# Presentation: 755438

## HIV Testing in Acute Care SettingsRich Rothman, MD, PhD, FACEPrrothman@jhmi.edu CDC, DHHS, OraSure Technologies, Abbott 

**Historical Perspective**
**Recent Urgent Care and Emergency Department Programs Using Rapid Test**

## U.S. Emergency Departments

**115 million visits/year**
**24/7**
**‘****Safety net’ ****	**
**Minority populations**
**Underinsured**
**Foreign born**
**Substance abusers (IDU)**
**High risk sexual behavior**

## 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 Ann Emerg Med***** 2002; 9:368-9; Rothman RE. 2004 (unpublished data); Mehta S., **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**

## Historical Trends in HIV Prevalence at JHU ED

**Historical Trends in HIV Prevalence at JHU ED**

**6.0%**

**11.4%**

**8.9%**

**11.8%**

**10.9%**

**Notes:**
The HIV-1 prevalence rate has increased over time in the Hopkins ED from 6% in 1988 to 11.4% in 1992, 8.9% in 2000 and 11.8% in 2001.  

The percentage of HIV infected individual who did not know they were infected in this population has decreased from 63% of the of the infected population in 1988 to less than 19% in 2001.

These results represent a significant upward trend in the percentage of HIV positive individuals who know there HIV infection status.

## 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)

**Notes:**
The HIV-1 prevalence rate has increased over time in the Hopkins ED from 6% in 1988 to 11.4% in 1992, 8.9% in 2000 and 11.8% in 2001.  

The percentage of HIV infected individual who did not know they were infected in this population has decreased from 63% of the of the infected population in 1988 to less than 19% in 2001.

These results represent a significant upward trend in the percentage of HIV positive individuals who know there HIV infection status.

## 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**

## 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**

## 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**

## 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**

## 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**

## 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) |

## Detection of Unrecognized HIV Infection Among 687 Participants 

## Previous HIV Testing in 16 HIV (+) Participants

## Follow-up of Referral on 15* HIV Positive Patients Identified by Rapid HIV Testing

*** 1 HIV positive patient who died was excluded**

## 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)**

## 4 Month Validation Study for JHU for OraQuick Advance	Rapid HIV1/2 Antibody Test (oral fluid)

| N | Sensitivity | Specificity | Positive
Predictive Value | Negative Predictive Value |
| --- | --- | --- | --- | --- |
| 204 | 100.00% | 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

## Routine ED Testing at Bedside	

**Early Pilot Data:**
**230 tested**
**10 (4.3%) positive**
**8 (80%) entered into care**

## 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**

## 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**