Public Health, EM & Public Health, EM & HIV at LAC+USCHIV at LAC+USC

Public Health, EM & Public Health, EM & HIV at LAC+USCHIV at LAC+USC

Shira Schlesinger, MD MPHShira Schlesinger, MD MPH

Kim Newton, MDKim Newton, MD

Mike Menchine, MD MPHMike Menchine, MD MPH

Kathleen Jacobson, MDKathleen Jacobson, MD

Sanjay Arora, MDSanjay Arora, MD

Shira Schlesinger, MD MPHShira Schlesinger, MD MPH

Kim Newton, MDKim Newton, MD

Mike Menchine, MD MPHMike Menchine, MD MPH

Kathleen Jacobson, MDKathleen Jacobson, MD

Sanjay Arora, MDSanjay Arora, MD

ObjectivesObjectivesObjectivesObjectives

To introduce history, advantages & To introduce history, advantages & disadvantages of implementing Public Health disadvantages of implementing Public Health screening in the Emergency Departmentscreening in the Emergency Department

To examine current epidemiology of HIV in our To examine current epidemiology of HIV in our patient population, changes to clinical indicators patient population, changes to clinical indicators and consent requirements for testingand consent requirements for testing

To introduce a new & exciting program coming To introduce a new & exciting program coming to the ED at LAC+USCto the ED at LAC+USC

To introduce history, advantages & To introduce history, advantages & disadvantages of implementing Public Health disadvantages of implementing Public Health screening in the Emergency Departmentscreening in the Emergency Department

To examine current epidemiology of HIV in our To examine current epidemiology of HIV in our patient population, changes to clinical indicators patient population, changes to clinical indicators and consent requirements for testingand consent requirements for testing

To introduce a new & exciting program coming To introduce a new & exciting program coming to the ED at LAC+USCto the ED at LAC+USC

Public HealthPublic HealthPublic HealthPublic Health

"preventing disease, prolonging "preventing disease, prolonging life and promoting health through life and promoting health through organized efforts " organized efforts "

"preventing disease, prolonging "preventing disease, prolonging life and promoting health through life and promoting health through organized efforts " organized efforts "

1920, C.E.A. Winslow1920, C.E.A. Winslow

Emergency MedicineEmergency MedicineEmergency MedicineEmergency Medicine

“… “… prevention, diagnosis and management of prevention, diagnosis and management of acute and urgent aspects of illness and injury….”acute and urgent aspects of illness and injury….”

““focuses on the immediate decision making and focuses on the immediate decision making and action necessary to prevent death or any further action necessary to prevent death or any further disability.”disability.”

“… “… prevention, diagnosis and management of prevention, diagnosis and management of acute and urgent aspects of illness and injury….”acute and urgent aspects of illness and injury….”

““focuses on the immediate decision making and focuses on the immediate decision making and action necessary to prevent death or any further action necessary to prevent death or any further disability.”disability.”

International Federation of Emergency MedicineInternational Federation of Emergency Medicine

ABMSABMS

Current & Past EM Current & Past EM Public Health ProjectsPublic Health ProjectsCurrent & Past EM Current & Past EM Public Health ProjectsPublic Health Projects

Arthritis, OsteoporosisArthritis, Osteoporosis Cancer Cancer Chronic Kidney Disease Chronic Kidney Disease Diabetes Diabetes Environmental HealthEnvironmental Health Family PlanningFamily Planning Food SafetyFood Safety Heart Disease & StrokeHeart Disease & Stroke HIVHIV ImmunizationImmunization Injury & Violence PreventionInjury & Violence Prevention

Arthritis, OsteoporosisArthritis, Osteoporosis Cancer Cancer Chronic Kidney Disease Chronic Kidney Disease Diabetes Diabetes Environmental HealthEnvironmental Health Family PlanningFamily Planning Food SafetyFood Safety Heart Disease & StrokeHeart Disease & Stroke HIVHIV ImmunizationImmunization Injury & Violence PreventionInjury & Violence Prevention

Maternal, Infant, & ChildMaternal, Infant, & Child Mental Health & Illness Mental Health & Illness Nutrition & Overweight Nutrition & Overweight Occupational SafetyOccupational Safety Oral Health Oral Health Physical Fitness & Activity Physical Fitness & Activity Respiratory Diseases Respiratory Diseases STDs STDs Substance AbuseSubstance Abuse Tobacco Use Tobacco Use Vision and HearingVision and Hearing

