Public Health, EM & HIV at LAC+USC

1. Public Health, EM & HIV at LAC+USC Shira Schlesinger, MD MPH Kim Newton, MD Mike Menchine, MD MPH Kathleen Jacobson, MD Sanjay Arora, MD

2. 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 LAC+USC

3. Public Health • "preventing disease, prolonging life and promoting health through organized efforts " 1920, C.E.A. Winslow

4. 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

5. 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 Current & Past EM Public Health Projects Public Health Projects in Emergency Medicine, 2000-Present. SAEM Public Health Interest Group. 21 November 2005

6. 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), pp194–197, Feb 2008.

7. 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

8. HIV in L.A. County

9. HIV in the USA

10. HIV in L.A. County • > 45,000 known cases of HIV in LAC • 88% males, 12% females • 60% in regions included in LAC+USC catchment area • Estimated 11,000 additional undiagnosed Insert charts here of gender/race breakdowns HIV Epidemiology Program, LAC-DPH

11. Transmission and HIV Status Knowledge Marks et al. AIDS 20, no. 10 (2006): 1447-1450

12. Clinical Indicators? Weight Loss (<10%) Minor mucocutaneous eruptions Herpes Zoster Recurrent URIs Cervical Dysplasia Carcinoma in situ of the cervix Pelvic Inflammatory Disease (PID)

13. How about these: Have you seen this in the ED? • Diarrhea for greater than 1 month • Fever for greater than 1 month • Oral hairy leukoplakia • Thrush (oral candidiasis) • Persistent fungal infections of skin or fingernails • Sexually transmitted infection • Recurrent community acquired pneumonia • Pulmonary TB • Thrombocytopenia • Recurrent vulvovaginal candidiasis • Seborrheicdermatitis

14. Question: How many HIV tests have you ordered in the past month? How many HIV tests have you ordered on patients you were planning/ expecting to discharge home? • 0 • 1 - 5 • 6 - 10 • >10 • >5 • 3 - 4 • 1 - 2 • Huh? Why would I do that?

15. 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%) • LAC+USC ED currently tests <1% Liddicoat et al. Assessing Missed Opportunities for HIV Testing in Medical Settings. J Gen Intern Med. 2004 April; 19(4): 349–356. 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.

16. 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 2005;352:586--95. Walensky RP, et al. Routine HIV testing: an economic evaluation of current guidelines. Am J Med 2005;118:292--300.

17. Transmission and HIV status knowledge Marks et al. AIDS 20, no. 10 (2006): 1447-1450

18. 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

19. LAC+USC 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 < $20,000 • ED as primary/sole source of care

20. HIV & Screening Criteria

21. Universal HIV Screening at LAC+USC Coming soon to a pod near you!

22. HIV Screening at LAC+USC • Target Outcomes • Earlier first-time diagnosis • Linking known diagnoses to care • North pod pilot period • 8am-9pm • Research Assistants (RAs)

23. 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

24. 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

25. 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

26. 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)

27. Let’s say… • I’m 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

28. A Partnership of Immense Proportions • LAC+USC 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

30. Questions? Thank you for your time and for your help in making this program a success