AlbanyMedicalCollege

division of Hiv medicine

S P R I N G 2 0 0 8

Rapid Hiv Testingin emergency departments

A cme-Accredited Resource

LEAD AUTHORRalph Liporace, MD, AAHIVSMedical DirectorClinical Research ProgramDivision of HIV MedicineAlbany Medical CollegeAlbany, NY

CO-AUTHORSWayne R. Triner, DOAttending Physician Emergency MedicineAlbany Medical CollegeAlbany, NY

W. Patrick Bowden, PA, AAHIVSNicholas A. Rango HIV Clinical ScholarDivision of HIV MedicineAlbany Medical CollegeAlbany, NY

EDITORIAL BOARD

L e a d e d i t o r & C o u r s e

d i r e C t o r

Douglas G. Fish, MDMedical DirectorAIDS Designated CenterAssistant Professor of MedicineAlbany Medical CollegeAlbany, NY

P r o j e C t M a n a g e r s

Abigail V. GallucciDirector of AIDS EducationDivision of HIV MedicineAlbany Medical College Albany, NY

Sarah J. Walker, MSAssociate Director of Correctional EducationDivision of HIV MedicineAlbany Medical CollegeAlbany, NY

C o n t i n u i n g e d u C at i o n

d i r e C t o r

Jennifer L. PriceOffice of Continuing Medical EducationAlbany Medical CollegeAlbany, NY

P r o d u C t i o n a s s i s ta n t

Cathryn R. CorlewEducation & Outreach CoordinatorDivision of HIV MedicineAlbany Medical CollegeAlbany, NY

FACULTY DISCLOSURERalph L. Liporace, MD, AAHIVS

s P e a k e r ’ s b u r e a u : Gilead Sciences, Inc., Pfizer, Inc., Roche Laboratories, Inc. & Tibotec Therapeutics

Douglas G. Fish, MD

s P e a k e r ’ s b u r e a u : Gilead Sciences, Inc. & Roche Laboratories Inc.

C o n s u Lta n t: Monogram Biosciences, Tibotec Therapeutics & Trimeris

Wayne R. Triner, DO, W. Patrick Bowden, PA, AAHIVS, Abigail V. Gallucci, Sarah J. Walker, Jennifer L. Price & Cathryn R. Corlew:These individuals have no financial arrangement or affiliation with any corporate organizations that offer financial support for continuing medical education activities.

TARGET AUDIENCEThis monograph is designed for physicians, physician assistants, nurse practitioners, registered nurses and licensed practical nurses in an emergency department setting.

LEARNING OBJECTIVESBy the end of this module, the reader should be able to:

1) DescribethecurrentepidemiologyofHIVinfectionintheUnitedStates.

2) DiscussHIVAcuteRetroviralSyndrome.3) IdentifypatientsathighriskforHIV

infectionintheEmergencyDepartment.4) ReviewthecurrentCDCguidelines

fortestingpatientsforHIV,tailoredtoStateLaw.

5) OutlinehowtoinitiateHIVtestinginEmergencyDepartmentsusingrapidHIVtests.

ACCREDITATIONAlbany Medical College is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Albany Medical College designates this educational activity for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

ACKNOWLEDGEMENTS

This monograph is a collaborative initiative among the Division of HIV Medicine at Albany Medical College, in partnership with the New York/ New Jersey AIDS Education & Training Center.

Thank you to Gilead Sciences, Inc. for their support via an unrestricted educational grant.

Dear Col league,

The Centers for Disease Control (CDC) has recently made new recommendations for the testing of individuals for HIV. This is in response to the fact that although major strides have been made in the treatment of HIV and survival, new infections continue to occur at the rate of approximately 40,000 new infections per year. This new infection rate is primarily driven by the 25% of HIV-infected individuals who do not yet know they are infected. It is clear that previous testing strategies have failed, and new strategies are needed.The CDC hopes and believes that wider testing in the acute primary care setting will greatly increase HIV status awareness, and reduce the number of persons who are unaware of their infection.We hope that this monograph will prepare you to begin testing in your Emergency Department.

Thank you,

Ralph Liporace, MD AAHIVS

Rapid HIV Testingin Emergency Departments

A CME-Accredited Resource

About Continuing Medical Education (CME) To obtain CME credit, a minimum of 70% of the questions must be answered correctly on the self assessment test on page 9. The estimated time for completion of this activity is 1 hour.