Maternal, Infant, & ChildMaternal, Infant, & Child Mental Health & Illness Mental Health & Illness Nutrition & Overweight Nutrition & Overweight Occupational SafetyOccupational Safety Oral Health Oral Health Physical Fitness & Activity Physical Fitness & Activity Respiratory Diseases Respiratory Diseases STDs STDs Substance AbuseSubstance Abuse Tobacco Use Tobacco Use Vision and HearingVision and Hearing

Public Health Projects in Emergency Medicine, 2000-Present. SAEM Public Health Interest Group. 21 November 2005Public Health Projects in Emergency Medicine, 2000-Present. SAEM Public Health Interest Group. 21 November 2005

Costs of Public Health Costs of Public Health ED ProgramsED ProgramsCosts of Public Health Costs of Public Health ED ProgramsED Programs

Minutes per patient represents thousands Minutes per patient represents thousands of hours of diverted patient careof hours of diverted patient care

Few EDs, if any, have down time available Few EDs, if any, have down time available to undertake nonessential tasks or to to undertake nonessential tasks or to incorporate new programsincorporate new programs

Infused resources for parallel-run Infused resources for parallel-run programs better used for improving ED programs better used for improving ED carecare

Minutes per patient represents thousands Minutes per patient represents thousands of hours of diverted patient careof hours of diverted patient care

Few EDs, if any, have down time available Few EDs, if any, have down time available to undertake nonessential tasks or to to undertake nonessential tasks or to incorporate new programsincorporate new programs

Infused resources for parallel-run Infused resources for parallel-run programs better used for improving ED programs better used for improving ED carecare

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.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.

WHO Screening CriteriaWHO Screening Criteria

Condition is important health problem for individual Condition is important health problem for individual and communityand community

Natural history of disease understoodNatural history of disease understood Latent or early symptomatic stageLatent or early symptomatic stage Acceptable screening test Acceptable screening test Treatment exists & more beneficial if started earlierTreatment exists & more beneficial if started earlier Facilities for diagnosis and treatment availableFacilities for diagnosis and treatment available Agreed policy on whom to treatAgreed policy on whom to treat Cost economically balanced in relation to other Cost economically balanced in relation to other

medical expendituresmedical expenditures Continuing processContinuing process

Condition is important health problem for individual Condition is important health problem for individual and communityand community

Natural history of disease understoodNatural history of disease understood Latent or early symptomatic stageLatent or early symptomatic stage Acceptable screening test Acceptable screening test Treatment exists & more beneficial if started earlierTreatment exists & more beneficial if started earlier Facilities for diagnosis and treatment availableFacilities for diagnosis and treatment available Agreed policy on whom to treatAgreed policy on whom to treat Cost economically balanced in relation to other Cost economically balanced in relation to other

medical expendituresmedical expenditures Continuing processContinuing process

HIV in L.A. CountyHIV in L.A. CountyHIV in L.A. CountyHIV in L.A. County

HIV in the USAHIV in the USAHIV in the USAHIV in the USA

HIV in L.A. CountyHIV in L.A. CountyHIV in L.A. CountyHIV in L.A. County

> 45,000 known cases of HIV in LAC > 45,000 known cases of HIV in LAC 88% males, 12% females88% males, 12% females 60% in regions included in LAC+USC catchment area60% in regions included in LAC+USC catchment area Estimated 11,000 additional undiagnosedEstimated 11,000 additional undiagnosed

> 45,000 known cases of HIV in LAC > 45,000 known cases of HIV in LAC 88% males, 12% females88% males, 12% females 60% in regions included in LAC+USC catchment area60% in regions included in LAC+USC catchment area Estimated 11,000 additional undiagnosedEstimated 11,000 additional undiagnosed

HIV Epidemiology Program, LAC-DPHHIV Epidemiology Program, LAC-DPH

Insert charts here of gender/race breakdowns

Marks et al. AIDS 20, no. 10 (2006): 1447-1450Marks et al. AIDS 20, no. 10 (2006): 1447-1450

Transmission and HIV Transmission and HIV Status KnowledgeStatus KnowledgeTransmission and HIV Transmission and HIV Status KnowledgeStatus Knowledge

Clinical Indicators?Clinical Indicators?Clinical Indicators?Clinical Indicators?

