offering HIV testing in
  Emergency Department setting
• Development of the HIV testing program in the
  University Hospital ED
• Implementation of rapid HIV testing technologies
  into the program
• Characteristics of positive patients identified
  through ED Rapid HIV testing

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BACKGROUND HIV in the ED
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Background Stalled Progress in HIV Prevention

• No reduction in rate of new infections or
  proportion of late diagnosis for 10 years
• Approximately 56,000 new cases/year
• Diagnosis is only one prevention component, but
• The epidemic is differentially fueled by those
  patients who are diagnosed late
• Late diagnosis prevents the application of
  therapy that improves outcomes for infected
  patients and limits further transmission
• Screening has been shown to be cost-effective

Marks G, Crepaz N, Janssen RS. Aids
200620(10)1447-50. Sanders GD, Bayoumi AM,
Sundaram V, et al. N Engl J Med
2005352(6)570-85 Paltiel AD, Weinstein MC,
Kimmel AD, et al. N Engl J Med 2005352(6)586-95
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CDC Recommendations for Expanded Testing Health
Care Objectives

• Increasing HIV testing in health-care settings
• Move healthcare settings from a paradigm of
  diagnostic testing (late) to non-targeted
  screening (early)
• Once identified, counsel persons with newly
  diagnosed HIV infection and link them to clinical
  and prevention services
• Further reduce perinatal transmission

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Suggested Strategies

• Expand screeningbut where and for whom?
• Access to Key Populations
• Epidemiology of HIV and potential settings for
  diagnosis
• Missed Opportunities
• Many undiagnosed HIV-infected persons access
  health care but are not tested until symptomatic
• Patient Selection Strategies
• Within a given setting, what factors would allow
  for more effective HIV identification according
  to public health priorities

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Access to Key Populations

• Socioeconomic Disparities/Access to Care
• Homeless
• Psychiatric Illness
• Prisoners
• Substance Abuse
• Non-traditional healthcare settings
• Emergency departments, urgent care clinics,
  substance abuse treatment clinics, correctional
  health-care facilities

Macalino GE, Vlahov D, Sanford-Colby S, et al. Am
J Public Health 200494(7)1218-23. Robertson MJ,
Clark RA, Charlebois ED, et al. Am J Public
Health 200494(7)1207-17. Meade CS, Sikkema KJ.
Clin Psychol Rev 200525(4)433-57 Avants SK,
Warburton LA, Hawkins KA, Margolin A. J Subst
Abuse Treat 200019(1)15-22
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Why Emphasize Emergency Departments?

• EDs see at-risk, vulnerable population
• Many patients not otherwise accessing the health
  system
• Using the ED as a primary care provider
• Difficulty accessing other healthcare providers
• HIV follows patterns of health disparity
• Overlap between populations at risk and
  difficulty accessing healthcare
• Missed opportunities and high prevalence
  documented

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HIV Testing Practices in EDs

• Survey of 154 ED providers
• Average 13 STD patients per week
• Only 10 always recommend HIV test
• Reasons for not testing for HIV
• 51 concerned about follow up
• 45 not a certified counselor
• 19 too time-consuming
• 27 HIV testing not available

Branson (2006). Revised Recommendations for HIV
Testing in Healthcare Settings in the U.S.,
presentation
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HIV Testing at University Hospital ED
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University Hospital ED Setting

• High volume urban ED (90,000 visits)
• Frequently used as primary source of care
• Demographics
• Treat large number of high risk patients
• Homeless
• Incarcerated
• Alcohol and Other Drug Abuse
• Psychiatric Emergencies
• Preventable Injuries and Physical Violence
• 60 African American population

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Early Intervention Program

• Began in July,1998
• Department of Emergency Medicine
• Infectious Disease Center
• Identify HIV positive individuals who are unaware
  of their status
• Reduce HIV transmission by providing direct
  counseling aimed at HIV prevention
• Increase research participation
• Increase funding regionally for HIV/AIDS care

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Funding

• Needed resources to expand the ED mission
• Sources
• Cincinnati Health Department / Ohio Department of
  Health
• Cincinnati Health Networks Ryan White Funding
• Research Program
• Not Sources
• Hospital/ED Subsidization
• Department of Emergency Medicine Subsidization
• Reimbursement

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EIP Clinical Program Research Opportunities

• EIP is a clinical program
• IRB approved informed consent allows us to use
  collected data for de-identified analysis and
  publication
• Data collected allows us to evaluate and compare
  success of program
• Other research projects evolving from data

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Program Staff

• Michael S. Lyons MD
• Assistant Professor and Medical Director, EIP
• Alexander Trott, MD- Asst. Medical Director, EIP
• Carl Fichtenbaum, MD- Program Advisor
• Andy Ruffner, MA, LSW Clinical Program
  Coordinator
• Jessica Baum, MSW, LSW Asst. Program
  Coordinator
• Beth Wayne, BSN, JD - Research Coordinator
• EIP Counselors Adjunct health professionals

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Counselor Training

• Two, 4-hour didactic training sessions8 hours
• General orientation of program
• HIV/AIDS Overview
• HIV Prevention Counseling
• Program Standard Operating Procedures
• Three on-line research training requirements5
  hours
• HIPAA OSHA CITI
• Technical training2 hours
• OraQuick sample collection and processing
• Database entry
• Shadowing Other Counselors minimum of 8 hrs.
• Observation prior to check off minimum 2 hrs.
• TOTAL TRAINING 25 hrs.

