In 2000 Nancy Glick, M.D., of the Infectious Disease Division of the Department of Medicine and Steve Whitman, Ph.D., Director of SUHI, decided that it would be important to bring HIV counseling and testing to the Emergency Room (ER) at Mount Sinai Hospital. The motivating idea was that many ER patients may not regularly access care and thus not get tested for HIV. Patients who are unaware of their positive status cannot be linked to life-saving treatment. Further, prevention messages in this environment might also prevent the spread of some HIV infections.
With this in mind Glick and Whitman obtained a small grant of $75,000 from a pharmaceutical company to offer HIV testing to high-risk ER patients. In the middle of this one-year project, the Centers for Disease Control and Prevention (CDC) issued a call for proposals to implement routine HIV testing in ERs. With the experience of the first project to guide them and with the addition of Abigail Silva, who had just recently joined SUHI, the team was successful in obtaining $504,000 for three years (from 7/01 – 9/04). Soon afterwards, this same team applied for and received a 4-year $1,200,000 grant from the Health Resources Services Administration for HIV prevention with people who are already infected with the virus (from 9/03 to 9/07). In the wake of this work, we partnered with the Access Health Centers Network on a CDC proposal to implement routine HIV testing in primary care settings. We received a two-year $412,000 grant to do this work. All together, a total of $2.2 million in HIV/AIDS prevention grants has been brought to the Sinai Health System.
As a result of this work the Sinai Health system has become nationally recognized as a site that does excellent research and evaluation and that delivers quality HIV services.
HIV Testing in the Emergency Department (ED)
The Centers for Disease Control and Prevention (CDC) recommends that hospitals and acute-care facilities with a high (=>1%) HIV seroprevalence rate routinely offer HIV counseling and testing to its patients. Mount Sinai hospital’s emergency department is one such venue. Therefore, in 2001 a one-year pilot project was implemented in which high-risk and symptomatic patients were offered standard HIV testing by a health educator. The goal was to assess: if such a strategy was feasible in a resource-poor hospital; whether patients would consent at a high rate; if indeed patients with a previously unrecognized HIV infection would be identified; and whether HIV-positive patients could be successfully linked to care. The strategy proved to be feasible. More then 50% of the patients that were approached consented to testing. In addition, 15 HIV positive patients were found of which most were successfully linked to care.
Routinely Recommending HIV/STD Testing in the ED
In 2001, the Centers for Disease Control funded four sites across the country for two years to assess the feasibility, effectiveness, and cost of routinely recommended HIV/STD screening in an urban emergency department (ED). Mount Sinai Hospital’s ED was one of the selected sites. The goals were to routinely recommend rapid HIV/STD testing to patients 15-54 and also offer gonorrhea (GC) and chlamydia (CT) to patients 15-25. Testing was offered Monday-Friday, 11AM-8PM. Infected patients were referred for treatment and care.
From April 2003 to August 2004, 3,030 patients were offered HIV testing of which, 1,447 (47.8%) accepted, 8 (0.6%) tested positive, and 3 (37.5%) were linked to care. Among 791 patients offered STD testing, 386 (48.8%) accepted, 320 provided urine (82.9%), 48 (15.0%) tested positive, and 42 (87.5%) were treated for GC or CT. The program cost was $72,928. Costs per HIV-infected patient identified and linked to care were, respectively, $9,116 and $24,309; cost per STD-infected patient treated was $1,736. The program cost for HIV/STD screening was only $14,340 more than if we only screened for HIV.
Through ED-based HIV/STD screening, we identified and treated many STD-infected patients, but identified few HIV-infected patients and linked even fewer to care. However, it was found that STD screening can be added to HIV screening at a reasonable cost.
Additionally, we also have received a grant from the Chicago Department of Public Health to routinize STD testing in the ED. Specifically, our Health Educator approaches 15-25 year old patients during high traffic times in Sinai’s ED and offers free Chlamydia and gonorrhea testing. He also offers free HIV testing. Once a patient is found to be positive, he contacts the patients, informs him/her of their STD/HIV result, ensures that he/she is treated appropriately and offers testing and treatment to his/her partner. Our staff will also ensure that a patient who is over the age of 25 is made aware of their STD result and follows up regarding treatment options. If the patient has no sources of primary care, our staff will treat the patient as well. Finally, our staff ensures that all positive STD and HIV results found through the ED are reported to the Health Department.
The project has found consistently high STD rates. In fact over the last 2 years the overall STD positivity rate has ranged between 15% and 18%. These rates are among people aged 15-25, who are unaware of their disease. We have also maintained a high follow-up rate ranging from 80% for the overall ED census to 93% among patient approached by our health educator. We have also reported 100% of our positive cases. HIV testing was recently added on as a priority for this project. We have recently begun offering HIV testing, thus numbers are not available for this part of the project.
Routinely Recommending HIV Testing in Primary Care Settings
In 2004, the Centers for Disease Control awarded ACCESS a two-year grant to carry out a demonstration project designed to evaluate the feasibility and sustainability of routinely recommending rapid HIV testing to patients in two of its primary care clinics. The project was collaboration between ACCESS and Mount Sinai Hospital and builds on the previous work done on HIV testing in health care settings. The goal was to use existing clinic staff to routinely recommend rapid HIV testing to patients over the age of 15 and link HIV-infected patients to care. The project was implemented at the Kling Adult Internal Medicine and Ashland Family Care Clinics.
From April 2005 to August 2006, 4,703 patients were offered HIV testing of which, 2,750 (58.4%) accepted, 4 (0.15%) tested positive, and 4 (100.0%) were successfully linked to care. Because existing staff was used and patients were successfully linked to HIV care, routinely recommending HIV testing in similar settings appears to be feasible and sustainable. ACCESS is currently considering implementing routine HIV testing at other clinics.
Perinatal Enhanced Case Management Evaluation
The Pediatric AIDS Chicago Prevention Initiative (PACPI) was established in 2000 by Pediatric AIDS Chicago to help eradicate the transmission of HIV/AIDS from mother to child. One way that PACPI is trying to eliminate vertical transmission is through its Perinatal Enhanced Case Management (PECM) Program which provides intense case management to high risk HIV+ women who are pregnant or have recently delivered and their babies in order to: 1) ensure healthy outcomes for the mothers and their babies, and 2) prevent HIV transmission to the babies. In order to do this they provide support to the mother so that she can adhere to her HIV medication, HIV care visits, and prenatal care visits. They also help her adhere to her baby’s medication regimen and pediatric care visits. This program, which was established in 2002, has never been evaluated. In 2006, PACPI received funding from the Centers for Disease Control and Prevention to have the Sinai Urban Health Institute evaluate the PECM program and conduct a cost analysis.