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 Shira Schlesinger, MD MPH Kim Newton, MD Mike Menchine, MD MPH Kathleen Jacobson, MD Sanjay Arora, MD

2. ObjectivesObjectives  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  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.”  “… 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. Current & Past EM Public Health Projects  Arthritis, Osteoporosis  Cancer  Chronic Kidney Disease  Diabetes  Environmental Health  Family Planning  Food Safety  Heart Disease & Stroke  HIV  Immunization  Injury & Violence Prevention  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 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  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  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  > 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 HIV Epidemiology Program, LAC-DPH Insert charts here of gender/race breakdowns

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

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? a) Diarrhea for greater than 1 month b) Fever for greater than 1 month c) Oral hairy leukoplakia d) Thrush (oral candidiasis) e) Persistent fungal infections of skin or fingernails f) Sexually transmitted infection g) Recurrent community acquired pneumonia h) Pulmonary TB i) Thrombocytopenia j) Recurrent vulvovaginal candidiasis k) Seborrheic dermatitis a) Diarrhea for greater than 1 month b) Fever for greater than 1 month c) Oral hairy leukoplakia d) Thrush (oral candidiasis) e) Persistent fungal infections of skin or fingernails f) Sexually transmitted infection g) Recurrent community acquired pneumonia h) Pulmonary TB i) Thrombocytopenia j) Recurrent vulvovaginal candidiasis k) Seborrheic dermatitis

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? 1.0 2.1 - 5 3.6 - 10 4.>10 1.>5 2.3 - 4 3.1 - 2 4.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%  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  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. Marks et al. AIDS 20, no. 10 (2006): 1447-1450 Transmission and HIV status knowledge

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  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  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  Important health problem Estimated prevalence 10x higher than national average of 0.1% Estimated prevalence 10x higher than national average of 0.1%  Natural history understood, with latent/early symptomatic stage Average 9 years before AIDS diagnosis Average 9 years before AIDS diagnosis  Acceptable screening test OraQuick: rapid, non-invasive OraQuick: rapid, non-invasive  Treatment more beneficial if started earlier Early HAART  50% mortality decrease at 10 years Early HAART  50% mortality decrease at 10 years  Facilities for diagnosis and treatment available ED as primary health resource ED as primary health resource Link to Rand Schrader Link to Rand Schrader  Cost economically balanced with other medical expenditures Targeted funding for 3 years Targeted funding for 3 years Support by LAC DHS & CDC Support by LAC DHS & CDC  Continuing process Exploring long-term integration Exploring long-term integration

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)  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 Unknown HIV Patient brought to North Pod No further HIV-specific management, continue with routine care HIV status requested Patient offered HIV test by RA RA notes reason for decline Patient declines Patient accepts OraQuick test performed Result noted into Sunquest lab system RA informs patient of negative result Patient given copy Negative Screen Positive Screen 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 RA telephone follow up at 2 weeks Document linkage to care Follow up appointment with Rand Schrader arranged for 5-7 days Rand Schrader Clinic personnel notified

24. Patient presents to Triage Known HIV + In HIV care (visit within 6 months) Patient brought to North Pod No further HIV-specific management, continue with routine care HIV status requested Out of HIV care (no visit in past 6 months) RA telephone follow up at 2 weeks Document linkage to care Follow up appointment with Rand Schrader arranged for 5-7 days Rand Schrader Clinic personnel notified

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  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  How many people are we talking about?  Anticipated overall seroprevalence 1-2%  4 new diagnoses per week CDC, “Rapid HIV testing in emergency departments--three U.S. sites, January 2005-March 2006,” MMWR. 56(24) (June 22, 2007) Pictures of people (some of these people…)

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