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EIP Counselor Role

• Screening and selecting patients for HIV test
  offers
• Responding to physician referrals for HIV
  testing
• Conducting risk assessment interviewing
• Collecting and processing samples
• Developing risk reduction plans
• Providing post-test counseling and referral

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Patient Selection Methods
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Concepts Enrolling ED Patients

• Approach Introducing the program
• Offer Asking for the HIV test
• Informed consent Giving the patient sufficient
  time and information to make an informed decision
  to accept the HIV test offer.
• Informed refusal Giving the patient sufficient
  time and information to make an informed decision
  to refuse the offer.

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Refusals

• Consent rate 60 consent to testing 40 refuse
• Common reasons for refusal
• Prior negative test during window period
• Patient denies risk behaviors
• Too much pain/nausea or illness
• Afraid of test result

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Risk Assessment Interview Topics

• Personal Information and Demographics
• Sexual Risk Factors
• Alcohol and Drug Risk Factors
• Other Risk Factors Homeless, Psychiatric,
  Incarceration, Physical and Sexual Violence
• Development of a risk reduction plan

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Conventional HIV TestingChallenges in the ED
setting

• Venipuncture phlebotomy skills, privileges
• IV blood draws RN requirement
• Storing/Shipping/Lab Analysis off-site
• Patient notification of test results for
  post-test counseling delays, patients lost to
  follow up

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Post-Test Counseling Challenges in Conventional
Testing Negatives

• Minimum of 4 attempts to contact at numbers
  provided
• Workflow balancing increasing load of telephone
  call backs with testing new patients.
• 75-80 completion rate

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Post-Test Counseling Challenges in Conventional
Testing Positives

• Telephonic contact to set up return appointment
  to ED for result notification
• Workflow Only administrative staff provide
  counseling due to availability
• No Show/Reschedule Difficult to coordinate
  intake at Infectious Disease Center
• 80 to 90 notification rate

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Meeting the ChallengeRapid Testing in the ED
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Rationale for Implementing Rapid Testing

• Diminishes barriers based on phlebotomy
• Reduces administrative burden of follow up for
  post test result notification
• Integrates HIV testing with ED medical treatment
  in the same visit benefits for handling positive
  test results, context in STD treatment
• Increases of patients tested

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Rapid Testing Process Sequence

• Approach and obtain informed consent
• Collect demographic and contact information
• Collect oral sample
• Run oral assay
• Conduct risk assessment interview
• Read assay and record result
• Provide post test counseling

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Reactive Results Process

• Confer with medical team and inform patient of
  result
• Collect whole blood samples for 2nd rapid assay
  and conventional testing (Western Blot)
• Positive result, 2nd rapid assay consider
  positive and initiate referral to IDC.
• Negative result, 2nd assay consider negative,
  confirm with conventional Western Blot.

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Rapid Reactive Counseling Stages

• Oral rapid reactive result notification
• Whole blood rapid reactive result
• Follow up medical treatment IDC
• Check in assess emotional state
• Assess need for psychological support
• Explain health department HIV positive
  notification requirement and partner notification
  procedures
• Summarize plans medical treatment, support
  system, partner communication

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Program Statistics 2008

• Approached 6546 patients
• Tested 3911 patients
• Identified 35 positive patients (0.89 prevalence
  rate)

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EIP Positives in 2008

• Demographics
• N35
• Age
• lt20 5 (14)
• 20-29 9 (43)
• 30-39 7 (14)
• 40-49 6 (17)
• 50 1 (11)
• Gender
• Male 27 (77)
• Female 7 (20)
• Transgender 1 ( 3)

• Race/ethnicity
• African-American 31 (89)
• White 3 ( 8)
• Other 1 ( 3)

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Chief Complaints of Positive Patients

• STD Check 7/35 (20)
• Other Examples
• Nausea/Vomiting/Diarrhea
• Cough/Congestion
• Sore Throat
• Tooth Pain
• Back Pain
• Hit by a car

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Prevention for Positives

• Prevention, assessment, and referral program for
  known HIV patients in the ED
• Risk assessment counseling
• Community partnerships
• Infectious Disease Center, Stop AIDS, Caracole,
  and Cincinnati Health Department.

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• THANK YOU

• Andrew Ruffner, MA, LSW
• Andrew.Ruffner_at_uc.edu
• Division of Public Health Research
• Department of Emergency Medicine
• University of Cincinnati, University Hospital

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To Get your CMEs

• After viewing this eLearning Seminar, please go
  to our website, www.stdptc.uc.edu
• Sign in, look for the title of this seminar
• Follow directions to register
• Complete the evaluation
• Print out your CEU certificate!