NC HIV/STD Screening Initiatives: HIV in the ER Brooke Hoots, MSPH Fall 2008 HIV/STD Update September 25, 2008
NC HIV/STD Screening Initiatives:HIV in the ER
Brooke Hoots, MSPHFall 2008 HIV/STD Update
September 25, 2008
Acknowledgements
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
WakeMed Jennifer Raley, MD Janice Frohman, RN Susan Harris, RN
CDC Bernard Branson, MD
Presentation Outline
Rationale and CDC recommendations for HIV screening in Emergency Departments
HIV in North Carolina UNC ED WakeMed ED Future directions
Awareness of HIV Status, US
Number HIV infected
Number unaware of their HIV infection
Estimated new infections annually
Those with unrecognized infection account for ~51%
of new infections
1,039,000 – 1,185,000
252,000 – 312,000(24-27%)
56,000
~29,000
Glynn M, Rhodes P. 2005 HIV Prevention Conference
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 (>5 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
Source of HIV Tests
Private doctor/HMOHospital/ED/OutpatientCommunity clinic (public)HIV counseling/testingCorrectional facilitySTD clinicDrug treatment facility
44%22%9%5%
0.6%0.1%0.7%
17%27%21%9%5%6%2%
HIV tests* HIV + tests**
*National Health Interview Survey, 2002
**Supplement to HIV/AIDS surveillance, 2000-2003
Reasons for Testing: Early v. Late
0%
20%
40%
60%
80%
100%
Illness Self/partnerat risk
Wanted toknow
Routinecheck up
Required Other
Late (Tested < 1 yr before AIDS dx)
Early (Tested >5 yrs before AIDS dx)
Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in
Health-Care Settings
MMWR 2006;55(No. RR-14):1-17Published September 22, 2006
http://www.cdc.gov/mmwr/pdf/rr/rr5514.pdf
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
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
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
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
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
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 1991;266(16):2238-43.Sun BC, Burstin HR, Brennan TA. Acad Emerg Med 2003;10(4):320-8.DHHS NC. North Carolina 2005 HIV/STD surveillance report. 2006. Available at www.epi.state.nc.us/epi/hiv.
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
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
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
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
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
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
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.
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
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
Provider documents consent and test in
patient’s record
*HIV-antibody negative samples are pooled for RNA testing by the UNC Hospitals lab
Testing Recommendations for Providers
REMEMBER SAASSORDER HIV TEST WHEN ≥18 years old & any signs of
STDAIDS
Acute InfectionSubstance Abuse (every 6m)
Sexual Risk Behavior (every 6m)
• 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
Think about Acute HIV with:
ID Clinic Referral Card
EMERGENCY ROOM TEST FOLLOW-UP
Please bring this card to the UNC Infectious Diseases Clinic (directions on back) to receive the results of your ER lab test.
You may walk in to the clinic on Fridays any time between 9:00 am and 12:00 pm at least one week after the date of
your ER visit.
If you cannot come to the clinic on Friday between 9:00 am and 12:00 pm, you may schedule an appointment by calling
919-966-7198 or 1-800-241-7586
ER entrance
Manning Drive
Enter the NC Memorial Hospital lobby (#1) and go to the Information Desk. You will be directed to the Infectious Diseases Clinic. Parking is available in the Dogwood Deck (#6).Today’s date: __________
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
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
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
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
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
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
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%)
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
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
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)