1. HIV Testing in Acute Care Settings Rich Rothman, MD, PhD, FACEP rrothman@jhmi.edu CDC, DHHS, OraSure Technologies, Abbott rrothman@jhmi.edu  Historical Perspective  Recent Urgent Care and Emergency Department Programs Using Rapid Test

2. U.S. Emergency Departments  115 million visits/year  24/7  ‘Safety net’ –Minority populations –Underinsured –Foreign born –Substance abusers (IDU) –High risk sexual behavior

3. JHU Emergency Department  Maryland: 19 th population; 3 rd AIDS incidence  Baltimore: 50% HIV+ patients live in Baltimore City  55,000 visits/year  > 75% African American  40% uninsured individuals  15% injecting drug use  14% unrecognized STDs in patients 18-31 years Kelen G., et al. Ann Emerg Med 2002; 9:368-9; Rothman RE. 2004 (unpublished data); Mehta S., et al. Clin Infect Dis 2001; 32:655-9

4. Historical Trends in HIV Prevalence at JHU ED 6.0% 11.4% 8.9% 11.8% 10.9%

5. Overall Rates of Unrecognized HIV Seropositivity in JHU ED (as % of ED population negative/untested) 3.8% 3.6% 2.8% 1.8% Percent of ED patients with newly identified HIV 2.3% (UCC)

6. National Perspective  USPHTF –HIV screening recommended for all person at high risk for infection –Beneficial effects associated with HIV CTR lead to early disease detection  Improve prognosis for those treated with HAART  Reduce OI  Reduce high risk behaviors  Reduce HIV transmission  Emergency Medicine (SAEM) PHTF –Similar evidence based evaluations for ED Applicability

7. ED Testing for HIV  Significant Disease Burden exists in many centers –Baltimore, Maryland 11.4-14% –Bronx, New York 7.8% –Atlanta, Georgia 2.0%  Testing for HIV is EDs is feasible –Consent: 50% –Follow-up: 70% –Rapid testing: Increased turn around time and reporting of results (80%)  Cost analysis suggests that $ testing in EDs is comparable to that spent in publicly funded health care clinics

8. Late 90’s - 2000  National Survey (95 Academic EDs) –Routine HIV testing not routinely performed  CDC Qualitative Survey –Majority physicians supported concept of preventive services –Lack of time major obstacle

9. Developments  Availability of rapid bedside test  Revision of CDC HIV CTR guidelines  Streamline counseling  Rationale for routine testing –Many patients don’t fully disclose risk –Targeted testing may introduce stigma –Increased rates of acceptance with routine testing

10. Rapid Testing Testing Integrated into Routine Care in UCC Provider driven 15 different staff members Department of Emergency Medicine and Pathology The Johns Hopkins University School of Medicine

11. Characteristics of 687 Participants of Rapid Point-of-Care HIV Testing Characteristics Number (%) African American 617 (89.8) No Primary Care Physician 499 (72.6) Uninsured 346 (50.4)

12. Detection of Unrecognized HIV Infection Among 687 Participants

13. Previous HIV Testing in 16 HIV (+) Participants

14. Follow-up of Referral on 15 * HIV Positive Patients Identified by Rapid HIV Testing * 1 HIV positive patient who died was excluded

15. Stage of Disease in Newly Identified HIV+ Patients (N = 15)  33% of newly diagnosed HIV+ patients had a CD4 Count < 200 (cells/mm3)  60% of newly diagnosed HIV+ patients had a viral load of > 10,000 (copies/ml)

16. 4 Month Validation Study for JHU for OraQuick AdvanceRapid HIV1/2 Antibody Test (oral fluid) NSensitivitySpecificityPositive Predictive Value Negative Predictive Value 204100.00%99.02%99.07%100.00%  100% of patients received test results during visit  4 out of 5 new HIV+ patients entered long term care

17. Routine ED Testing at Bedside  Early Pilot Data: –230 tested –10 (4.3%) positive –8 (80%) entered into care

18. Conclusions  Significant disease burden remains in US  Need innovative approaches (ED testing) to access population  ED stream-lined rapid testing –Easy to administer –Easy to interpret –Well accepted

19. Challenges/Barriers to ED based HIV testing  ED cultural issues  Time (provider)  Resources  Education of providers  Logistics of testing: provider or laboratory  Arranging follow-up  State regulations  QA/QC reporting and time requirements  Programmatic costs