Public Health, EM

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Public Health, EM HIV at LACUSC

• Shira Schlesinger, MD MPH
• Kim Newton, MD
• Mike Menchine, MD MPH
• Kathleen Jacobson, MD
• Sanjay Arora, MD

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Objectives

• To introduce history, advantages disadvantages
  of implementing Public Health screening in the
  Emergency Department
• To examine current epidemiology of HIV in our
  patient population, changes to clinical
  indicators and consent requirements for testing
• To introduce a new exciting program coming to
  the ED at LACUSC

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Public Health

• "preventing disease, prolonging life and
  promoting health through organized efforts "

1920, C.E.A. Winslow
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Emergency Medicine

• prevention, diagnosis and management of acute
  and urgent aspects of illness and injury.
• focuses on the immediate decision making and
  action necessary to prevent death or any further
  disability.

International Federation of Emergency
Medicine ABMS
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Current Past EM Public Health Projects

• Arthritis, Osteoporosis
• Cancer
• Chronic Kidney Disease
• Diabetes
• Environmental Health
• Family Planning
• Food Safety
• Heart Disease Stroke
• HIV
• Immunization
• Injury Violence Prevention

• Maternal, Infant, Child
• Mental Health Illness
• Nutrition Overweight
• Occupational Safety
• Oral Health
• Physical Fitness Activity
• Respiratory Diseases
• STDs
• Substance Abuse
• Tobacco Use
• Vision and Hearing

Public Health Projects in Emergency Medicine,
2000-Present. SAEM Public Health Interest Group.
21 November 2005
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Costs of Public Health ED Programs

• Minutes per patient represents thousands of hours
  of diverted patient care
• Few EDs, if any, have down time available to
  undertake nonessential tasks or to incorporate
  new programs
• Infused resources for parallel-run programs
  better used for improving ED care

Kelen GD. Public Health Initiatives in the ED
Not So Good for the Public Health?. Acad Emerg
Med. Vol 15 (2), pp194197, Feb 2008.
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WHO Screening Criteria

• Condition is important health problem for
  individual and community
• Natural history of disease understood
• Latent or early symptomatic stage
• Acceptable screening test
• Treatment exists more beneficial if started
  earlier
• Facilities for diagnosis and treatment available
• Agreed policy on whom to treat
• Cost economically balanced in relation to other
  medical expenditures
• Continuing process

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HIV in L.A. County
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HIV in the USA
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HIV in L.A. County

• gt 45,000 known cases of HIV in LAC
• 88 males, 12 females
• 60 in regions included in LACUSC catchment area
  
• Estimated 11,000 additional undiagnosed

Insert charts here of gender/race breakdowns
HIV Epidemiology Program, LAC-DPH
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Transmission and HIV Status Knowledge
Marks et al. AIDS 20, no. 10 (2006) 1447-1450
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Clinical Indicators?

• Weight Loss (lt10)
• Minor mucocutaneous eruptions
• Herpes Zoster
• Recurrent URIs
• Cervical Dysplasia
• Carcinoma in situ of the cervix
• Pelvic Inflammatory Disease (PID)

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How about these Have you seen this in the ED?

1. Diarrhea for greater than 1 month
2. Fever for greater than 1 month
3. Oral hairy leukoplakia
4. Thrush (oral candidiasis)
5. Persistent fungal infections of skin or
   fingernails
6. Sexually transmitted infection
7. Recurrent community acquired pneumonia
8. Pulmonary TB
9. Thrombocytopenia
10. Recurrent vulvovaginal candidiasis
11. Seborrheic dermatitis

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• Question How many HIV tests have you ordered in
  the past month?

1. 0
2. 1 - 5
3. 6 - 10
4. gt10

• How many HIV tests have you ordered on patients
  you were planning/ expecting to discharge home?

1. gt5
2. 3 - 4
3. 1 - 2
4. Huh? Why would I do that?

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Why Screen?

• Are clinical indicators enough?
• 4 visits in year prior to diagnosis
• 50 visits with 1 clinical indicator
• EDs among the lowest testing rates (11)
• LACUSC ED currently tests lt1

Liddicoat et al. Assessing Missed Opportunities
for HIV Testing in Medical Settings. J Gen
Intern Med. 2004 April 19(4) 349356. White DA,
et al. Missed opportunities for earlier HIV
diagnosis in an ED despite an HIV screening
program. AIDS Pat Care STDS. 2009 Apr Duffus WA,
et al. Risk-based HIV testing in SC health care
settings failed to identify majority of infected
individuals. AIDS Pat Care STDS. 2009 May.
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Screening for HIV

