1. No category

HIV Testing
1. Testing for HIV can be done by attending physicians, fellows and house
staff, PA's, NP's and any other medical personnel who has completed a one
day training on this subject.
2. Required is a consent form which consists of 2 parts. Part A which is
given to the patient with relevant information and Part B which is the actual
consent and needs to be signed by the patient and placed in the medical
record. These forms are issued by the Dept of Health AIDS Institute and are
considered to be the counseling piece of the testing process.
3. HN Testing is NOT ordered in PRISM. A speckled top tube is sent to the
lab with form # 61 159-5A which needs the provider's signature on the fiont,
the patients signature on the back and run through the addressograph
machine and labeled.
4. The HIV antibody test results will appear in SOFTLAB anywhere from 17 days. Results should be given directly to the patient and documented in the
medical record. In the event of a positive result, the H N social worker
should be immediately contacted (20-2779)
5. If the patient leaves the medical center prior to receiving the result please
get accurate demographic information and contact Dale Mandelman 212844- 1780 for assistance.
6. Rapid testing is done only for a source patient involved in an occupational
exposure. DOH form # 4054 is required in this situation. A speckled and
lavender top tube is necessary in this case. The lab form should note that this
is a HIV source patient test and should be sent to the stat lab for processing.
Results are available within 90 minutes.
Informed Consent
NEW YORK STATE DEPARTMENT OF HEALTH
to PerForm HIVTesting
AIDS Institute
-
i
My health care provider has answered any questions Ihave regarding
HIV testing and has given me written information with the following
details about HIV testing:
Part
HIV is the virus that causes AIDS.
The only way to know if you have HIV is to be tested.
HIV testing is important for your health, especially for pregnant women.
HIV testing is voluntary. Consent can be withdrawn at any time.
Several testing options are available, including anonymous and confidential.
State law protects the confidentiality of test results and also protects test subjects
from discrimination based on HIV status.
My health care providerwill talk with me about notifying my sex or
needle-sharing partners of possible exposure, i f Itest positive.
Iagree to testing for the diagnosis of H Ninfection. If Iam found to have HN, Iagree to
additional testing which may occur on the sample Iprovide today to determine the best
treatment for me and to help guide HIV prevention programs. Ialso agree to future tests
to guide my treatment. Iunderstand that Ican withdraw my consent for future tests at
any time.
For pregnant women only:
I n addition to the testing described above, Iauthorize my health care provider to
repeat HIV diagnostic testing Later i n this pregnancy. Iunderstand that my health
care provider willdiscuss this testing with me before the test is repeated and will
provide me with the test results.The consent to repeat diagnostic testing is limited
to the course of my current pregnancy and can be withdrawn at any time.
Signature:
Date:
'
(Test subject OF legally authorized representative)
If Legal.representative,indicate relationship to subject:
Printed Name:
Medical Record #:
Except for expedited HIV testing on labor units, this form repiaces other HIV testing consent forms
as of June 1,2005.
NOTE: this fonn isintended to be used i n conjunctionwith DOH-2556i. Part A.
wtr-+sp) .
.
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CLIENT
: 80711
IIcCOyblT MHmE: 4 1 1 s CENTER
e4DIRfSS
: 1 FIERHAN ROOH 1 3
FIRST 4VE FIT 16TH STREET
Neu York, NY 10003
212 420 4196
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INSURED PATIENT'S ADDRESS
TEL U (NIGHTEMERG)
I
I
ZIP
STATE
CITY
MALE
FEMALE
DATE OF BIRTH (MIDY)
MEDICARE
.
PATIENT'S SOCIAL SECURITY NUMBER
MEDICAID
OTHER
INSURED'S NAME
POLICY
SECONDARY INSURED NAME
#
1
I
SECONDARY INSURANCE
PRIMARY INSURANCE
I
POLICY
r
I
ADDRESS
ADDRESS
I
DATE COLLECTED
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....,.. ,.,..,
TIME COLLECTED
AM
COLLECTED BY
..,.- .., ..,.,-.
o And Medicaid Patients, Please Select Only ThoseTests Which Are Medically Necessary. For The
Diagnosis Or Treatment Of The Patient. M-edicar.e. Does Not Reimburse For Routine ScreeningTests
I
DIAGNOSTIC testing means the performance of HIV testing for purposes of making a diagnosis of HIV infection. PROGNOSTIC testing means the performance
of HIV tests for clinical management of patients who have been diagnosed as having HIV infection.
