HIV Counseling, Testing and Referral (CTR) Services at Boston Medical Center

Vanessa J. Sasso, MSW

Manager, HIV CTR Program

Center for HIV/AIDS Care and Research (CHACR)

Background

• Over 1 million people are living with HIV in the US• Approximately 25% don’t know it • Approximately 40K new cases of HIV per year• 40 - 50% of all new HIV cases develop AIDS within

1 year of first testing HIV positive

CDC

Major Objectives of our CTR Program

• Find all HIV+ patients

• Link all HIV+ patients to care

• Prevent new cases of HIV

Testing Sites at BMC

• Urgent Care Center / ED Hierarchical routine screening/

Patients typically don’t utilize PCP’s

• Inpatient Medical Service Hierarchical routine screening/

Some physician referrals

• Public Health STD Clinic All patients receiving

STD screens offered HIV CTR

• Adult Primary Care Clinic Patients mostly referred by

physicians/ Some routine testing

• Project TRUST Drop-in Center Harm reduction center/ Clients

acknowledge risk

• Other: Community venues i.e. Dimock Detox, BPHC Needle Exchange Van, MALE Center

Program Data (2006)

Location # Tested # Positive Prevalence

UCC 1018 14 1.38%

Drop-In 2063 25 1.21%

Primary Care 995 8 0.80%

Inpatient 1345 24 1.78%

STD 1736 30 1.73%

Overview

• One of the first CTR sites in the nation• Largest case reporter in MA• High volume testing program• Originally only drop in testing; now fully

integrated into medical system• Pioneered routine hospital based testing• Piloted Urgent Care/Emergency Room testing• Piloted rapid testing for MDPH

Testing “Technologies” Offered

• Traditional Venipuncture OMT (OraSure)

• Rapid Testing (OraQuick Advance)

Rapid vs. Traditional

• With Traditional Tests: Pre-test Counseling Session (Visit #1) 2 weeks for result to come back HIV counselor can prepare for positive results

and plan for linkage to care Post-test Counseling Session (Visit #2) Loss to follow-up: ~85% overall return rate within

our program, CDC reports a national average of ~30%

Rapid vs. Traditional

• With Rapid Tests: Same day test results No “preparation time” for HIV Counselor Explanation of test result meaning

• Negative• Preliminary positive and/or Reactive

Essentially 100% of negatives get results Immediate linkage to care

Pre-test Counseling Changes

• It is now one visit (pre- and post-test counseling in one visit)

• Patient acceptance and competency for testing assessed initially

• Consent form must specify need for confirmatory serum sample (Patient needs to understand RT is a screening tool)

• Risk/demographic data collected while test is running

• If reactive/preliminary positive, immediate blood draw and linkage to care occurs

Rapid vs. Traditional

• Monthly we are doing ~100% rapid testing

• Linkage to care for HIV+ increased from 85% to ~100%

• Community satisfaction!

Implementation of Rapid Testing

• Specialized staff training

• Coordination with BMC’s Department of Laboratory Medicine and MDPH

Rapid Testing Roll-Out

• Rapid Test Trainings: Massachusetts Department of Public Health (MDPH) BMC’s Department of Laboratory Medicine

• Counselors now wear two hats: Counselor and Lab Tech!

Staff Training

Laboratory Medicine

• Buy-in and support from Laboratory Director• CLIA• Point of Care Coordinator

Monitors QA/QCTrains and evaluates Counselors; Approves

competency and ongoing proficiency Approves paperwork and documentationEnters results into BMC medical records

Logistics

• Designed special rolling mobile testing carts

proper lighting, temperature and work space

Lid on the cart can be closed while test is running so counselor and/or patient is not distracted

• Counselors are now delivering a preliminary diagnosis to the client

• More staff time is dedicated to paperwork and performing the test

• Storage and cost of kits and controls

Conclusion

• Dedicated staff instrumental

• Major institutional commitment required

• Laboratory support and involvement crucial

• Actual supply costs high

• Inpatient and outpatient clinical areas well suited for hierarchical routine

testing

• Routine testing facilitates testing and improves case identification• Linkage to care for HIV+ patients is crucial and rapid testing helps facilitate

immediate linkage to care

Acknowledgements

• Paul Skolnik

• Jon Hall

• Jeff Greenwald

• Kim Gregory

• Joann Crain

• All of the 11 HIV

Counselors

• MDPH

• CDC

• BMC

Collaborators Funding