1. HIV TESTING AND DELIVERY PRELIMINARY POSITIVE HIV RESULT IN THE EMERGENCY DEPARTMENT TESTAZ PROGRAM AMY EDMONDS, MSW, LMSW PROGRAM COORDINATOR TESTAZ PROGRAM, MIHS DISCHARGE PLANNING TRAINING MEETING FEBRUARY 24, 2015

2. Learning Objectives  Understand the TESTAZ program  Why test? Public Health in the ED Reduce other infections Identify earlier in diagnosis and access to care Linking newly diagnosed patients to medical care 2

3. TESTAZ Statistics July 11, 2011 – February 17, 2015 154 preliminary positive HIV results 116 true HIV positive results 33 false positives Approximately 3 preliminary positive HIV results per month MIHS HIV positivity rate.3%. CDC recommends routine HIV testing if.1% positivity rate. 3

4. 21% OF HIV POSITIVE PEOPLE IN THE UNITED STATES DO NOT KNOW THEY ARE HIV POSITIVE THE HIV POSITIVE UNAWARE ACCOUNT FOR 48% OF NEW HIV INFECTIONS. Spach, David, M.D., University of Washington. 2010 HIV/AIDS: New Issues. PowerPoint presentation. April 23, 2010. 4 HIV-positive Unaware and New Infections

5. Awareness of Serostatus Among People with HIV and Estimates of Transmission ~21% Unaware of Infection ~75% Aware of Infection People Living with HIV/AIDS: 1,148,200 New Sexual Infections Each Year: ~50,000 Account for: ~54 - 70% of New Infections ~30 - 46% of New Infections Marks, et al AIDS 2006

6. Magnitude of the epidemic Each year about 50,000 new infections 17,000 deaths among people with AIDS Net increase of 33,000 people with HIV People who start ART are expected to live at least an additional 35 years CDC surveillance reports; ART Cohort Collaboration Lancet 2008

7. Source of HIV Tests and Positive Tests HIV tests * HIV diagnoses ** Private doctor/HMO53%18% Hospital, ED, Outpatient18%32% Community clinic (public)5%7% HIV counseling/testing5%2% Correctional facility0.4%4% STD clinic0.1%1% Drug treatment clinic0.4%0.1% *National Health Interview Survey, 2006 **HIV Surveillance System, 2007 60% of adults age 18-64 have been tested 18 million adults age 18-64 tested annually in U.S.

8. Screening: HIV vs. Cervical Cancer HIV Cervical CA Annual new cases 50,00011,270 Deaths 14,935 4,070 Branson, Bernard, M.D., CDC, Preventive Medicine Joins Emergency Medicine in Promoting HIV Screening Symposium, November 28, 2012.

9. Persons Whose HIV is Diagnosed Are Less Likely to Transmit Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the U.S. Marks G, et al. JAIDS. 2005;39:446 After people become aware they are HIV- positive, the prevalence of high-risk sexual behavior is reduced substantially. Reduction in Unprotected Anal or Vaginal Intercourse with HIV-neg partners: HIV-pos Aware vs. HIV-pos Unaware 68%

10. 10 HIV Problem is So Serious and the Solution so Simple: Begin Testing Between 50% and 90% of newly HIV infected people who develop symptoms seek medical care for their symptoms. These individual require multiple doctor/emergency room visits before a provider checks for HIV. Of those diagnosed with Acute HIV, 50% of patients were seen at least 3 times before diagnosis (Source: Kahn et al, MEJM, 1998, Weintrob et al, Arch Int Med 2003

11. Care Management Role in Notification and Follow-Up P&P: Care Management: HIV Notification in the Adult and Burn Emergency Departments  Lab notifies the nurse who is caring for the patient  The nurse and/or physician will inform Care Manager personally and through a Care Management consult  The physician will inform the patient of the preliminary positive result with the care manager present in a confidential manner. The provider should remain in the room to answer any medical questions for the patient. 11

12. Care Management Role in Notification and Follow-Up  While the patient is still in the Emergency Department the care manager will: Provide emotional support and resources to the patient Coordinate with the medical staff to complete the follow up lab tests per HIV Testing in the Adult and Burn Emergency Departments Protocol Number: 47001 Provide the patient with the “Positive Packet” detailing outpatient follow up Provide the patient with the phone number of the MIHS Patient Navigator Provide support and referrals to community resources to link the newly diagnosed HIV-positive patient to medical care and support services Discuss referral information with the patient 12

13. Care Management Role in Notification and Follow-Up Inform patient that they will be contacted by the Patient Navigator either the same day or the next business day Confirm patient’s contact information and inquire regarding alternative phone numbers, e-mails, or other ways to contact the patient Obtain the patient signature on the Release of Information forms to make referrals to outpatient medical care and support services Send an e-mail to the HIV team (Amy Edmonds, Cheri Tomlinson, Eric Moore, and Hector Valdez) to inform of the new preliminary positive patient for follow up. The email will include: i. Patient name ii. MRN number iii. Current contact number (or way to follow-up with patient) iv. Any additional information Document interaction and interventions in EPIC with Adult intake template 13

14. Notification Reminders 14 Inform patient the result is preliminary and further testing completed to confirm Follow-up confirmatory HIV testing: HIV RNA viral load, RPR, and Hep C Ensure have a good/reliable contact phone number for confirmatory results Provide results in private manner  Ask all visitors/family to leave room when providing results – it s the patients decision when to tell others about diagnosis (recommend waiting until after confirmatory result) Provide emotional support Do not use the words “not a death sentence like it used to be”  Patients only hear death  Many of the younger patients were not around in early years of HIV

15. Resources and Follow-up 15  Linkage to Care Specialist will:  Contact person with confirmatory test results.  Provide person with following and make appropriate referrals: Positive Packet HIV Resources Support Groups Support  Elicit partners from the person Report the name of the patient and their partners, including identifying and location information for both to the Partner Services Program at MCDPH. Notify the patient that the partner services program will be contacting them.  Schedule person’s first appointment at McDowell Healthcare Clinic  Follow person for one year to ensure medical adherence

16. 16 Other Health Care Provider Resource  Developed website www.testaz.orgwww.testaz.org  Resources  Training  AETC

17. Questions: www.testaz.orgwww.testaz.org

18. Accomplishments of TESTAZ The journal Social Work will publish “Social Work and the HIV Care Continuum: Assisting HIV Patients Diagnosed in an Emergency Department” The Annals of Emergency Medicine published “Identification of Acute HIV Infection Using Fourth-Generation Testing in an Opt-Out Emergency Department Screening Program” in 2014. 2013 – Gage Awards - Remarkable Project Honor the outstanding work of America's Essential Hospitals members. Spread best practices to other members and hospitals that care for the vulnerable. 2014 -Case in Point Platinum Awards - Honorable Mention Transitions of Care (Acute) Case in Point Platinum Awards Recognize the most successful case management and care coordination programs and individuals working to improve the healthcare system. Set the standard of excellence for programs that deliver sustained success throughout the continuum of care coordination 18

19. Acknowledgements This project is funded by the Bureau of Tobacco & Chronic Disease, Office of HIV Prevention Office of the Arizona Department of Health Services through the HIV Prevention Program Cooperative Agreement funds provided by the U. S. Centers of Disease Control and Prevention. Linkage to Care activities are funded in whole or in part by the United States Department of Health and Human Services, Health Resources and Services Administration, the Ryan White HIV/AIDS Treatment Extension Act of 2011, the Maricopa County Department of Business Strategies and Health Care Programs, and the Maricopa Integrated Health System.