I
Please (x) Desired Test(s).
DIAGNOSTICTESTS: Supplemental testing for confirmation wlll be performed when indicated.
I I
HIV-I Antibody Screen (Confirmation of positive results by Western Bbt)
I
PROGNOSTICTESTS:
HIV-1 RNA, bDNA, Quantitative Assay
HIV-1 RNA, PCR, Quantitative Assay, 1st Generation
HIV-1 RNA. PCR, Quantitative Assay, 2nd Generation, Ultra Sensitive
For Diagnostic Tests Only
New York regulations require an authorized signature (submitting physician or designee).
By signature below, the submitting physician or designee confirms that pre-test counseling has been provided, post-test counseling will be provided and that the
patient has given informed consent for the HIV AntibodyIAntigen test(s) based on a full explanation of the test@) and subsequent ramifications including,
without limitation, the following:
1. The test is to determine the presence or absence of antibodytantigen to Human ImmunodeficiencyVirus (HIV).
2. The test for HIV AntibodyIAntigen is VOLUNTARY.
3. This test is not diagnostic for AIDS. Though most patients with AlDS or AlDS Related Complex have antibody to HIV, the reverse is
not necessarily true. You may have antibody and not develop AIDS.
4. Repeatedly react~veHIV ELlSA screening tests may be evidence of infection and may imply risk to develop AlDS or ARC. All
reactive ELSA tests will be confirmed by Western Blot.
Authorized Signature (submitting phystcian or designee)
Date
I have been Informed that Medlcare will only pay for servtces that it determines to be I authorize the release to my insurance carrier of any med~calinformation necessary to process
"reasonable and necessary" under sectlon 1862(a)(1) of the Med~carelaw I have been this claim, and I authorize payment of medical benefits directly to Beth Israel Laboratory.
notifled on the date indicated above that Medlcare IS l~kelylo deny payment for the test@)
denoted (') because Med~careusually does not pay for th~sservlce for my condition. If
Medlcare denles payment. I agree to be personally and fully respons~blefor payment
I
S~gnature(Medicare Beneficiary) X
Signature (Med~careBenel~c~ary)
X
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&nfidnrtlallty of HN TbtR Resub and lnfwtnatlon
HIV tmtlng is vdun$ry and requlres your consent In writing. The
purposeol HIV testing Is to show If you are infected with HIV, the vlrus
that c a w AIDS. The m a t commonly used lest for HIV is the HIV
IT?
;
- -
; lf y a ~ t &
the HIV wtfbady t a t , your test resub are cmfkWW.
York State law, confidenW HIV in(wmatlon can only be
mto~~u~tohaveitbygMngyour~approval,or
need to b o w your HIV status In order to pmide
A negative result on the HIV antibody test most Ukely means you
care and sewlcguxinduding: medlcel care providers; persons
ur not Infected with HIV, but it may not show recent Infection. Ifyou
ed wlth foster care, or adoption; parents and guardians of
tMnk you hew been exposed to HIV, you should take the test three to
pinws; jell, $rim, probation and parde employees; and
$ix tiwnU~efter the lest W
b
k expoeure.
lorganizahs that rev(ew the services you recehre. The law also
A p o r n mult on the test meens you are infected with HIV and
e releesepl under lknlted
CanMeCtmers.
-I<,
to public heelth afl#aQ when
ecessarytopayforcereand
b n o f b d HIV testing:
,..
health worker can notify your
a c+ B B W or
~ needle sheoRlg partners, but only after drsarsslng lt with you
b u r health care pmvlder or counselor wiU tell you how lo pmea - and w i e t putding-your m.
