Image: Barry Zingman, MD
March 29, 2010 - Bronx, NY - While helping prevent the spread of human immunodeficiency virus (HIV), the Montefiore AIDS Center’s innovative testing initiative may also serve as a model program for a “test and treat” strategy currently being considered by federal health officials.
“Test and treat” is the name being given to a proposed three-year NIH study to take place in Washington, DC and the Bronx, where the highest HIV/AIDS rates in the nation prevail. While the final protocol and study objectives are still being determined, the overall goal of the project is to determine whether universal HIV testing of adults and prompt treatment of those infected would stop the spread of HIV. Montefiore Medical Center has been invited to participate in the protocol, but barriers to testing and medical care have led officials to question whether such a strategy is unrealistic and have delayed the start of the study.
In the Bronx, the AIDS Center’s own initiatives, fully up and running since 2008, have put the test-and-treat concept into action. Implemented by Barry Zingman, MD, medical director of the AIDS Center, in collaboration with colleagues from the Montefiore Emergency Department (ED) and Adolescent AIDS program, the initiative has expanded placement of dedicated HIV tester-counselors to offer HIV tests in Montefiore’s ED, inpatient units, and outpatient clinics. Those who test positive are referred to appropriate medical care at the AIDS Center’s Center for Positive Living/I.D. Clinic. The AIDS Center is a treatment facility for Einstein Division of Infectious Diseases physician faculty and a HIV/AIDS professional education source for physicians worldwide.
Montefiore’s Emergency Department, one of the country’s top five busiest and the most-visited in New York state, treats approximately 275,000 patients each year, many of whom are uninsured and at high risk for contracting and transmitting HIV. In the past, high patient volumes and unfamiliarity with treatment resources have deterred emergency departments from regularly offering HIV testing. In 2009, tester-counselors tested nearly 2000 patients, about 20 of whom were positive. “These results were highly successful,” said Zingman. “Twenty people who came in for minor things like colds left knowing that they were HIV positive, and they all were linked to care.” The ED’s tester-counselor also seeks out HIV-positive patients who are using the ED instead of another more appropriate site. Numerous patients have been linked to care in this way as well.
Getting emergency department and outpatient clinic staff to offer patients HIV tests regularly without the assistance of tester-counselors has been challenging. Zingman is currently working to streamline the testing process, including lobbying the New York state legislature to remove the written informed consent requirement. “It would make a big difference in healthcare if an HIV test could be ordered as easily as a CBC or a urinalysis,” he said. “I would bet that this would at least double HIV testing in primary care settings.”
With a captive patient audience having blood drawn regularly for other tests, hospital inpatient units present the fewest barriers. Montefiore’s inpatient tester-counselor currently makes “cold calls” throughout the Department of Medicine’s inpatient floors to offer HIV tests to patients and remind care providers to do the same. Currently tests are offered to nearly 90 patients a month, about half of whom accept—a tremendous response, according to Zingman.
Thirty years since the first case was reported, HIV has become a highly treatable condition, with early diagnosis and aggressive intervention affording a near-normal life expectancy. Still, over 25 million lives have ended from AIDS, and well over a million people in the United States are living with the virus, about a quarter of whom remain undiagnosed and may unknowingly pass on the virus.
Normalizing the idea of routine HIV testing is still in its infancy, but Zingman is hopeful. “Even though only about half of Bronx residents have been tested for HIV, that’s a larger percentage than the rest of the nation,” he said.
As the nation looks to the Bronx for ways to control AIDS, Montefiore’s HIV testing initiatives and its comprehensive HIV care services provide a proactive response—a beacon of light in a borough historically strapped for healthcare. “There’s probably no place better than the Bronx to live and be cared for if you have HIV/AIDS,” said Zingman.