Weight Loss (<10%)Weight Loss (<10%) Minor mucocutaneous eruptionsMinor mucocutaneous eruptions Herpes ZosterHerpes Zoster Recurrent URIsRecurrent URIs Cervical DysplasiaCervical Dysplasia Carcinoma in situ of the cervixCarcinoma in situ of the cervix Pelvic Inflammatory Disease (PID)Pelvic Inflammatory Disease (PID)

Weight Loss (<10%)Weight Loss (<10%) Minor mucocutaneous eruptionsMinor mucocutaneous eruptions Herpes ZosterHerpes Zoster Recurrent URIsRecurrent URIs Cervical DysplasiaCervical Dysplasia Carcinoma in situ of the cervixCarcinoma in situ of the cervix Pelvic Inflammatory Disease (PID)Pelvic Inflammatory Disease (PID)

How about these: Have How about these: Have you seen this in the ED?you seen this in the ED?How about these: Have How about these: Have you seen this in the ED?you seen this in the ED?

a)a) Diarrhea for greater than 1 monthDiarrhea for greater than 1 month

b)b) Fever for greater than 1 monthFever for greater than 1 month

c)c) Oral hairy leukoplakiaOral hairy leukoplakia

d)d) Thrush (oral candidiasis)Thrush (oral candidiasis)

e)e) Persistent fungal infections of skin or fingernailsPersistent fungal infections of skin or fingernails

f)f) Sexually transmitted infectionSexually transmitted infection

g)g) Recurrent community acquired pneumoniaRecurrent community acquired pneumonia

h)h) Pulmonary TBPulmonary TB

i)i) ThrombocytopeniaThrombocytopenia

j)j) Recurrent vulvovaginal candidiasisRecurrent vulvovaginal candidiasis

k)k) Seborrheic dermatitisSeborrheic dermatitis

a)a) Diarrhea for greater than 1 monthDiarrhea for greater than 1 month

b)b) Fever for greater than 1 monthFever for greater than 1 month

c)c) Oral hairy leukoplakiaOral hairy leukoplakia

d)d) Thrush (oral candidiasis)Thrush (oral candidiasis)

e)e) Persistent fungal infections of skin or fingernailsPersistent fungal infections of skin or fingernails

f)f) Sexually transmitted infectionSexually transmitted infection

g)g) Recurrent community acquired pneumoniaRecurrent community acquired pneumonia

h)h) Pulmonary TBPulmonary TB

i)i) ThrombocytopeniaThrombocytopenia

j)j) Recurrent vulvovaginal candidiasisRecurrent vulvovaginal candidiasis

k)k) Seborrheic dermatitisSeborrheic dermatitis

Question:Question: How many HIV tests have you ordered in the past How many HIV tests have you ordered in the past month?month?

Question:Question: How many HIV tests have you ordered in the past How many HIV tests have you ordered in the past month?month?

How many HIV tests have you ordered on patients How many HIV tests have you ordered on patients you were planning/ expecting to discharge home?you were planning/ expecting to discharge home?

How many HIV tests have you ordered on patients How many HIV tests have you ordered on patients you were planning/ expecting to discharge home?you were planning/ expecting to discharge home?

1.1. 002.2. 1 - 51 - 53.3. 6 - 106 - 104.4. >10>10

1.1. >5>52.2. 3 - 43 - 43.3. 1 - 21 - 24.4. Huh? Why would I do that?Huh? Why would I do that?

Why Screen?Why Screen?

Are clinical indicators enough?Are clinical indicators enough? 4 visits in year prior to diagnosis4 visits in year prior to diagnosis 50% visits with 1+ clinical indicator50% visits with 1+ clinical indicator EDs among the lowest testing rates (11%) EDs among the lowest testing rates (11%) LAC+USC ED currently tests <1%LAC+USC ED currently tests <1%

Are clinical indicators enough?Are clinical indicators enough? 4 visits in year prior to diagnosis4 visits in year prior to diagnosis 50% visits with 1+ clinical indicator50% visits with 1+ clinical indicator EDs among the lowest testing rates (11%) EDs among the lowest testing rates (11%) LAC+USC ED currently tests <1%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.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 AprWhite 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 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.May.

