Pacific AIDS Education

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Pacific AIDS Education Training Center2006
Southern California Forum on Rapid Testing
Challenges SolutionsI. Jean Davis, PhD, DC,
PAAssistant Professor, Dept. Internal
MedicineCharles R. Drew University of Medicine
Science University of California, Los
AngelesCo- Principal Investigator
DirectorPacific AIDS Education Training
Centers National Minority AIDS Education
Training CentersMarch 23, 2006
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Routine STD (HIV/Chlamydia/Gonorrhea) Counseling
and Testing in the Urgent Care Unit of Martin
Luther King / Charles Drew Medical Center
Los Angeles County STD Program / Charles R. Drew
University of Medicine and Science
/ Collaborative Alcohol Research Center Funded by
National Center for HIV Prevention, CDC
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Project Team

• Peter R. Kerndt, MD, MPH (LA-STD)
• Shahrzad H. Bazargan, PhD (Drew)
• Eric G. Bing, MD, PhD (Drew)
• Lisa V. Smith, MS, DrPH (LA-STD)
• Apurva Uniyal, MA (LA-STD)
• Marjan Javanbakht, PhD (LA-STD)
• Sheryl Lyss, MD (CDC, Project Officer)

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Project Team

• Eugene Hardin, MD, (King-Drew)
• Wilbert Jordan, MD (Oasis Clinic)
• Chandra Higgins, MPH (LA-STD)
• Lina Sy, MPH (LA-STD)
• Guillermo Campos (LA-STD)
• Cynthia Davison (LA-STD)
• Jacqueline Moore (LA-STD)

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Why should we use rapid tests in Urgent Care
settings?

• Recent advances in the treatment of HIV infection
  have increased the value of early diagnosis and
  medical intervention
• Individuals identified with pre-clinical HIV
  infection can be referred for medical evaluation
  and treatment which improves the quality of life
  and survival of infected individuals
• Since the approval of Oraquick HIV rapid test in
  2002 and the rapid tests categorization as a
  waived test under Clinical Laboratory Improvement
  Amendment in 2003, use of rapid HIV tests in
  clinical and non-clinical settings has increased
  dramatically

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Goal

• To assess the feasibility and acceptability of
  rapid HIV testing and STD screening in the Martin
  Luther King / Charles Drew Hospital Urgent Care
  Unit
• To facilitate the transition from research
  protocol to programmatic screening and beyond

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• Why King-Drew?
• King-Drew/SPA 6
• LA Countys highest chlamydia and gonorrhea rates
• LA Countys 3rd highest AIDS rates
• Previous screenings suggest the true HIV
  prevalence lies between 0-10
• No systematic HIV/STD screening at the time of
  the study

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Research Programmatic Screening in KDMC Urgent
Care 10/03 to 11/05

• 1. Routine rapid HIV testing in the King-Drew
  Medical Center (KDMC) Urgent Care Unit
  Study
• ? October 2003 September 2004
• 2. Programmatic screening
• ? October 2004 November 2005

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Rapid Study Patient Recruitment
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Patient Screening Research Protocol
Accepted
Informed consent, Locator form, Data Collection
form
OraQuick Rapid HIV test (finger stick)
Aptima 2 CHL GC test (urine) Samples sent to
Public Health Lab
Negative
Negative
Client Satisfaction Survey
Positive
Positive
Follow up by Public Health Investigators
Confirm by Western Blot
Refer to medical treatment and social services
(OASIS)
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Intake Forms Client Satisfaction Survey

• Intake Form Patients age, race, gender, reason
  for refusing
• STD and/or HIV tests
• Client Satisfaction Survey 4-point Likert scale
  (1strongly
• agree 4strongly disagree)
• 1. I understand the results of my test
• 2. I would recommend testing to a friend
• 3. I have tested in the past and I prefer
  receiving
• my results the same day
• 4. I found the rapid HIV test stressful
• 5. I received the results of my HIV test too
  quickly
• 6. I found the blood specimen draw uncomfortable
• 7. It would have been better to wait a week

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HIV Testing with OraQuick
Chlamydia and Gonorrhea Screening
HIV Case Management
Nutritional Counseling and Resources
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Recruitment Summary 10/03 9/05
2344 names abstracted from Urgent Care Roster
1342 Non-participants
1002 Participants
98 age (lt18 or gt54) 2 HIV
120 Ineligible
576 Not approached
Not in waiting room
2 Not recommended
50 mentally unstable 50 repeat visit
41 Recently tested 17 Too much pain/too
sick 42 Other/Not specified
644 Refused
Participants also offered choice of testing for
chlamydia and gonorrhea
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Participation status by gender (male/female)

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Participation status by age

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Participation status by race/ethnicity

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Programmatic Screening Protocol10/04-11/05

• Programmatic screening protocol similar to study
• protocol, which also included
• Intake Form Patients age, race, and gender
• Client Satisfaction Survey 4-point Likert scale
  (1strongly agree 4strongly disagree)
• With the exception of age, the patients
• demographics during programmatic screening were
• comparable to those obtained during the study
• protocol

