HIV Testing Expansion: Overview, District of Columbia DOH

1. Jurisdictional Context: DC Population: ~600,000, ~64 sq miles HIV Prevalence: 3.2% (adults/adolescents) Routine Opt-out Testing Policy, 6/2006 Implementation Context & Results: Volume: 92,748 publicly supported HIV tests FY09 ~90% in clinical venues [nearly 5-fold increase since 2004] Linkage: 67% linked within 3 months [36% increase since 2004] 77% linkage by clinical testing partners Early Dx—median CD4+ at dx: 339 [50% increase since 2004] Impact on AIDS & Death: 33% decrease in new AIDS diagnosis (2004-2008) 30% decrease in AIDS death (2004-2007) ED Context: 8 EDs + VAMC ED 2 since 2007 (GWU, Howard U) 5 more 2009/2010 (WHC, UMC, Providence, CNMC Georgetown) VA expanding/working through implementation & reporting HIV Testing Expansion: Overview, District of Columbia DOH

2. George Washington University: ED Testing Overview • Emergency Department Setting • Program funding: • DC DOH/CDC Grant (3yr, to end in Sept 20101) • $250,000/yr for salary support; test kits provided by DC DOH • Staffing: • Multiple ED HIV screeners providing 24 hour coverage • Program Coordinator • Medical Director • ID physician for referral of preliminary positive • Patient selection • Routine • Pre-test counseling & consent • No pre-test counseling • Oral consent • Testing method • Bedside, OraQuick • Confirmatory testing: Western Blot, (CD4 and VL also sent for all preliminary positive) • Post test communication • One page summary sheet

3. George Washington University: ED HIV Testing Results • Overall outcomes measures • Program duration: 3½ yrs (Sept 06-March 2010) • 34,230 tests offered: 140 positive (112 confirmed +, 11 confirmed -) 20,340 negative • Linkage to care: • 100% of all confirmed + • 88% of all preliminary + • 17 Lost to follow-up • $250,000/yr for 3 yrs, PLUS cost of kits • Funding sources: DC DOH/CDC, Gilead (for initial 2 ys) Cost per patient screened: $47 Cost per preliminary reactive: $8,306 Cost per confirmed positive: $9,112

4. George Washington University: ED Lessons Learned • Most challenging aspect of the program • Initial logistics • Ongoing recruitment of screeners • Ability to fund research • Feature that works well – “Best Practice” • Oral consent • ID follow-up • Future plans especially sustainability • Outreach to those who consider themselves “low risk” • Trial of ED billing resulted in no reimbursement

5. District of Columbia: Looking to the Future • Next steps from Health Dept Expanding coverage & options: admit orders; lab-based platform testing on routine blood draws; new sites from start-up to full-force; Transitioning from Public Health to Health Care Financing • Next steps from ED Expanded research into best way to reach “low risk” Attempts to achieve sustainability (need CMS input) • Other points Maintaining highest level of linkage successes

6. California Department of Public Health Office of AIDS • 07-768 grant provides $716,250 • Split evenly with three Bay area Emergency Departments

7. Rapid HIV Screening in Three Bay Area Emergency Departments

8. Outcome Measures

9. Challenges and Lessons Learned

10. Next Steps

11. Health Dept Overview • Florida • One of the largest publicly-funded testing programs in the U.S. • Over 395,000 HIV tests in 2009 in all site types • Testing is funded through CDC Prevention grant and 07-768 (AATI in FL) • Testing is offered via conventional blood-based testing, rapid testing, and OraSure • There are 6 EDs where testing funded under 07-768 is performed

12. ED Slide 1 • Setting – Funded EDs statewide • Funded through Department of Health – African American Testing Initiative (AATI) • Designated staff for testing only • Patient selection • Both diagnostic and “routine” opt-in testing. SFAN/JHS offers HIV test to patients in ER. Patients are also received from doc or nurse recommendations based on symptoms/risk factors • Pre-test counseling & consent • Pre-test counseling has been abbreviated for ER and clinical settings • Florida statue requires informed consent. Can be verbal, must be noted in client’s chart, but at JHS/SFAN it is always written. • Testing method • Rapid testing offered at bedside and in the designated testing area/room • Confirmatory testing conducted through the state lab • Post-test communication • Education provided by HIV tester and if needed, SFAN has an Educator on site which is available. Pre-printed brochures also available for non-reactive results. All confirmed positives referred to STD program