Screening for HIVScreening for HIVScreening for HIVScreening for HIV

Without treatment HIV Without treatment HIV death in 10 years death in 10 years Late initiation of treatment associated with a Late initiation of treatment associated with a

doubled mortality risk at 10 yearsdoubled mortality risk at 10 years 25yo with early initiation of treatment has an 25yo with early initiation of treatment has an

average life expectancy of 64 yearsaverage life expectancy of 64 years Cost effectiveness in moderate-to-high Cost effectiveness in moderate-to-high

prevalence areas demonstrated in modelingprevalence areas demonstrated in modeling

Without treatment HIV Without treatment HIV death in 10 years death in 10 years Late initiation of treatment associated with a Late initiation of treatment associated with a

doubled mortality risk at 10 yearsdoubled mortality risk at 10 years 25yo with early initiation of treatment has an 25yo with early initiation of treatment has an

average life expectancy of 64 yearsaverage life expectancy of 64 years Cost effectiveness in moderate-to-high Cost effectiveness in moderate-to-high

prevalence areas demonstrated in modelingprevalence areas demonstrated in modelingUNAIDS Reference Group on Estimates, Modelling and Projections, 2006UNAIDS Reference Group on Estimates, Modelling and Projections, 2006Kitahata, MM. et al. Effect of Early versus Deferred Antiretroviral Therapy for HIV on Survival (NA-ACCORD). NEJM. 2009 April 30Kitahata, MM. et al. Effect of Early versus Deferred Antiretroviral Therapy for HIV on Survival (NA-ACCORD). NEJM. 2009 April 30http://www.cdc.gov/vitalsigns/HIVtesting/LatestFindings.htmlPaltiel AD, et al. Expanded screening for HIV in the United States---an analysis of cost-effectiveness. N Engl J Med 2005;352:586--95. 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.Walensky RP, et al. Routine HIV testing: an economic evaluation of current guidelines. Am J Med 2005;118:292--300.

Marks et al. AIDS 20, no. 10 (2006): 1447-1450Marks et al. AIDS 20, no. 10 (2006): 1447-1450

Transmission and HIV status knowledgeTransmission and HIV status knowledge

2006 CDC Recommendations2006 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

LAC+USC ED PopulationLAC+USC ED PopulationLAC+USC ED PopulationLAC+USC ED Population

Over 170,000 patients per yearOver 170,000 patients per year 42% of visits are by women 42% of visits are by women 65% Hispanic/Latino65% Hispanic/Latino 15% African American15% African American 5.4% Asian5.4% Asian 80% report household income < $20,00080% report household income < $20,000 ED as primary/sole source of careED as primary/sole source of care

Over 170,000 patients per yearOver 170,000 patients per year 42% of visits are by women 42% of visits are by women 65% Hispanic/Latino65% Hispanic/Latino 15% African American15% African American 5.4% Asian5.4% Asian 80% report household income < $20,00080% report household income < $20,000 ED as primary/sole source of careED as primary/sole source of care

HIV & Screening HIV & Screening CriteriaCriteriaHIV & Screening HIV & Screening CriteriaCriteria

Important health problemImportant health problem Estimated prevalence 10x higher than Estimated prevalence 10x higher than national average of 0.1%national average of 0.1%

Natural history understood, with Natural history understood, with latent/early symptomatic stagelatent/early symptomatic stage

Average 9 years before AIDS Average 9 years before AIDS diagnosisdiagnosis

Acceptable screening test Acceptable screening test OraQuick: rapid, non-invasiveOraQuick: rapid, non-invasive

Treatment more beneficial if Treatment more beneficial if started earlierstarted earlier

Early HAART Early HAART 50% mortality 50% mortality decrease at 10 yearsdecrease at 10 years

Facilities for diagnosis and Facilities for diagnosis and treatment availabletreatment available

ED as primary health resource ED as primary health resource Link to Rand SchraderLink to Rand Schrader

Cost economically balanced Cost economically balanced with other medical expenditureswith other medical expenditures

Targeted funding for 3 yearsTargeted funding for 3 years Support by LAC DHS & CDCSupport by LAC DHS & CDC

Continuing processContinuing process Exploring long-term integrationExploring long-term integration

Universal HIV Screening Universal HIV Screening at LAC+USCat LAC+USC

Universal HIV Screening Universal HIV Screening at LAC+USCat LAC+USC

Coming soon to a pod near Coming soon to a pod near you!you!

Coming soon to a pod near Coming soon to a pod near you!you!

