HIV Testing in the Emergency Department

HIV Testing in the Emergency Department Michael Waxman, MD, MPH, FACEP Department of Emergency Medicine Albany Medical College OBJECTIVES Review the New York State plan to end the AIDS epidemic. Provide an update regarding changes to HIV testing policies and processes in NYS. Describe the HIV testing options available and when to use them. Discuss how routine HIV testing can be made simpler and is an opportunity in the ED setting, drawing from the success of Albany Medical Center's Expanded HIV Testing Initiative. DISCLOSURES I have no financial conflicts My salary is partially supported by the Expanded HIV Testing Initiative which is a CDC funded, NYSDOH AIDS Institute administered, AMC awarded grant Emergency Physician Specialization in Preventive Medicine HIV Prevention Researcher 1

New York State Expanded HIV Testing (EHT) Project nyhospitalstest4hiv.org Regional EHT Champions Albany Medical Center: Lisa Sutton 518-262-7143 suttonl@mail.amc.edu Northwell Health: Jenny Doyle 516-562-3748 jdoyle4@nshs.edu Audience Diversity Work in the field of HIV/AIDS Clinical experience Administrative experience New York State funded project Accessed April 29 th, 2016. http://hab.hrsa.gov/livinghistory/images/issues/conf_photo_10.jpg 2

HIV treatment and prevention are linked Newly acquired HIV infections Knowledge of serostatus leads to change in risk behaviors More transmission of HIV infection Higher HIV prevalence in the community Treatment of HIV leads decrease transmission New York State s plan to end the HIV/AIDS epidemic 3

https://www.governor.ny.gov/news/governor-cuomo-receives-final-blueprint-end-hivaids-epidemic-new-york-state-end- 2020. Accessed April 29 th, 2016 For decades, New York State was the epicenter of the HIV epidemic in the United States. In the early 1990s, nearly 15,000 persons were diagnosed annually. In 2013, there were approximately 3,300 newly- diagnosed HIV cases 4

Scale up HIV testing to identify those undiagnosed Link and retain those diagnosed with HIV in care, to maximize viral suppression (Pre Exposure Prophylaxis (PrEP) to at risk populations MSM, IDUs, partners of positives, etc.) 5

Many of the new HIV infections in the Unites States are spread by individuals who are unaware of their status. Cohen SM, et al. Vital Signs: HIV Prevention Through Care and Treatment United States. MMWR. December 2, 2011 / 60(47);1618-1623. Update on the HIV testing policy changes over the last decade 6

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant WomeninHealth-Care Settings 9/ 26/ 11 3:36 PM 2006 CDC HIV Testing Recommendations Routinize HIV testing Non targeted screening in clinical settings No written consent Opt out testing Optional prevention counseling Recommendations and Reports September 22, 2006 / 55(RR14);1-17 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings Prepared by Bernard M. Branson, MD 1 H. Hunter Handsfield, MD 2 Margaret A. Lampe, MPH 1 Robert S. Janssen, MD 1 Allan W. Taylor, MD 1 Sheryl B. Lyss, MD 1 Jill E. Clark, MPH 3 1 Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed) 2 Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed) and University of Washington, Seattle, Washington 3 Northrup Grumman Information Technology (contractor with CDC) The material in this report originated in the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), Kevin A. Fenton, MD, PhD, Director; and the Division of HIV/AIDS Prevention, Timothy D. Mastro, MD, (Acting) Director. Corresponding preparer: Bernard M. Branson, MD, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (proposed), 1600 Clifton Road, N.E., MS D-21, Atlanta, GA 30333. Telephone: 404-639-0900; Fax: 404-639-0897; E-mail: bbranson@cdc.gov. Summary These recommendations for human immunodeficiency virus (HIV) testing are intended for all health-care providers in the public and private sectors, including those working in hospital emergency departments, urgent care clinics, inpatient services, substance abuse treatment clinics, public health clinics, community clinics, correctional health-care facilities, and primary care settings. The recommendations address HIV testing in health-care settings only. They do not modify existing guidelines concerning HIV counseling, testing, and referral for persons at high risk for HIV who seek or receive HIV testing in nonclinical settings These are federal guidelines http:/ / www.cdc.gov/ mmwr/ preview/ mmwrhtml/ rr5514a1.htm Page 1 of 27 2010 NYS HIV testing law 2010 New York State HIV Testing Law Only state in the nation to mandate HIV screening in clinical settings Written consent was still required in most clinical settings since amended and not needed in ED 7

2010 NYS HIV testing law HIV test must be offered at least once to all patients between the ages of 13 and 64 receiving hospital or primary care services, with limited exceptions noted in the law Who should be offered an HIV test? 8

What proportion of ED patients should be offered a test? And, what are good acceptance rates? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% >1mo 1 >3mo 3 >1year 1 >5 5 years Never never tested offered, Never offered never tested When was the last time that you have been tested for HIV? never offered Non Eligible Eligible What proportion of ED patients should be offered a test? And, what are good acceptance rates? The rate of retesting probably depends on the local prevalence and resources 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% >1mo 1 >3mo 3 >1year 1 >5 5 years Never never tested offered, Never offered never tested When was the last time that you have been tested for HIV? never offered Non Eligible Eligible 9

What proportion of ED patients should be offered a test? And, what are good acceptance rates? The rate of retesting probably depends on of the local prevalence and resources 100% 90% 80% 70% What 60% compromises a good acceptance rate probably depends on (1) local prevalence and HIV testing stigma and (2) how often you offer the test 50% 40% 30% 20% 10% 0% >1mo 1 >3mo 3 >1year 1 >5 5 years Never never tested offered, Never offered never tested When was the last time that you have been tested for HIV? never offered Non Eligible Eligible How should the offer be made? 10

This image cannot currently be displayed. This image cannot currently be displayed. 5/16/2016 Albany Medical Center workflow practice offering the test We emphasize that the offer for HIV testing is part of routine care for all patients AMC offers a test to all patients at each visit regardless of previous response or date of last test Reduces stigma to HIV and HIV testing Albany Medical Center Best Practices Albany Medical Center workflow practice offering the test The offer is incorporated in the primary nurses assessment Automatically generated order 11

Language of the Offer According to NYS law, AMC offers HIV testing as part of routine care to all patients (between the ages of 13 and 64). Would you like an HIV test today? We encourage all patients receiving care in the ED to have an HIV test, can we add an HIV test as part of your care today? Can we add on an HIV test to your routine blood work today? Evolution of HIV Testing in AMC s Emergency Department HIV TESTS COMPLETED 2000 1500 1000 500 0 Point of care rapid HIV testing begins 771 1382 Have you ever been offered an HIV test? Separate written consent Dependent on availability of external counselor Routine Offer Begins: Would you like an HIV test today? Verbal consent only 925 883 1009 990 970 873 Order generated during primary nurse assessment Patient offered at every visit 1684 2007 2008 2009 2010 2011 2012 2013 2014 2015 12