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Part 5: HIV POCT Tests

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Note that as of 2018 we no longer do HIV POCT tests. Please have the clinical team order an HIV-1 and HIV-2 serum antibody test, and do a blood draw.

The protocol below is preserved only for historical reference.

PRE-TESTING:

1) HIV tests are located in the preceptor room.

• HIV Rapid Testing (POCT) order appears in the Labs In Basket
• Obtain Consent

2) Teaching Seniors MUST provide the 7 points of information required by NYS Law (see below or in TS binder).

3) Teaching Seniors MUST confirm that the patient consents to the HIV test.

TESTING

1) Perform the HIV Rapid Test using the oral swab or fingerstick.

• Specific instructions for each are in the TS Labs binder.
• Remember: do not use the first drop of blood
• One the blood soaked loop is collected, swirl the loop in the developer and DISPOSE OF IN BIOHAZARD
• Insert the OraSure test probe in developer and set an alarm for 20 minutes
• Ask the patient to wait in the waiting room while the results are obtained
• Dispose of ALL MATERIALS in the biohazard afterwards
• Refer to the OraSure testing protocol for any questions about how to read/administer.

POSITIVE TEST RESULTS: Band present at C and T

NEGATIVE TEST: Band present at C only.

INDETERMINATE

INDETERMINATE

2) Document the test results:

• Click the POCT lab in the In Basket
• Click on the Edit Rslt button located on top bar in the In Basket
• Double click on the order to open it. This opens a screen where a lot of information needs to be entered. The KEY information must be entered in the Value/Comment box on the bottom of the page (bottom left)
• Under Type — enter 22 (blood), Under Collected by — enter your name, Enter the collection date and time
• Enter the VALUE in the Components box (there is a free text area that says VALUE — enter the result — for example, NEGATIVE or POSITIVE or INDETERMINATE).
• Under “Narrative Comments” on the 3rd tab of the same bottom box, enter the following text, if the test is a negative result “.EHHOPHIVRAPID” and click ENTER.
• This will populate the following smart phrase: "The 7 points of information were provided to the patient, per NYS guidelines and oral consent was obtained. Fingerstick HIV Rapid Test was performed. Pt was provided with results and counseled regarding the 90 day window period and assessed for possible need for repeat testing."
• Under “Narrative Comments” also document the lot number and expiration date.
• Addend as needed for ambiguous or Positive Results (see below).
• Enter the Attending of the Day under “Results Message” (top right corner) and enter Dr. Meah as the Billing and Resulting provider
• Enter today’s date and time in the right hand column.
• Click on the Abnormal button and change the result to Normal. Click on the Status button located at the bottom right of the screen and change the status from In process to Final Result.

3) Go back to the In Basket message, highlight the order that was just completed, and click on Done located right above the messages.

If you forget to document before clicking “DONE” on the order, you need to search for the DONE order. Go to In Basket –> Orders –> Click Search –> Under Statuses, uncheck everything except for Done –> Click Search. (Before clicking Search, You may also search for specific patients if you do not want to pull up all the recent Done orders from Saturday — just click on the magnifying glass to do so). This should take you do the Ad Hoc search results. The Done results are all greyed out but you can still edit the result. Click on the patient and the test you want, and click Edit Result.

POST-TESTING:

If the patient’s Rapid Test Results are Negative:

1. Teaching Senior should inform the patient in person in a private room and MUST DISCUSS a) the meaning of a negative test result and b) the 90 day window period and assess need for repeat test/appointment.

2. Clinical team is informed and may document in note.

3. Follow up regarding Safe Sexual Practices and additional counseling with the clinic team and Social Work/ Patient Education as needed.

If the patient’s Rapid Test Results are Indeterminate:

1. If the OraQuick test is indeterminate, explain the situation and strongly recommend that the patient repeat the rapid test. If the patient declines, suggest future testing as soon as possible for the patient.

2. Document in Narrative Comments (in the enter/edit results pane) and in your TS Note addendum.

If the patient’s Rapid Test Results are Positive (Modified DOH):

1. Clinical Team and Attending MUST be informed immediately, and if possible, Social Worker and Chief TS. Also, email/call Dr. Thomas and Dr. Meah.

2. Patient should be informed in private room by Clinical Team and Attending: Escort the patient back to the designated testing room to discuss the test result and how care will continue. Collect all contact information (phone number, address, whether or not it is all right to call the home, what time of day is best, alternate contact person). You must:

   Explain that the test result is preliminary and that a follow-up test is needed to tell for sure whether the patient has HIV; Inform the patient when the confirmatory result will be available and emphasize the importance of learning the final result; Explain that if infected, the patient could pass HIV to his/her sexual or needle sharing partners; Emphasize the importance of avoiding behaviors that could pass the virus to others; Conduct a risk assessment to gain a better understand of the likelihood that the test result is a true positive; and, Based on the results of the risk assessment, help the client understand the likelihood that the preliminary positive test result is a true positive; If the patient has a history of high risk behaviors or if acute infection is suspected, consider contacting Partner Services and initiating a referral to an HIV specialist for care.

3. Document in Narrative Comments (in the enter/edit results pane) and in your TS Note addendum.

4. Clinical team will immediately order ELISA/ Western Blot for confirmatory testing. Escort the patient to the lab room to have blood drawn; alternatively, blood can be drawn in the designated testing room for maximum confidentiality.

5. Make the pt a one week follow up Labs ONLY appt (results must be given in person) to discuss the result of confirmatory Western blot testing and arrange referral to the Jack Martin Clinic as required.

6. Until the confirmatory test result comes back from Sinai Labs, the clinical team, Teaching Senior, and Jack Martin referral liaison coordinate frequent check- ins with the patient to provide emotional and medical support and referral to community-based resources as needed. The default contact unless a specific exception is made is the Teaching Senior who administered the rapid test for that patient.