13. ED Slide 2 • Overall outcomes measures • Program funded for 3 years beginning October 2007 • Current data (10/07 to 1/2010) 49,122 tests in EDs • 48,236 negative, 886 positive (1.8%) (SFAN/JHS 10000, 280 positive) • 820 (93%) were linked to care and STD for Partner Services (SFAN all are preliminarily linked to care) • 171 (19%) were lost to follow-up; 54 (6%) were unable to locate (SFAN: 20% failed to return for confirmatory test results, at which time they were referred to the local DIS- Surveillance Team) • All program costs are funded through DOH – includes: staff, testing supplies, confirmatory testing, training

14. ED Slide 3 • Most challenging aspect of the program • Getting buy-in from key stakeholders(public health problem, testing doesn’t belong in the ED, no time, not enough staffing, misunderstanding of pre-test counseling requirements) • Feature that works well • Finding a champion within the system (ER doc, nurse, other administrator) • ERs that allow CBOs in the ER to conduct testing • Future plans especially sustainability • Apply for continued funding (10-10138) • Advocacy (work with Medicaid and private insurers to ensure testing services are paid for if billed)

15. Combined ED & Health Dept • Next steps from Health Dept • Continue to promote routing testing in clinical settings • Seek policy changes to allow for more “routine” testing • Address sustainability • Next steps from ED • Continue to promote/offer HIV testing • Utilize physician or health professionals as advocates for HIV testing in other communities

16. Maryland Team HIV Testing in Hospital Emergency Departments: Collaborative Strategies for Implementation NASTAD Consultation April 9, 2009 Claudia Gray, MS, RN Chief, Center for HIV Prevention Maryland Department of Health and Mental Hygiene Infectious Disease and Environmental Health Administration

17. MISSION • To improve the health of Marylanders by reducing the transmission of infectious diseases, helping impacted persons live longer, healthier lives, and protecting individuals and communities from environmental health hazards • We work in partnership with local health departments, providers, community based organizations, and public and private sector agencies to provide public health leadership in the prevention, control, monitoring, and treatment of infectious diseases and environmental health hazards.

18. Maryland DHMH HIV Testing Overview • HIV tests (routine and targeted) supported by MD DHMH annually ~ 115,000 • Routine HIV Screening in Healthcare settings • High prevalence healthcare and correctional settings (EDs, STD clinics, substance abuse treatment centers, correctional facilities, perinatal settings) • Approximately 50,000 HIV screening encounters annually • ED testing programs supported by MD DHMH • Initiated and expanded routine HIV testing in 8 emergency departments and 1 urgent care center in the two jurisdictions with the highest HIV incidence and prevalence. • These programs have provided 25,000 HIV tests in the past year, with 147 newly identified HIV positive patients (0.6%)

19. Routine HIV Testing in Selected MD Emergency Departments

20. Routine HIV Testing in Selected MD Emergency Departments

21. Routine HIV Testing in Selected MD Emergency Departments

22. Moving forward • Cross-site (all Maryland) comparison of different models/yields planned • JH plans self-service interactive waiting room kiosk to cut staffing needs • JH plans use of student volunteers to reduce costs • Using current models (with specific testing staff) need to identify ongoing funding • MD DHMH seeking HIV testing grant funding to continue and expand ED testing to other sites • Explore insurance reimbursement for routine HIV testing

23. Maryland Infectious Disease and Environmental Health Administration http://eh.dhmh.md.gov/ideah

24. Routine HIV Screening in Hospital Emergency Departments: Massachusetts NASTAD Consultation April 9, 2010 Dawn Fukuda, ScM, MA Department of Public Health Joanne de Vries, MPH, MA Department of Public Health Paul Skolnik, MD, Boston Medical Center