There is no fee for the CME credit for this monograph. This learning activity is awarded 1.0 contact hour until June 30, 2008.

Directions1. Time yourself throughout all portions of this activity.

2. Read the enclosed monograph.

3. Take the self assessment test.

4. Fill out the program evaluation. Please be sure to include the length of time it took you to complete the activity, self assessment test, and evaluation.

5. Complete the reader information form including your name and address.

6. Fully complete the HRSA participant information form in black pen. Each bubble must be fully shaded.

7. To assure your receipt of CME credit, please mail your completed self assessment test, program evaluation, reader information form and HRSA participant information form (3 pages total) to:

Cathryn R. CorlewAlbany Medical College47 New Scotland Avenue, Mail Code 158Albany, NY 12208

If you have any questions, please contact Cathryn R. Corlew at (518) 262-6864 or corlewc@mail.amc.edu.

PAGE1

INTRODUCTION

More than twenty five years into the HIV epidemic, the spread of HIV continues unabated, with approximately 40,000 new infections annually in the United States. Currently, there are approximately 1,000,000 persons in the United States living with HIV; approximately 25% or 250,000 persons are unaware of their infection.1 Some estimate that as many as 75% of new cases are transmitted from the 25% of HIV-infected individuals who are unaware of their status.2 According to the Kaiser Family Foundation, which conducted a survey via telephone interviews with 2,517 respondents, 46% of respondents had never been tested for HIV and of those, 61% stated the reason for not being tested was that they did not feel they were at risk.3 Lack of risk perception has led to a lack of status awareness. Since a tremendous increase in HIV infection rates is occurring in persons who do not have traditional risk factors, risk-based testing is proving ineffective in containing the spread of HIV.

TESTINGGUIDELINESRecently there have been major revisions to the HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings Recommendations published by the Centers for Disease Control (CDC).4 Recognizing the limitations of HIV testing based solely upon traditional risk factors, the CDC has proposed routine voluntary testing for patients ages 13-64 in all healthcare settings – not based upon risk. Additionally, the recommendations suggest that medical providers offer opt-out testing. In opt-out testing, a separate informed consent for HIV testing is not necessarily required, and prevention counseling/pre-test counseling is not required. Check with your health department regarding the law in your state.

E d i t i o n 1

RAPIDHIVTESTINGINEmERGENCyDEPARTmENTSACmE-Accredi tedResource

WHyTESTINTHEEmERGENCyDEPARTmENT?

Often individuals who are ultimately diagnosed with HIV have been seen in acute care settings years before receiving an HIV diagnosis and are not tested for HIV. Of 4,315 cases of HIV infection in South Carolina during 2001-2005, 41% were in persons in whom AIDS was diagnosed within 1 year of their initial HIV diagnosis, demonstrating how late in their infection they were actually diagnosed.5 73% of these late testers had visited a health care facility at least once prior to their first positive HIV test. 79% of these visits did not involve diagnoses that would have prompted HIV testing, providing evidence and highlighting the need for routine screening rather than screening based on risk. Of these cases of HIV late testers, 79% had visited an Emergency Department (ED), 12% had been inpatient, 7% had made outpatient visits, and 1% had been seen in a free clinic prior to being diagnosed with HIV infection.5 This again demonstrates the necessity of routine testing, not risk-based testing, and the utility of testing in the ED.

Status awareness also has the potential to prevent transmission and reduce high-risk sexual behavior. Mother-to-child transmission (MTCT) has been reduced to < 2%, with universal screening of pregnant women in combination with prophylactic administration of antiretroviral drugs, scheduled cesarean delivery when indicated, and avoidance of breastfeeding. In a meta-analysis of 8 studies, the prevalence of unprotected vaginal or anal intercourse with uninfected partners was, on average, 68% lower for HIV-infected persons who were aware of their status, compared to HIV-infected persons unaware of their status. This highlights that status awareness does often influence personal behavior.2

As demonstrated by the South Carolina study, many visits are made to the ED and patients at risk for HIV are not being screened. Given that rates of new HIV infections may have risen in some groups and that

PAGE2 RapidHIVTestinginEmergencyDepartments

traditional risk-based testing is not working, many states such as New York are embarking on a program to make HIV testing more widely available in acute care settings, including the ED.

BARRIERSTOHIVTESTINGINTHEED

Current barriers to HIV testing in EDs arise from two principle areas: the lack of resources required for testing and perception of the role of the ED in the healthcare system. Although the CDC no longer recommends pre- and post-test counseling, it is legally required as part of the public health laws in many states.