{
yoorSen from getting Inkcted wW1 the virus in the future.
If you feel your confidentiality has been broken, or kw mare
# You can end the mkertahty whlch mey c ~ from
e not knowing If < Information abwt HIV ~ontidentiallty,call the New York State
Department of He& HIV Confidentiality Hotline at 1-800-982-5085.
yw are Mxted.
Any h3alth.mSQW
emvice pmvkler wtio Ulegany tells anyone abwt
b
v
b
u health care pfovlder can give y w medical care and treatment
your HIV Iniwnation may be punlshed by a flne d up to $5,000 and
'
enttbody test.
-8
A
--
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the results of your t8bt, '*OM bbt.h
anmywuws test site. l-hmmr, peogk
apostivetestraudlus,yaUyhmmIb~
retest@, %vjtlchcan d_elay madlcal care. For a list of ammymom te&
sttes, call the New York State AIDS Hottlne 1-800-541-2437.
Wxbd with HIV.
It you mrnwho k pmgnmnt or consld.rlng apregMncy
rwlyou-krtpMluve:
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n
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6
Ywr hePllh oere pravlder can tell you about the risk of passing the
vlna from mother to child.
-
212-306-7500.
..
lbr health can, provkler can tell you about medlcaUon that may
reduce the chances of pacidng the virus from mother to baby.
1
Phu OWmmWt your baby by nM breast-feeding. If you have HIV,
I
ywr bE& ndk can Infect ywr beby. If you tMnk that you might be
61 rhk tor HIV lqbctkm, and you da not take the HtV test, you flsk
pssshg the vim b your baby if y w dedde to breast-feed.
i
- :,
"
W h d t care
~ prwlder can test your baby to find out if he or she
Is lnlIlCEBd with HN, aml, if so, glve the special medical care your
w-
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l
.
A
' >
IpavlckdpntertlngcounreRngh acowdsncaw~th~rbckt27-Fofthe NwYkkSInm Pubk HePHhLw. I r n e r m m d V l e a b w e i n d M d w l b ~ a b w l ~ l u t l n d d h m d ~
of m* brm. I have Inkxtned the patent that q u a n t h h delmnhm kr HIV-1. RNA, shoukl not be used as a dhOnoptic procodurn wilhwt m t b n d 11
~ b y ~ m e d l c a U y e ~ m e e n s
M m&mal,
-.
Th p.Lknt h a been I n l o r d that, shce lhey may be drscherged bekre thsb HIV results wwd available. they should obmtn these results at thek nexl clWcal encounm.
1
NEW YORK STATE DEPARTMENTOF HEALTH
AIDS Institute
Informed Consent
to Perform MI\/ Testing
New York State HIVIAIDS Hotlines (toll-free)
Call the Hotlines for information about HIV and AIDS and to find HIV testing sites
1-800-541-AIDS (2437) English
1-800-233-SIDA (7432) Spanish
New York State TTYmO HIVlAIDS Information Line
1-212-925-9560
HIV testing i s voluntary. Consent can be with-
Voice callers use the NY relay:
711 or 1-800-421-1220 and ask the operator for: 1-212-925-9560
drawn at any time by informing your provider.
w
Please read Parts A and B of this form, and sign
New York State HIVIAIDS Counseling Hotline
* 1-800-872-2777
at the bottom of Part B, i f you understand the
following information and want HIV testing.
NYSDOH Anonymous HIV Counseling and Testing Program
For HIV information, referrals, or information on how to get a free, anonymous HIV test,
call the Anonymous HIV Counseling and Testing Programs.
HIV infection is a serious health concern.
Albany Region 1-800-962-5065
The New York State Department of Health
Buffalo Region 1-800-962-5064
=
Nassau Region 1-800-462-6785
recommends HIV testing. For pregnant women,
New Rochelle Region 1-800-828-0064
the Department recommends HIV testing early i n
Queens Region 1-800-462-6785
pregnancy and again Late in pregnancy.