HIV Screening at LAC+USCHIV Screening at LAC+USC Target OutcomesTarget Outcomes

Earlier first-time diagnosisEarlier first-time diagnosis Linking known diagnoses to careLinking known diagnoses to care

North pod pilot periodNorth pod pilot period 8am-9pm8am-9pm Research Assistants (RAs)Research Assistants (RAs)

Target OutcomesTarget Outcomes Earlier first-time diagnosisEarlier first-time diagnosis Linking known diagnoses to careLinking known diagnoses to care

North pod pilot periodNorth pod pilot period 8am-9pm8am-9pm Research Assistants (RAs)Research Assistants (RAs)

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 ScreenPositive 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

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

What does this have to What does this have to do with me?do with me?What does this have to What does this have to do with me?do with me? Be awareBe aware Help prevent fall-outs & missesHelp prevent fall-outs & misses Be friendly to the RAsBe friendly to the RAs Order WBs, CD4, & Viral LoadOrder WBs, CD4, & Viral Load Give patients their preliminary positives Give patients their preliminary positives

& explain the next steps with the RA& explain the next steps with the RA Write their follow-up info in the chartWrite their follow-up info in the chart

Be awareBe aware Help prevent fall-outs & missesHelp prevent fall-outs & misses Be friendly to the RAsBe friendly to the RAs Order WBs, CD4, & Viral LoadOrder WBs, CD4, & Viral Load Give patients their preliminary positives Give patients their preliminary positives

& explain the next steps with the RA& explain the next steps with the RA Write their follow-up info in the chartWrite their follow-up info in the chart

Whoa there…Whoa there…

How many people are we talking How many people are we talking about?about? Anticipated overall seroprevalence 1-2%Anticipated overall seroprevalence 1-2% 4 new diagnoses per week4 new diagnoses per week

How many people are we talking How many people are we talking about?about? Anticipated overall seroprevalence 1-2%Anticipated overall seroprevalence 1-2% 4 new diagnoses per week4 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)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…)

Let’s say…Let’s say…

I’m in a different area & want to test someoneI’m in a different area & want to test someone UniversalUniversal screening in North screening in North Rapid testing for indicators Rapid testing for indicators anywhereanywhere in the ED in the ED Call the RA, Call the RA, 8am-11pm8am-11pm

My patient is AMSMy patient is AMS General medical consent?General medical consent? Must “know” they are being testedMust “know” they are being tested

My patient asks my opinionMy patient asks my opinion

I’m in a different area & want to test someoneI’m in a different area & want to test someone UniversalUniversal screening in North screening in North Rapid testing for indicators Rapid testing for indicators anywhereanywhere in the ED in the ED Call the RA, Call the RA, 8am-11pm8am-11pm

My patient is AMSMy patient is AMS General medical consent?General medical consent? Must “know” they are being testedMust “know” they are being tested

My patient asks my opinionMy patient asks my opinion

A Partnership of Immense ProportionsA Partnership of Immense Proportions

LAC+USC Emergency DepartmentLAC+USC Emergency Department Kim Newton Kim Newton Mike MenchineMike Menchine Sanjay AroraSanjay Arora Shira SchlesingerShira Schlesinger

Rand Schrader (5P21) ClinicRand Schrader (5P21) Clinic Kathleen JacobsonKathleen Jacobson Stella QuanStella Quan

Office of AIDS Programs & PreventionOffice of AIDS Programs & Prevention Centers for Disease ControlCenters for Disease Control Pacific AIDS Education and Training CenterPacific AIDS Education and Training Center

Kathleen JacobsonKathleen Jacobson

LAC+USC Emergency DepartmentLAC+USC Emergency Department Kim Newton Kim Newton Mike MenchineMike Menchine Sanjay AroraSanjay Arora Shira SchlesingerShira Schlesinger

Rand Schrader (5P21) ClinicRand Schrader (5P21) Clinic Kathleen JacobsonKathleen Jacobson Stella QuanStella Quan

Office of AIDS Programs & PreventionOffice of AIDS Programs & Prevention Centers for Disease ControlCenters for Disease Control Pacific AIDS Education and Training CenterPacific AIDS Education and Training Center

Kathleen JacobsonKathleen Jacobson

- Nico Forget- Nico Forget

Questions?Questions?Questions?Questions?Thank you for your time and for your Thank you for your time and for your

help in making this program a successhelp in making this program a successThank you for your time and for your Thank you for your time and for your

help in making this program a successhelp in making this program a success