7. If the confirmatory test is positive, refer the patient to the Jack Martin clinic at Mount Sinai for all further primary care services and initiation of an ADAP application.

8. Make an appointment with the Jack Martin scheduler, Angie Rivera – 212.824.7389

9. Contact the Jack Martin social worker, Laura Friedman – 212.824.7427

10. If possible, a member of the patient’s EHHOP clinical team can accompany the patient to his/her first visit at the Jack Martin Clinic

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Mount Sinai Policy A4-120

1. HCP documents post-test counseling in the Medical Record: i) Discuss the meaning of the test result. ii) Encourage timely access to health care and give referrals.
2. Referrals shall include (but not be limited to) counseling:
3. for coping with the emotional consequences of learning the result.
4. regarding discrimination problems that disclosure of the result could cause.
5. for behavior change to prevent transmission or contraction of HIV infection.
6. to inform the patient of available medical treatments.

7. regarding the need to notify the patient’s contacts.

8. With the patient’s consent (or, if the patient lacks capacity, consent of the patient’s legal representative), provide or arrange with a healthcare provider for an appointment for follow-up medical care for HIV for the patient.

9. For a pregnant patient coordination of care is provided by a designated Provider or the Social Work team. Discussion will include a recommendation for early entry into prenatal care to reduce maternal-child transmission and risk of transmission through breast feeding.

10. Discuss requirement to report patient’s name, with positive test result to NYSDOH (New York State Department of Health) for epidemiological and Partner Notification purposes.

11. Review the following in relation to Partner Notification:

12. Benefits (partner at risk can learn HIV status)
13. Domestic Violence screening will be conducted before any assisted notification;

14. Patient’s name is never disclosed during partner notification.

15. Discuss known partner/spouse and provider’s responsibility to report name(s) to NYSDOH.

16. Discuss additional partners and select the best option for each partner and conduct domestic violence screening. Note: Partner name is not kept by NYSDOH for more than one year after completion of partner notification. A common question is whether patients must name partners. Partner notification is voluntary, and there is no penalty for not naming partners.

17. Explain partner notification options:

18. Notification by a Partner Notification Assistance Program (PNAP)/CNAP counselor or provider. The patient’s name or other identifying information is never revealed.
19. PNAP/CNAP or provider-assisted notification.

20. Self-notification (if patient chooses not to name partner). Explain that when self notification is chosen, a confirmation plan will be worked out between the provider and PNAP/CNAP.

21. The attending of record must complete the “Medical Provider HIV/AIDS and Partner/Contact Report Form” (DOH #4189). This form is used only for patients with an initial positive HIV antibody test. Hand deliver or mail confidentially both the white and yellow copies to:
    Administrator, Box 1009 Jack Martin Fund Clinic CAM Building 3rd Floor No copy should be filed in the patient’s medical record.

22. There will be a monthly pick-up of the yellow copies from the JMFC by the DOH of these forms. The white copies will remain on file.

23. Outpatient practice areas providing HIV testing and counseling should keep a copy of DOH for 4189 in a locked, confidential file.

24. Provide or refer patient to medical services and counseling for needed support services (e.g., education to prevent transmission to others, emotional support, legal and domestic violence services).

FAQs:

Modified from NYS DOH FAQs regarding the amended HIV testing law

Who should be tested? All persons between 13 and 64 need to be offered an HIV test at least once. In addition, the law requires that offers be made to any person, regardless of age, if there is evidence of risk activity. Testing should be offered annually to persons whose behavior indicates elevated risk such as sexual or drug use activity, or even more often for those with very high risk behaviors such as unprotected anal intercourse. Since many people choose not to disclose their risks, providers should consider adopting a low threshold for recommending the test.

What kind of consent needs to be obtained for rapid HIV testing? Oral consent may be obtained and documented in the patient’s chart.

What information must patients be provided before consent is obtained? Prior to being asked to consent to HIV testing, patients must be provided the seven points of information about HIV required by the Public Health Law.

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7 Points English: http://www.health.ny.gov/diseases/aids/testing/seven_key_facts.htm

Spanish: Siete puntos importantes sobre la prueba de VIH:

1. El VIH (o Virus de Inmunodeficiencia Humana) es el virus que causa SIDA. Se transmite por: 1) relaciones sexuales (vaginales, anales o orales) con una persona que tiene VIH; 2) contacto con sangre infectada por jeringas contaminadas (perforación, tatuaje, o aparatos de drogas) o transfusiones de sangre contaminada; 3) de una madre con VIH a su bebé en el embarazo, el parto o al darle pecho.

2. Hay tratamientos para VIH/SIDA que le ayuda a una persona mantener su salud.

3. Personas con VIH/SIDA puede usar métodos seguros para evitar que otras se infecten. Métodos seguros también evitan que personas con VIH/SIDA se infecten con otra variedad de VIH.

4. La prueba es voluntaria y también se puede hacerlo sin nombre en un centro de pruebas público (de manera anónima).

5. Por ley, los resultados de la prueba de VIH y otra información acerca de esto se mantiene confidencial (privado).

6. Discriminación basado en el estado de VIH de una persona es ilegal. Personas afectadas por discriminación pueden conseguir ayuda.

7. Consentimiento para una prueba de VIH es efectivo hasta que sea quitado verbalmente o por escrito. Si se da consentimiento por un período de tiempo específico, el consentimiento se aplica a ese perídodo de tiempo solamente. Se puede quitar el consentimiento en cualquier momento.

Prepared for EHHOP by Jennifer Long Diaz, August 2012 Sources:

7 Key Facts to Know Before Getting an HIV Test. New York State Department of Health.

Regulations. New York State Department of Health, Nov 2, 2011.