Public health law that addressed HIV testing originated at a time when there was no effective treatment, and significant social stigma was attached to the diagnosis. These regulations were aimed at protecting the individual’s privacy and sensitivity to the psychological impact associated with a non-treatable fatal illness. At that time, such protections were required to facilitate a willingness to undergo HIV testing. As a result, HIV testing is not handled in the same manner as most other diagnostic testing carried out in the ED. There are significant requirements for pre- and post-test counseling as well as availability of appropriate follow-up medical care. In the present context, providers engaged in traditional ED clinical activities would find it difficult to fulfill the requirements mandated for HIV testing. Therefore, centers that have initiated routine testing of ED patients for HIV have utilized personnel whose sole job is to carry out HIV testing and the associated requirements. As a result, the cost of such programs must be included in planning. To date, most of these programs have been linked to external funding.

The second barrier to routine ED testing for HIV is the diversion of ED activity from an acute care to a public health role. Though EDs have long played an indirect or implicit role in public health activities, until now disease screening of asymptomatic patients has not been mandated by public health agencies. It is, however, the unique nature of many patients seen in EDs that makes this initiative attractive; namely that for many individuals, their healthcare encounters occur only in EDs.

There is some experience with routine ED testing for HIV reported in peer-reviewed literature.6,7,8,9 Almost all centers that have undertaken this have done so as either a pilot program or as part of an academic endeavor with external funding. The rate of willingness to be tested has been in the range of 40% to 70% and may be partially related to perceived risk and community factors. Most programs report a positive finding in one to two percent of those tested, and this may be linked to the community prevalence of HIV.6,7,8,9

Administratively, there are important elements of ED HIV testing to consider. There are occasions when an individual’s test result, either positive or negative, is not available upon conclusion of the ED visit (as may happen when a patient leaves the ED prior to completion of care, or from administrative failures whereby results are not reported to the patient). In such cases, our obligation is to expend significant efforts to locate the individual and make the results known to him/her. The linking of an individual to confirmatory testing and follow-up care may be challenging. Financial incentives and immediate referral (walking the patient to the appropriate clinic at the time of ED discharge) have been shown to increase this connection to care.8

The culmination of these factors may increase the cost of such a program for each case diagnosed and linked to follow-up care.10 Combined, these factors sharply illustrate the need for administrative expertise in overseeing these programs. Additionally, ED HIV testing will require aggressive quality assurance and ongoing cost analysis.

There is the possibility of improving the lives of many by reducing transmission of HIV and by linkage to care through ED testing.10 Yet the initiative comes at a time when EDs are stressed with increasing numbers and complexity of patients, and with challenges for reimbursement and unmet workforce needs. Initiating such a program will require ingenuity and motivation to ensure success. Regulatory agencies may need to participate by restructuring the legal mandates that accompany HIV testing in your state, creating financial avenues to support the initiative and

RapidHIVTestinginEmergencyDepartments PAGE3

providing data for use in quality assurance for your state.

ACUTEHIVINTHEEmERGENCyDEPARTmENT

In 1985 the first description of acute HIV infection was described as a “mononucleosis-like” illness.13 Since that time, multiple larger studies have described the clinical and laboratory features of primary or acute HIV infection. This identification of acute HIV infection is made more urgent for several reasons. First there is an emerging body of research which suggests that starting antiretroviral therapy during acute HIV infection may improve prognosis by preserving the HIV-specific immune response.11 Second, as stated earlier, the majority of new HIV infections are coming from that population of individuals who are unaware of their infection. Early identification and intervention can help to significantly reverse this trend.

A variety of symptoms and signs may be seen in association with acute HIV infection. The most common findings are fever, lymphandenopathy, sore

throat, mucocutaneous lesions, myalgia/arthralgia, diarrhea, headache, nausea/vomiting, and weight loss (Table 1).12 Generally, any instance where mononucleosis enters the differential diagnosis, so should acute HIV infection.

It is difficult to determine the incidence of symptomatic versus subclinical primary HIV infection. However, the majority of patients with primary HIV infection appear to be symptomatic. Several studies place the incidence of symptomatic acute HIV between 52 and 92 percent, and more than 85 percent of these patients have sought medical attention for the acute viral syndrome.13,14

TImECOURSE

The usual time course from exposure to development of symptoms is two to four weeks; however, an incubation period as long as 10 months has been reported.15 The onset of symptoms is usually abrupt, and severe symptoms last an average of 1.5 to 2 weeks. Like with mononucleosis, low-grade lethargy and depression may persist for weeks to months.

