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5/16/2016
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HIV Testing in the Emergency Department
Michael Waxman, MD, MPH, FACEP
Department of Emergency MedicineAlbany 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
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New York State Expanded HIV Testing (EHT) Projectnyhospitalstest4hiv.org
Regional EHT ChampionsAlbany Medical Center: Lisa Sutton [email protected]
Northwell Health: Jenny [email protected]
Accessed April 29th, 2016. http://hab.hrsa.gov/livinghistory/images/issues/conf_photo_10.jpg
Audience
Diversity
Work in the field of HIV/AIDS
Clinical experience
Administrative experience
New York State funded project
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HIV treatment and prevention are linked
Newly acquired HIV
infections
Newly acquired HIV
infections
Higher HIV prevalence
in the community
Higher HIV prevalence
in the community
More transmission
of HIV infection
More transmission
of HIV infection
Treatment of HIV leads decrease transmission
Knowledge of serostatus leads to change in risk behaviors
New York State’s plan to end the
HIV/AIDS epidemic
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“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…”
https://www.governor.ny.gov/news/governor-cuomo-receives-final-blueprint-end-hivaids-epidemic-new-york-state-end-2020. Accessed April 29th, 2016
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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.)
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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
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9/ 26/ 11 3:36 PMRevised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health- Care Settings
Page 1 of 27http:/ / www.cdc.gov/ mmwr/ preview/ mmwrhtm l/ rr5514a1.htm
Recommendations and ReportsSeptember 22, 2006 / 55(RR14);1-17
Revised Recommendations for HIV Testing ofAdults, Adolescents, and Pregnant Women in
Health-Care SettingsPrepared by
Bernard M. Branson, MD1 H. Hunter Handsfield, MD2
Margaret A. Lampe, MPH1 Robert S. Janssen, MD1
Allan W. Taylor, MD1 Sheryl B. Lyss, MD1
Jill E. Clark, MPH3
1Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention(proposed)
2Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention(proposed) and University of Washington, Seattle, Washington
3Northrup 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, ViralHepatitis, 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: [email protected].
Summary
These recommendations for human immunodeficiency virus (HIV) testing are intended for all health-careproviders 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, communityclinics, correctional health-care facilities, and primary care settings. The recommendations address HIVtesting 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
2006 CDC HIV Testing Recommendations
Routinize HIV testing
Non‐targeted screening in clinical settings
No written consent
Opt‐out testing
Optional prevention counseling
These are federal guidelines
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
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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?
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0%10%20%30%40%50%60%70%80%90%
100%
>1mo >3mo >1year >5years
nevertested
offered,nevertested
neveroffered
Non Eligible
Eligible
What proportion of ED patients should be offered a test? And, what are good acceptance rates?
When was the last time that you have been tested for HIV?
1 mo 3 mo 5 years
Nevertested
Never offered
1 year
What proportion of ED patients should be offered a test? And, what are good acceptance rates?
0%10%20%30%40%50%60%70%80%90%
100%
>1mo >3mo >1year >5years
nevertested
offered,nevertested
neveroffered
Non Eligible
Eligible
The rate of retesting probably depends on the local prevalence and resources
When was the last time that you have been tested for HIV?
1 mo 3 mo 5 years
Nevertested
Never offered
1 year
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0%10%20%30%40%50%60%70%80%90%
100%
>1mo >3mo >1year >5years
nevertested
offered,nevertested
neveroffered
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 of the local prevalence and resources
What compromises a good acceptance rate probably depends on (1) local prevalence and HIV testing stigma and (2) how often you offer the test
When was the last time that you have been tested for HIV?
1 mo 3 mo 5 years
Nevertested
Never offered
1 year
The rate of retesting probably depends on the local prevalence and resources
How should the offer be
made?
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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
This image cannot currently be displayed.
Albany Medical Center workflow practice – offering the test
The offer is incorporated in the primary nurses assessment
Automatically generated order
This image cannot currently be displayed.
Albany Medical Center Best Practices
Albany Medical Center workflow practice – offering the test
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“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?”
Language of the Offer
0
500
1000
1500
2000
2007 2008 2009 2010 2011 2012 2013 2014 2015
7711382
925 883 1009 990 970 873
1684
HIV
TE
ST
S C
OM
PL
ET
ED
Point of care rapid HIV testing begins
“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
Order generated during primary nurse assessment
Patient offered at every visit
Evolution of HIV Testing in AMC’s Emergency Department