25. Counselor-InitiatedTesting Model: A Routine Approach • Patient receives services at ED • within a personal exam room or space • Patient is approached by the HIV counselor • while in the ED exam space and is • provided with HIV brochure and consent form • Patient considers testing for HIV and • declines or accepts to test (via written consent) • Patient meets with the HIV counselor in the ED exam space • during the clinical visit as time and patient flow allows • Bedside rapid HIV testing occurs via OraQuick Advance finger stick • Results are immediately shared with the patient in person • by the counselor. Confirmatory specimen is obtained. • Physician is notified of the test result; entered in EMR. • Patient is linked into medical, preventiveand supportive • services as appropriate within the health center. Both EDs • support referrals to HIV/ID clinic care within 48 hours.

26. Overall Outcomes Measures Baystate • 12 months • Began 03/09 • 1 FTE, day hours • 3 positive patients • 1,104 negatives • All + linked to care • $55,000*, RHT Boston Medical • 5 months • Began 11/09 • 1 FTE, mixed hours • 1 positive patient • 295 negatives • All + linked to care • $63,000*, RHT

27. ED Routine Screening: Successes • 1,403 HIV tests over last 12 months • Identified 3 new positives (0.21%) • Opportunity to reengage one known positive into HIV care • ED clinical staff refer high risk patients • Proven effect wins support from clinicians • Importance of a “champion” in leadership

28. ED Routine Screening: Challenges • Buy-in across hospital divisions • Data collection and submission • Counselor burn-out • Repeat patient presentation • Research paperwork burden • Bundled reimbursement • Seroprevalence lower than anticipated

29. Routine screening at Baystate ED begins 03/09 Routine screening at BMC ED begins 11/09

30. Expansion Plans • Short-Term Plans: • Add evening/weekend capacity • Examine effect of elimination of research component • Tailor delivery model for ED populations • Long-Term Plans: • Examine cost of initiative • Assess billing and reimbursement practices • Explore potential for replication • Incorporate emerging technologies

31. Questions?Please contact: • Joanne de Vries MDPH Office of HIV/AIDS (617) 624-5372 Joanne.Devries@state.ma.us • Routine HIV screening guidance and materials available at: www.mass.gov/dph/aids

32. NASTAD: HIV Testing in Hospital ERs M. Monica Sweeney, MD, MPH NYC Department of Health and Mental Hygiene Ethan Cowan, MD, MS Albert Einstein College of Medicine April 9, 2010

33. NYC continues to be the epicenter of the HIV/AIDS epidemic in the U.S. • 2008 Basic Stats • 105,633 persons living with HIV/AIDS • 3,126 new AIDS diagnoses • Includes 938 (24.6%) concurrent HIV/AIDS diagnoses Testing Programs in New York City • Jurisdictional Expanded Testing • The Bronx Knows • Hospitals accounted for 60% of The Bronx Knows Year 1 Testing among reporting partners

34. Project BRIEF • Setting • Level 1 Trauma Center • Level 2 ED, in-patients • Dental clinic • DOH funding • Site 1 has 4PHAs • Site 2 has 3 PHA in the ED • Patient selection • Non-targeted , routine testing • Pre-test counseling & consent • Multimedia tool • Written consent • Testing method • Point of care • Confirmatory • Post test communication • Results given to patient during same visit

35. Linkage to Care (10/05 – 2/10) • Testing numbers • 54,957 patients approached • 48,912 eligible (89%) • 47,031 tested (96%) • Number of patients diagnosed with HIV • 186 (0.4%) of which 151 new diagnoses • Number of patients linked to outpatient care • 153 (82%) of which 140 (92%) linked @NBHN • Program Costs • Counselor 30,000/year • 15,000 tests/year = $165,000 • One time computer purchase - $1000/tablet • One time software cost - $20,000

36. Project Brief (10/05 – 2/10) • Most challenging aspect of the program • Leadership by-in • Feature that works well – “Best Practice” • Effortless data acquisition • Easy form of consistent education/linguistically sensitive • High rates of patient satisfaction with testing program • 99.2% felt HIV testing in the ED was helpful • 96.0% felt the video answered their questions regarding HIV testing • 86.5% learned a moderate to large amount of new information • Future plans especially sustainability • High volume testing and linkage to care for positive patients increase revenues for the hospital