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SymPTOmSOFACUTEHIVINFECTIONTABLE1:

FrequencyofCommonSymptomsinAcuteHIVInfection Symptom No.Patients Percent___________________________________________________________________________________________________________ Fever 200 96___________________________________________________________________________________________________________ Adenopathy 154 74___________________________________________________________________________________________________________ Pharyngitis 146 70___________________________________________________________________________________________________________ Rash 146 70___________________________________________________________________________________________________________ Myalgia/arthralgia 112 54___________________________________________________________________________________________________________ Diarrhea 67 32___________________________________________________________________________________________________________ Headache 66 32___________________________________________________________________________________________________________ Nausea/vomiting 56 27___________________________________________________________________________________________________________ Neuropathy 13 6___________________________________________________________________________________________________________ Encephalopathy 12 6

Adapted from Niu, MT, Stein, DS, Schnittman, SM, J Infect Dis 1993; 168:1490.

CONSTITUTIONALSymPTOmS

Fever in the range of 38C to 40C is almost always present with symptomatic acute HIV infection. Nontender lymphadenopathy involving axillary, cervical, occipital and epitrochlear nodes develops in the majority of patients in the second week of illness, concomitant with the emergence of the HIV-specific immune response.

mUCOCUTANEOUSDISEASE

Sore throat is a frequent manifestation of acute HIV infection. Painful mucocutaneous ulceration is one of the most distinctive manifestations of the syndrome. Shallow, well-demarcated ulcers may be found in the oral mucosa, anus, penis, esophagus or vagina. One theory holds that these ulcers represent the portal of entry of HIV, or form of “chancre.”16

A generalized macular or maculopapular rash on the upper thorax, collar region, face, scalp and extremities may develop 48 to 72 hours after the onset of fever. The palms and soles may also be affected. This rash is most commonly non-pruritic.

GASTROINTESTINALSymPTOmS

Many patients with acute HIV infection complain of nausea, vomiting, diarrhea, anorexia and weight loss averaging 5 kilograms.

OTHER

Rarely, patients with acute HIV infection can present with opportunistic infections, including pneumocystis jiroveci pneumonia (PCP), thrush, and others. LABORATORyFEATURES

CBC results are consistent with acute viral illness. Lymphopenia, atypical lymphocytosis and monocytosis are common. Elevated liver enzymes, mild anemia and thrombocytopenia have also been described.

DIFFERENTIALDIAGNOSIS

The differential diagnosis of acute HIV infection includes mononucleosis due to Epstein–Barr virus (EBV) or cytomegalovirus, toxoplasmosis, rubella, viral hepatitis, disseminated gonococcal infection, and other viral infections. One key finding which helps distinguish these disorders from HIV infection is mucocutaneous ulceration. Mucocutaneous ulceration is unusual in all of these entities, and when present should raise the suspicion for acute HIV infection.

DIAGNOSISOFACUTEHIV

Rapid tests designed to detect antibody are not useful in detecting acute HIV infection, nor is the Western Blot, as antibody to HIV is not present in the face of acute infection. Again, written informed consent is necessary in many states to perform any test which may lead to the diagnosis of HIV. If acute HIV infection is suspected, one should obtain written informed consent, where necessary, and send an HIV RNA PCR to measure the HIV viral load. Alternatively, one could measure the level of p24 antigen. In acute HIV infection, both the HIV RNA and p24 antigen will typically be very high, and diagnostic of HIV disease. A rapid test should be done at this time also, though not to make the diagnosis, but rather to determine this to be acute infection versus ongoing infection. In the setting of acute HIV, the rapid test will be negative. An HIV medicine specialist should be consulted to follow-up and interpret results.

RAPIDHIVTESTING

There are four rapid HIV tests that are currently approved by the FDA. These include:

• OraQuick Advance: can be used for testing on blood (sens. 99.6%, spec. 100%), plasma, and oral fluid (sens. 99.3%, spec. 99.8%) • UniGold Recombigen: can be used for testing on blood (sens. 100%, spec. 99.7%) plasma and serum

RapidHIVTestinginEmergencyDepartments PAGE5

• Reveal G2: can be used for testing on plasma and serum • Multispot HIV-1/HIV-2: can be used for

testing on serum.

