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Project B.R.I.E.F. Yvette Calderon, M.D., M.S. Associate Professor of Clinical Emergency Medicine Albert Einstein College of Medicine Jacobi Medical Center,

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Presentation on theme: "Project B.R.I.E.F. Yvette Calderon, M.D., M.S. Associate Professor of Clinical Emergency Medicine Albert Einstein College of Medicine Jacobi Medical Center,"— Presentation transcript:

1 Project B.R.I.E.F. Yvette Calderon, M.D., M.S. Associate Professor of Clinical Emergency Medicine Albert Einstein College of Medicine Jacobi Medical Center, NY Jason Leider, M.D., Ph.D. Associate Professor of Internal Medicine Albert Einstein College of Medicine Jacobi Medical Center, NY Analysis of a High Volume Rapid HIV Testing Multimedia Model

2 USA Stats At the end of 2003, an estimated 1.1 million persons in the United States were living with HIV/AIDS 21% are undiagnosed and unaware of their HIV infection CDC estimated that approximately 56,300 people were newly infected with HIV in 2006


4 Bronx Demographics 3 rd most densely populated county in US >80% Hispanic and African American 1/3 households headed by a single parent 2003 Bronx Median income = $27,331 Manhattan = $47,415, Brooklyn = $35,168) 1/3 of the population is below the poverty line 40% of Bronx adults lack a high school diploma Highest unemployment rate in NYC

5 RegionHIV/AIDS Prevalence Rate African-Am HIV/AIDS Prevalence Hispanic HIV/AIDS Prevalence New York State 0.58%1.74%1.18% New York City 1.04%1.97%1.30% Bronx Borough 1.57%2.18%1.56% NYSDOH 2005 Surveillance Report, including cases reported and confirmed through 2006 HIV/AIDS in New York

6 RegionFunctionally illiterateMarginally literate NYC36%27% Bronx borough46%33% Brooklyn borough41%32% Manhattan borough31%19% Queens borough33%30% Staten Is borough18%28% New York State24%26% Adult Literacy in NYC

7 Why test in the ED? A significant percentage of patients presenting to inner-city EDs have unrecognized HIV-1 infection. (Alpert 1996, Kelen 1995, Schoenbaum 1993, et al.) Inner city EDs serve disadvantaged patient populations who continue to bear a disproportionate burden of the health disparities in our country. These patients utilize the ED for their primary care and have limited or no access to ongoing regular health care with a provider. The CDC recommends that diagnostic HIV testing and HIV screening be a part of routine clinical care in all health-care settings (CDC 2006 Revised Recommendations)

8 Barriers to ED HIV Testing Responsibility Time Cost

9 Educational Videos Increase Access to HIV Counseling/Testing in the ED Rapid HIV Testing Public Health Advocate Project B.R.I.E.F Behavior intervention Rapid HIV test Innovative video Efficient cost and health care savings Facilitated seamless linkage to outpatient HIV care

10 Trauma Exam rm Triage Registration Work Station Bathroom Exam rm

11 Project BRIEF HIV testing





16 Daytime Hours: Patient are walked to ACS clinic and seen by a provider Evening Hours: Patients are given an appointment to return on next open visit at the ACS clinic Protocol for People Testing Positive

17 28,365 patients approached 24,495 pts (95%) tested 1,376 pts (5%) refused 116 (0.47% tested HIV+) Project BRIEF Results 10/05-1/09 25,871 (91%) eligible

18 B.R.I.E.F. n=23,894 responded Self-identified race Hispanic52.9% Black/ African-American33.6% White5.9% Multiracial5.0% Asian1.4% American Indian0.6% Native Hawaiian/ Pacific Islander 0.1%

19 Mean age35 % male43% Preferred Language English Spanish Other 84% 15% 1% Age, Gender, Language of Patients Tested via BRIEF

20 Self-reported Risk Factors % population answering affirmatively Have had sex without using a condom83% Have more than 3 drinks before sex38% Previous non-IV drug use22% Previously had an STD18% Currently use non-IV drugs10.30% Sex with drug user9.20% Previously used street drugs before sex9.20%

21 MalesFemales Never/Almost Never/Sometimes 69.2%78.2% Almost/Every time30.0%21.1% *of patients who stated they were sexually active in the past 3 months Condom Use Reported by BRIEF ED Patients

22 99.3% felt HIV testing in the ED was helpful 96.0% felt the PHAs made getting tested in the ED easier 94.3% felt the video answered their question regarding HIV testing BRIEF Patient Satisfaction with BRIEF

23 86.4% learned a moderate to large amount of new information 80.8% felt the video gave them new information to influence their sexual practice Patient Satisfaction with BRIEF

24 Under 21 Cohort Acceptance(3660/3774) = 96% Male40% (n=1457) Hispanic54% (n=1974) African American32% (n=1178) Mean age19.5 ± 1.4 years Previously tested for HIV62% (n=2274) HIV Prevalence0.16% (6/3660)