• Without treatment HIV ? death in 10 years
• Late initiation of treatment associated with a
  doubled mortality risk at 10 years
• 25yo with early initiation of treatment has an
  average life expectancy of 64 years
• Cost effectiveness in moderate-to-high prevalence
  areas demonstrated in modeling

UNAIDS Reference Group on Estimates, Modelling
and Projections, 2006 Kitahata, MM. et al. Effect
of Early versus Deferred Antiretroviral Therapy
for HIV on Survival (NA-ACCORD). NEJM. 2009
April 30 http//www.cdc.gov/vitalsigns/HIVtesting/
LatestFindings.html Paltiel AD, et al. Expanded
screening for HIV in the United States---an
analysis of cost-effectiveness. N Engl J Med
2005352586--95. Walensky RP, et al. Routine
HIV testing an economic evaluation of current
guidelines. Am J Med 2005118292--300.
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Transmission and HIV status knowledge
Marks et al. AIDS 20, no. 10 (2006) 1447-1450
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2006 CDC Recommendations

• Universal screening in health care settings.
• Requirements
• Inform that you're going to test
• Opt-out rights
• Part of routine medical care
• CDC HIV Testing Guidelines
• Test results provided in the same manner as that
  of other diagnostic or screening tests

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LACUSC ED Population

• Over 170,000 patients per year
• 42 of visits are by women
• 65 Hispanic/Latino
• 15 African American
• 5.4 Asian
• 80 report household income lt 20,000
• ED as primary/sole source of care

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HIV Screening Criteria
Important health problem Estimated prevalence 10x higher than national average of 0.1
Natural history understood, with latent/early symptomatic stage Average 9 years before AIDS diagnosis
Acceptable screening test OraQuick rapid, non-invasive
Treatment more beneficial if started earlier Early HAART ? 50 mortality decrease at 10 years
Facilities for diagnosis and treatment available ED as primary health resource Link to Rand Schrader
Cost economically balanced with other medical expenditures Targeted funding for 3 years Support by LAC DHS CDC
Continuing process Exploring long-term integration
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Universal HIV Screening at LACUSC

• Coming soon to a pod near you!

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HIV Screening at LACUSC

• Target Outcomes
• Earlier first-time diagnosis
• Linking known diagnoses to care
• North pod pilot period
• 8am-9pm
• Research Assistants (RAs)

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Patient presents to Triage
Patient brought to North Pod
HIV status requested
Unknown HIV
Patient offered HIV test by RA
Patient accepts
Patient declines
OraQuick test performed

• Follow up appointment with Rand Schrader arranged
  for 5-7 days
• Rand Schrader Clinic personnel notified

Positive Screen
Negative Screen
RA notes reason for decline

• Result noted into Sunquest laboratory system
• RA informs treating MD
• MD discloses result to patient
• Copy of results given
• Confirmatory Western Blot, CD4 and HIV viral load
  drawn

• Result noted into Sunquest lab system
• RA informs patient of negative result
• Patient given copy

• RA telephone follow up at 2 weeks
• Document linkage to care

No further HIV-specific management, continue with
routine care
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Patient presents to Triage
Patient brought to North Pod
HIV status requested
Known HIV
Out of HIV care (no visit in past 6 months)
In HIV care (visit within 6 months)

• Follow up appointment with Rand Schrader arranged
  for 5-7 days
• Rand Schrader Clinic personnel notified

• RA telephone follow up at 2 weeks
• Document linkage to care

No further HIV-specific management, continue with
routine care
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What does this have to do with me?

• Be aware
• Help prevent fall-outs misses
• Be friendly to the RAs
• Order WBs, CD4, Viral Load
• Give patients their preliminary positives
  explain the next steps with the RA
• Write their follow-up info in the chart

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Whoa there

• How many people are we talking about?
• Anticipated overall seroprevalence 1-2
• 4 new diagnoses per week

Pictures of people (some of these people)
CDC, Rapid HIV testing in emergency
departments--three U.S. sites, January 2005-March
2006, MMWR. 56(24) (June 22, 2007)
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Lets say

• Im in a different area want to test someone
• Universal screening in North
• Rapid testing for indicators anywhere in the ED
• Call the RA, 8am-11pm
• My patient is AMS
• General medical consent?
• Must know they are being tested
• My patient asks my opinion

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A Partnership of Immense Proportions

• LACUSC Emergency Department
• Kim Newton
• Mike Menchine
• Sanjay Arora
• Shira Schlesinger
• Rand Schrader (5P21) Clinic
• Kathleen Jacobson
• Stella Quan
• Office of AIDS Programs Prevention
• Centers for Disease Control
• Pacific AIDS Education and Training Center
• Kathleen Jacobson

- Nico Forget
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(No Transcript)
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Questions?

• Thank you for your time and for your help in
  making this program a success