Oraquick Advance utilizing oral fluid or whole blood, as well as UniGold Recombigen utilizing whole blood, are both CLIA-waived, and the remainder are classified as moderately complex. Oraquick costs approximately $17.50 per test and external controls must be purchased separately (approximately $25.00). UniGold Recombigen costs $15.75 and controls also must be purchased separately (approximately $26.00).

CONCLUSION

Survival benefits of HIV/AIDS treatments have been impressive and improving steadily. However, new infections are continuing at approximately the same rate over the last decade and show no signs of abating. This is primarily driven by the approximately 250,000 individuals in the United States who are HIV-infected but unaware of that infection. Testing individuals for HIV in the acute and primary care settings is hoped to dramatically increase the awareness of individual HIV status. We hope that wider screening of individuals at point of care venues like emergency departments, urgent care centers, and primary care offices will help reduce the infection rate and improve survival.

PAGE6 RapidHIVTestinginEmergencyDepartments

DOyOUNEEDHELPImPLEmENTINGATESTINGPROGRAmINyOURHOSPITAL?

The Adolescent AIDS Program at Montefiore Medical Center in the Bronx, in collaboration with the New York/New Jersey AIDS Education and Training Center, has developed ACTS (Assess, Counsel, Test, Support), a paradigm-shifting approach to HIV Counseling and Testing (C&T) that is designed to help make C&T a more routine part of health care services in various health care settings.

See for yourself how ACTS can make HIV testing a routine part of the care you deliver by accessing the online ACTS tutorial and materials found at www.hivgettested.com. In less than 2 hours, you will understand the ACTS approach and how to put its easy-to-use tools to work in your practice. After you experience the tutorial, adapt the slide set as needed to train your staff, or use it as a train the trainer tool. For more information call (718) 882-0232.

RapidHIVTestinginEmergencyDepartments PAGE7

ADDITIONALRESOURCESAIDS Education & Training Centers, National Resource Center www.aidsetc.org

AIDS.Gov (provides information on types of HIV tests) www.aids.gov/testing/types/index.html

CDC’s National HIV Testing Resource Website www.hivtest.org

CDC’s Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

Food and Drug Administration (provides a list of HIV tests approved by the FDA) www.fda.gov/cber/products/testkits.htm

New York/New Jersey AIDS Education & Training Centerwww.nynjaetc.org

New York State Department of Health, AIDS Institute (provides HIV clinical guidelines)www.hivguidelines.org/content.asp

New York State Department of Health, AIDS Institute (provides general HIV Information) www.health.state.ny.us/diseases/aids

ACCREDITEDDVDs&VIDEOTAPES

Rapid HIV Testing & Diagnosing Acute HIV Infection

There is no fee for this resource.Contact Jim Ybarra at (518) 262-4674 or ybarraj@mail.amc.edu to request a copy.

PAGE8 RapidHIVTestinginEmergencyDepartments

REFERENCES1. Glynn M, Rhodes P. Estimated HIV prevalence in the

United States at the end of 2003. Presented at: 2005 National HIV Prevention Conference; June 12-15, 2005; Atlanta, GA. Abstract T1-B1101.

2. Marks G, Crepaz N, Senterfitt JW, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005: 39L446-53..

3. Kaiser Family Foundation 2006 Survey of Americans on HIV/AIDS. http://www.kff.org/kaiserpolls/upload/7521.pdf. Accessed 30 April 2007.

4. Branson B, Handsfield H. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings. MMWR. Sept 22, 2006/55(RR14); 1-17.

5. MMWR Missed opportunities for earlier diagnosis of HIV infection – South Carolina, 1997-2005. Dec 1, 2006. 55(47) 1269-1272.

6. Mehta SD, Hall J, Lyss SB, Skolnik PR, Pearler LN, Kharasch S. Adult and pediatric emergency department sexually transmitted disease and HIV screening: Programmatic overview and outcomes. Acad Emerg Med. 2007 Mar;14(3):250-8.

7. Lyss SB, Branson BM, Kroc KA. Couture EF, Newman DR, Weinstein RA, Detecting Unsuspected HIV Infection with a Rapid Whole-Blood HIV Test in an Urban Emergency Department. J Acquir Immune Defic Syndr. 2007 Apr 1; 44(4):435-42.

8. Haukoos JS, Witt MD, Coil CJ, Lewis RJ. The effect of financial incentives on adherence with outpatient human immunodeficiency virus testing referrals from the emergency department. Acad Emerg Med. 2005 Jul;12(7):617-21.

9. Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT, Emergency department HIV testing and counseling: an ongoing experience in a low-prevalence area. Ann Emerg Med. 2005 Jul;46(1):22-8.

10. Silva A, Glick NR, Lyss SB, Hutchinson AB, Gift TL, Pealer LN, Broussard D, Whitman S. Implementing an HIV and Sexually Transmitted Disease Screening Program in an Emergency Department. Ann Emer Med. 2006 Nov 17; [Epub ahead of print]

11. Kahn, JO, Walker, BD. Acute human immunodeficiency virus type 1 infection. N Engl J Med 1998; 339-33.

12. Niu, MT, Stein, DS, Schnittman, SM. Primary human immunodeficiency virus type 1 infection: Review of pathogenesis and early treatment intervention in humans and animal retrovirus infections. J Infect Dis 1993; 168-1490.

13. Tindal, B, Barker, S, Donovan, B, et al. Characterization of the acute clinical illness associated with human immunodeficiency virus infections. Arch Intern Med 1988; 148:945.

14. Schacker T, Collier, AC, Hughes, J. et al. Clinical and epidemiologic features of primary HIV infection. Ann Intern Med 1996; 125:257.

15. Ridzon, R, Gallagher, K, Ciesielski, C, et al. Simultaneous transmission of human immunodeficiency virus and hepatitis C virus from a needle-stick injury [see comments]. N Engl J Med 1997; 336:919.

16. Gaines, H, Von Sydow, M, Pehrson, PO, et al. Clinical picture of primary HIV infection presenting as a glandular fever-like illness. Br Med J 1988; 297:1363.

Directions: Please select the BEST answer by circling your response directly on this test. To obtain CME credit, a minimum of 70% of the questions must be answered correctly.

Rapid HIV Testingin Emergency Departments

s E l f a s s E s s m E n T T E s T

[ over ]

Rapid HIV Testing in state Emergency Departments PaGE 9

1) WhatpercentageofHIV-infectedindividualsintheUnitedStatesisunawareoftheirinfection?

a. 10% b. 50% c. 25%

2) SomestatesrequirethatwritteninformedconsentbedonepriortotestingapatientforHIV,whileothersdonot.

a. True b. False

3) NewCDCguidelinesfortestingpatientsforHIVrecommendtestingallindividualsbetweentheagesof________.

a. 21 to 45b. 18 to 65c. 13 to 64

4) Themethodofuniversaltestingofpregnantwomenhasreducedtherateofmother-to-childHIVinfectiontolessthan2%.

a. True b. False

5) EarlierprogramsestablishedtoperformroutineHIVtestinginEmergencyDepartmentsettingshavefoundtherateofwillingnesstohavearapidtesttobebetween?

a. 20% to 35%b. 40% to 70%c. 100%

6) StudieshaveshownthatthemajorityofpeopleexperiencinganAcuteRetroviralSyndromefromHIVinfectionhavesoughtmedicalattention.

a. True b. False

7) TheusualtimecoursefromexposuretodevelopmentofsymptomsofacuteHIVinfectionistwotofourweeks.

a. Trueb. False

8) TheAcuteRetroviralSyndromeofHIVinfectionisverysimilartomononucleosis.

a. True b. False

9) ArapidHIVantibodytestwillbepositiveinapatientwithacuteHIVinfection.

a. True b. False

10) InordertodiagnosisapatientwithacuteHIVinfection,itisnecessarytoorderaHIVRNAPCRorp24antigen,becausetheantibodytestwillstillbenegative.

a. True b. False

To assure your receipt of CME credit, please mail your completed self assessment test, program evaluation, reader information form and HRSA participant information form (3 pages total) to:

cathryn r. corlewAlbany Medical college47 new scotland Avenue, Mail code 158Albany, nY 12208

Please allow 6-8 weeks for education credit processing. An attendance certificate and self assessment test answer key will be mailed to you at that time. If you have any questions, please contact Cathryn Corlew at (518) 262-6864 or corlewc@mail.amc.edu.

PRoGRam EValuaTIon & REaDER InfoRmaTIon foRm

EValuaTIonPlease rate the feature article with respect to: Educational Value 5 4 3 2 1 5 = Excel lent 4 = Very good 3 = Good Clarity 5 4 3 2 1 2 = Fair 1 = Poor

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Rapid HIV Testingin Emergency Departments

A CME-Accredited Resource

PaGE 10 Rapid HIV Testing in Emergency Departments

5 90 1 1