38. North Carolina Expanded HIV Testing • PS 07-768 Grantee – $1.8 million • Expanded HIV Testing Sites (Clinical Settings) • Emergency Departments: Duke, UNC, WakeMed • Community Heath Centers • STD Clinics • County Jails • State Prison System • October 2008-December 2009 • 73,074 HIV tests conducted • 669 confirmed HIV positive test results (0.9%)

39. ED Program Descriptions

41. Program Outcomes

42. Program Lessons

43. Contact Information • Jan Scott NC DHHS HIV/STD Care Branch jan.scott@dhhs.nc.gov • Pamela Klein, MSPH UNC Gillings School of Global Public Health pklein@unc.edu • Mehri McKellar, MD Duke University Medical Center mehri.mckellar@duke.edu • Charles Hicks, MD Duke University Medical Center hicks014@mc.duke.edu

44. Ohio Department of Health • The Ohio Department of Health supports 351 HIV testing sites through the HIV Prevention Grant and additional 11 sites through the HIV Expanded Testing Grant with test kits and laboratory support. • Sites include: • Local Health Departments • AIDS Service Organizations • Community Based Organizations • FQHCs/RHCs • Treatment facilities • Emergency Departments/Urgent Cares • Planned Parenthoods • Correctional Institutions, ect.

45. University of Cincinnati • Program funding/staffing • CTC operating within an ED • ODH, CHN (Ryan White), UC Dept. of EM, NIH/research • Program Counselors (~10), coordinator, medical director • Patient selection (2009, N%) • Diagnostic Testing 151 (3.3%) • Targeted Screening 3382 (74.0%) • Non-targeted/universal screening 1038 (22.7%) • Pre-/Post-test counseling & consent • Formal Prevention Counseling (client-centered) • Post-test counseling augmented for reactive/positive • Signed, opt-in, separate, with explicit right of refusal • Testing method (2009)* • Near-patient rapid (ED lab), ODH confirmatory * Conventional assay when counselors unavailable

46. ED Outcome Measures * 2007 had 10 in determinants; 2009 had 12 false positives and one indeterminate • July 1998-present • 20,000 tested, 158 positive (%) • Annual Program Costs/Funding Sources • Ohio Department of Health $108,169 + rapid assays • Cincinnati Health Network (Ryan White) $60,166 • Indirect Support UC/Dept of EM $36,151 • NIH ~ $45,000

47. ED Summary & Future Directions • Most challenging aspect of the program • Parallel program improves resource barriers but creates integration barriers • Feature that works well – “Best Practice” • Quality Assurance / Informatics • Future plans & sustainability • Diverse portfolio of clinical and research support • Expanded collaboration/integration with hospital • Continued multi-model approach

48. Summary “ Public health programs can operate effectively in the ED. EDs should have a rapidly expanding role in the national public health system.” Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Health Department Collaboration with Emergency Departments as a Model for Public Health Programs Among At-risk Populations. Public Health Reports 2005; 120: 259-265

49. Expanded Testing in Texas: Sustainable, Integrated, Routine Texas Department of State Health ServicesCity of Houston Health and Human Services • Diffusion of innovation and cultural change effort • Legal environment conducive to routine testing • Flexibility: what will work in your setting? • Invest in laboratory infrastructure • Integrated into normal procedures and data systems • Test Texas HIV Coalition : peer leadership

50. ED Project Characteristics: Generalizing Across 6 Facilities • Staffing models: maximum integration of testing procedures, coordination & QA • Patient Selection: 24/7, routine, opt-out testing, low refusal rates • Major difference – test only those with phlebotomy for other reasons or do phlebotomy for the test • Consent & Counseling: • general medical consent with reference to HIV testing • Verbal presentation, signage, refusal noted in medical chart • no pre-test counseling • Low rates of refusal • Primarily laboratory-based testing • Post-test communication: coordinated between clinician, social worker, DIS, and linkage worker