Michigan devises plan for routine testing in ERs
Michigan devises plan for routine testing in ERs
Program finds 50 percent more new HIV cases
When Michigan public health officials reviewed HIV counseling and testing programs, they concluded they had penetrated as deeply as possible into the communities they served, with about 400 test sites statewide, and yet it seemed the program's effectiveness had reached a plateau.
"We had a five-year period where our volume of tests done in sites was stagnant," says Liisa M. Randall, PhD, manager of the community partnerships unit of the HIV/AIDS Prevention and Intervention Section, Division of Health, Wellness and Disease Control at the Michigan Department of Community Health in Lansing, MI.
Testing targeted at-risk individuals and was conducted at a variety of sites, including community-based organizations, health agencies, college clinics, community health clinics, etc.
"We also were identifying the same number of positives each year, so we'd reached a maximum effectiveness threshold through all of these other efforts," Randall says.
This might have been acceptable, but there were indications that the testing programs were not capturing all of the people who were HIV infected, she says.
"Our surveillance section had worked as part of a CDC project on late HIV diagnoses," Randall says. "We had data on individuals diagnosed late in their infection, and those cases were concentrated primarily in the Detroit area."
Since the community-based and targeted testing programs weren't capturing those individuals, public health officials decided to screen for HIV in nontraditional settings, such as the Detroit Receiving Hospital, which serves a great number of HIV infected people, Randall explains.
"The hospital's in the highest HIV ZIP code in the state," she says. "And it has the largest indigent population of uninsured people, so we knew they weren't routinely tested."
The project had to be done in a way that would not interfere with the hospital's emergency room patient flow, and there were refinements made after it first was implemented, Randall notes.
"In the first year of that project, there was a little bit under 10,000 tests done in the emergency department, but it's not a screening project by any means," Randall says. "We used a rapid, point-of-care test."
Of the 9,880 HIV tests conducted at the hospital in 2005, 96 were HIV positive, for a HIV rate of 0.96 percent, which is similar to the area's background HIV infection rate, Randall says.
By contrast, the number of tests performed through targeted community testing that year numbered 9,418, and the HIV positive cases numbered 84, for a 0.89 percent HIV infection rate, she says.
Since routine testing was implemented in the emergency department (ED), about 20,000 HIV tests have been conducted, with a 0.98 percent seroprevalence rate.1
Moreover, about one-third to 40 percent of the people who go through the hospital's ED have never had an HIV test before, Randall says.
"That's pretty significant, particularly when you're talking about an inner city hospital located in a high prevalence jurisdiction," Randall says.
The program uses dedicated testers who provide informed consent specific to the HIV test and who provide counseling, in accordance with Michigan regulations.
"There's still this myth that pre-test counseling has to be provided, but that's not what our state statute says, and we can educate clinicians that there are models that will work with consent as it is," Randall says.
"The biggest reason for using HIV testers instead of physicians is because we wanted to use rapid testing as a point-of-care service, and we wanted to get the results back to the individuals while they were physically in there during the visit," Randall says. "Clinicians and nurses didn't have enough time for this, so we needed someone who could take responsibility for doing it in a quality-assured manner."
When a patient tests positive for HIV, an HIV prevention counselor gives the results, explains how a confirmatory test will be done, and helps them determine their immediate needs, Randall says.
Detroit Receiving Hospital has an HIV program near the ED, so this makes it convenient to escort patients there during the HIV clinic's operating hours, or to make an appointment for the patient for the next weekday, Randall says.
The state provides funds to the hospital for the additional salaries, testing devices, and training, she notes.
The staffing costs are about $200,000 per year, so it's not a cheap program, Randall says.
It's too early to tell if the program has caused a drop in late HIV diagnoses, she says.
Michigan's other model program involves opt-out HIV testing at the Detroit Health Department's STD clinic.
"In that clinic, we also use the rapid test as a point-of-care test, and every client who comes through the STD clinic is offered and recommended the HIV test," Randall says. "Their blood is drawn for syphilis and the HIV test, and their consent is provided by the nurse."
Patients are given the results before they leave the clinic.
With the opt-out system, the number of HIV tests performed at the STD clinic doubled within a year, Randall says.
"Everyone who walks through the door is offered the test, and less than 5 percent of clients declined testing," she says. "The clinic and the local health department have a lot of credibility within the community."
Together, the HIV testing programs in the hospital ED and the STD clinic account for 20 to 25 percent of all new HIV positives identified through state-funded programs, Randall says.
Also, the ED and STD clinic HIV testing have contributed to a 23 percent increase in annual volume of tests and a 50 percent increase in the number of new infections identified through publicly-supported programs. In addition, 30 to 80 percent of patients successfully entered care after receiving their HIV infection status.1
"We'd like to see this expand in some way," Randall says.
But this could prove difficult since HIV prevention funding is drying up, and there are competing pressures and priorities, Randall says.
"So we have to make public dollars stretch even further," she adds.
Reference
- Randall L, Berk W. Effective HIV case identification through routine HIV testing in clinical settings in Michigan. Abstract presented at the XVI International AIDS Society Conference, held Aug. 13-18, 2006, in Toronto, Canada.
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