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Research Programmatic Screening Summary 10/03
to 11/05

• 2178 (63) accepted HIV and/or STD screening
  tests
• 55 Male
• 20 18-29 years
• 22 30-39 years
• 48 Black
• 48 Hispanic
• 2139 (98) tested with rapid HIV tests
• 1543 (71) tested with chlamydia/ gonorrhea tests

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Research and programmatic screening detected
numerous HIV/STD cases
HIV Patients Chlamydia Cases Gonorrhea Cases HIV Entered into Case manage-ment STD Cases Treated
Screened during study 10/03-9/04 14 (1.4) 25 (3.2) 14 (1.8) 10 (71) 28 (72)
Screened during programmatic screening 10/04-11/05 12 (1.1) 37 (4.6) 11 (1.4) 12 (100) 18 (39)
Total 26 (1.2) 62 (4.0) 25 (1.6) 22 (85) 46 (53)
Among HIV Among STD, patients still being
sought for treatment Co-infections 3 chl/gc, 1
HIV/chl, and 1 HIV/gc
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HIV/STD Case Profile
Period 10/03-11/05 HIV (26) Chlamydia/ Gonorrhea (87)
Gender Male 85 59
Age 18-29 30-39 18 60 71 16
Race/Ethnicity Black Hispanics 54 42 73 26
New Infections 15 (58) Unknown
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Client satisfaction with HIV rapid testing was
very high during study protocol and programmatic
screening sessions

• 99 understood the results of their HIV test
• 98 would recommend rapid testing to a friend
• 93 of previous testers preferred same day test
  results
• 60 did not find the test stressful
• 57 did not think they received HIV test result
  too quickly
• 90 did not find the fingerstick uncomfortable
• 93 did not feel it would have been better to
  wait a week for HIV test results

n2077 n1401 Satisfaction was comparable
among HIV vs. HIV- patients
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Patient / Staff Satisfaction
Thanks, man. Ive been meaning to get this HIV
testing done.
-Urgent Care Patient Can my friends come
and get tested? -Urgent Care Patient This
is a good idea. Can you also screen in the
parking lot in front of OASIS clinic? -OA
SIS employee We want everyone tested and flyers
posted throughout the hospital. Testing should
be a routine procedure. -Urgent Care Nurse
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Patient / Staff Satisfaction
Excellent project. It really helps the people
who want to be tested , but cant pay 80.00 for
the Urgent Care/ER visit. -Urgent Care
Nurse If you cant screen everybody, make sure
you screen the teenagers. -Urgent Care
Physician This is great. Can you test my
husband? I think hes playin
around. -Urgent Care Patient
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HIV/STD were detected among patients with
non-HIV/STD discharge diagnoses

• 2nd degree burns to leg
• Calculus of the kidney
• Cellulitis
• Changing surgical dressing
• Chest pain/palpitations
• Conjunctivitis
• Contusion of chest wall
• Dermatitis
• Diabetes
• Dizziness/giddiness
• Gastroenteritis

• Hair disease
• Head neck injury
• Headache
• Hypertension
• Insect bite
• Lumbar sprain
• Neck sprain
• Objective tinnitus
• Sprain in lumbar region
• Upper respiratory infection
• Urinary tract infection

Discharge diagnoses for some HIV patients
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Lessons Learned KDMC

• Rapid HIV testing is feasible at KDMC high
  acceptance of Rapid HIV testing, despite very
  little advertising.
• One of 100 KDMC Urgent Care patients tested
  positive for HIV and all HIV-positive patients
  received their test result (2,139 tested,1.2
  HIV, 5.5 CHL/GC).
• HIV prevalence was comparable with LAC STD
  clinics. Nearly half of the HIV infection was
  detected among the newly-infected patients.

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Lessons Learned KDMC

• Close proximity of a case management program
  facilitated linkage to care however, not all
  HIV patients accepted referral to services
• Patient satisfaction with rapid HIV testing was
  high KDMC staff satisfaction was equally high
• KDMC has embraced rapid HIV testing, getting HIV
  test results in twenty minutes is warranted, and
  screening should be made available to patients of
  all ages, some in which HIV/STD would otherwise
  go undetected, through programmatic screening

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Future Directions

• Establish STAT laboratory to screen patients in
  the examination room
• Explore implementation of opt-out program to
  increase the number of patients screened
• In the meantime, increase advertising of the
  availability of HIV/STD in Urgent Care
• Develop protocol to include rapid HIV test
  results into patients medical record

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Contact Information

• Lisa V. Smith, MS DrPH
• Director, Epidemiology Unit
• Sexually Transmitted Disease Program
• 2615 South Grand Avenue, Room 500
• Los Angeles, California 90007
• Phone [phone]
• Fax [phone]
• lismith_at_ladhs.org

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• Thank you!