25 Under 21 Cohort: Risk Factors 9.0% of males were MSM Unprotected Sex Anal Sex Vaginal Sex Multiple Partners STI Male n= % n=918 15% n=202 84% n= % n=866 8% n=120 Female n= % n= % n=260 89% n= % n=927 21% n=458 Total n= % n= % n=462 87% n= % n= % n=578

26 Linkage to Care Data October 2005 – August 2008

27 Building Linkage: Coordination of ED testing with HIV clinical care Pt tests HIV+ in UCA/ED Pt stable Pt unstable Pt admitted to inpt ACS HIV team Communication from PHA to HIV care team about pt Pt stabilized & d/c’d Pt d/c’d to NH (etc) Pt d/c’d home w/ f/u at ACS clinic Pt escorted to ACS clinic Open access ACS HIV clinic

28 Male* (n = 81) Female (n = 35) Total (n=116) Average Age40 (range: 21–71) 38 (range: 13-56) 40 (range: 13-71) # NBHN Visits prior to Dx # of pts newly dx’d HIV # NBHN Visits 1 year prior to Dx Initial CD4 Count (cells/mm 3 ) Median Initial Viral Load (c/mL) 68,35090,70074,450 BRIEF (10/05-1/09) HIV dx’d Patient Characteristics * 1 pt is transgender (M -> F)

29 Linkage to Care (10/05 – 1/09) # of pts linked to outpt care n= 97 (84%) # of pts dx’d HIV+ n= pts are newly dx’d # of pts linked to NBHN n= 86

30 Pts with with AIDS < 12 months after HIV dx # of Patients

31 Quinn T et al. N Engl J Med 2000;342: Mean (+SE) Rate of Heterosexual Transmission of HIV-1 among 415 Couples, According to the Sex and the Serum HIV-1 RNA Level of the HIV-1-Positive Partner

32 Disparities in Receipt of HHART Related to Racial Concordance HCSUS study –Examined time to HAART for 1241 patients cared for by 287 providers –African American patients with white providers received PIs significantly later than patients with concordant providers (p<.001) Low percentage of minority HIV providers and variable cultural competence among white HIV providers may contribute to disparities in receipt of HAART and outcome by race King WD et al. J Gen Intern Med. 2004; 19:

33 # of days: HIV dx to 1 st med clinic visit (range) Mean = 32 Median = 14 (0-696) # of clinic pts eligible for HAART (DHHS definition)44 # of days: HIV dx to HAART start (mean, median, range) (n = 36) Mean = 52 Median = 38 (1 – 238) # of pts started on HAART (% of eligible pts)35/44 (80%) # patients with viral load < 400 c/mL28 # patients with viral load < 50 c/mL16 Treatment Outcomes: NBHN (n=69)

34 ED Testing Systems SystemProsCons Counselor in ED (Queens, Bx Leb) Can do individualized counseling session Rate-limiting (can only see pts serially) Inefficient Nurses doing testing (Alameda, Metropolitan Physicians (not done yet) May have more contact with ptsLimited buy-in by staff More QI on testing practices Limited by staff availability Limited counseling Responsibility for linkage Public Health Advocate with video and technology support Able to efficiently offer high quality counseling High volume testing Data collection Linkage Start-up costs Requires cont’d oversight and program evaluation by expert leadership

35 ED HIV Screening Programs - MMWR June, 2007 NY (1/05 – 3/06) LA (1/05 – 3/06) Oakland (1/05 – 3/06) Chicago (1/03 – 4/04) GW (9/06 – 12/06) BRIEF (10/05- 12/07) Total Patients 72,94847,73665,731154,47914,98665,214 Offered and Eligible 1,543 (2%) 1,742 (4%) 31,342 (48%) 5285 (3.42%) 4,187 (27.94%) 7,109 (10.93 %) Accepted 1,296 (84%) 1,713 (98%) 16,547 (52%) 3285 (62.16%) 2,486 (59.37%) 6,214 (87.41%) Tested 1,288 (99.38%) 1,709 (99.77%) 6,368 (38.48%) 3238 (98.57%) 2,486 (100%) 6,214 (100%) Positive 19 (1.5%) 13 (0.8%) 65 (1%) 83 (2.56%) 26 (1.04%) 57 (0.92%) L to Care 15 (78.95%) 11 (84.61%) 59 (90.77%) 65 (78.31%) 8 (30.77%) 49 (84.21%)

36 Financial view of BRIEF Re-imbursement for testing 10/05 – 1/09 Estimated Operating Cost of BRIEF = $453,000 24,495 pts tested in ED For NY Medicaid*: $108 re-imbursement for pre-/post test HIV counseling, Approx 25% of pts in JMC ER have Medicaid, 33% have re- imbursable insurance for HIV T&C pts x 0.68 w/ Medicaid x $108/HIV C&T + 53 SNP> $1,798,913 + $1,060,000* *Note: 116 pts tested HIV+, 70% of pt come to NBHN (35 pts join SNP, 1.3 x rate for Medicare about 25% of ED pts are uninsured

37 BRIEF: HIV+ Oct ’07-Oct ’08 (all patients except for 1 pt from Philadelphia) H H

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