Rochester Region 1-800-962-5063
Suffolk Region 1-800-462-6786
Syracuse Region 1-800-562-9423
NYCDOHMH HIVIAIDS Hotline: 1-800-TALk-HIV(1-800-825-5448)
New York State PartNer Assistance Program: 1-800-541-AIDS
New York City Contact Notification Assistance Program: 1-212-693-1419
Confidentiality
New York State Confidentiality Hotline 1-800-962-5065
Legal Action Center 1-212-243-1313 or 1-800-223-4044
Human RightsIDiscrimination
New York State Division of Human Rights 1-800-523-2437
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Except for expedited HIV testing on labor
units, this form replaces other HIV testing
consent forms as of June1.2005.
NOTE: this form is intendedto be used in
conjunction with DOH-2556. Part 6.
New York City Commission on Human Rights 1-212-306-7500
DOH-2556i (5105) page 4 of 4
DOH-2556i 15/05) page 1 of 4
Part
Nl\l~testingis~esgedallyimp~rtantf~r~pr-omen.
HLV..i~the~rirus..3hiattca~ses5AIDS
i..................
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HIV is passed from one person to another during unprotected sex (vaginal anal or oral
sex without a condom) with someone who has HIV.
An infected mother can pass HIV to her child during pregnancy or birth or through
breastfeeding.
HIV is passed through contact with blood as in sharing needles (piercing, tattooing or
injecting drugs of any kind) or sharing works with a person who has HIV.
I t is much better to know your HIV status before or early i n pregnancy so you can make
important decisions about your own health and the health of your baby.
I f you are pregnant and have HIV. treatment is available for your own health and to
prevent passing HIV to your baby. If you have HIV and do not get treatment, the chance
of passing HIV to your baby is one i n four. I f you get treatment, your chance of passing
HIV to your baby is much lower.
The only way to know if you have HIV i s to be tested.
HIV tests are safe. They involve collecting one or more specimens (blood, oral fluid,
urine).
Your counselor or doctor will explain your test result as well as any other tests you may
need.
If you test positive:
Y~ur.HlV_teslladayinrludes:
I n almost all cases, you will be asked to give written approval before your HIV test
result can be shared.
I f you are HIV positive, additional tests may include tests to:
help your doctor decide the best treatment for you.
help guide the health department with HIV prevention programs.
Several testing options are available..
-
-.-
.
You can choose to have a confidential test where the result becomes part of your
medical record and can be given to your health care provider for HIV and other health
care services, or
You can choose to have an anonymous test, which means that you don't give your rlame
and no record is kept of the test result. I f your anonymous test is HIV-positive, you can
choose to give your name later so you can get medical care more quickly.
To get more information about options for testing and free or anonymous testing sites,
ask your counselorldoctor or call 1-800-541-AIDS.
HIV iestingis.impalrtant-f~r- your health.
.
State law protects the confidentiality of your t e d results and also protects you from
discrimination based on your HN status.
A test to see i f you have HIV infection (an antibody test or a test for the virus);
-
I f you are not tested during pregnancy, your provider will recommend testing when you
are i n labor. I n allcases, your baby will be tested after birth. A positive test on your
baby means that you have HIV and your baby has been exposed to the virus.
..
. .
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I f your test result is negative, you can learn how to protect yourself from being infected
i n the future.
If your test result is positive:
You can take steps to prevent passing the virus to others.
You can receive treatment for HIV and learn about other ways to stay healthy. As
part of treatment. additional tests will be done to determine the best treatment for
you. These tests may include viral load and viral resistance tests.
Your HIVinformation can be released to health providers caring for you or your
exposed child; to health officials when required by law; to insurers to permit payment;
to persons involved i n foster care or adoption; to official correctional, probation and
parole staff; to emergency or health care staff who are accidentally exposed to your
blood; or by special court order.
e?p
The names of persons with HIV are reported to the State Health Department for tracking the epidemic and for planning s e ~ c e s .
The HIV Confidentiality Hotline at 1-800-962-5065 can answer your questions and help
with confidentiality problems.
The New York State Division of Human Rights at 1-800-523-2437can help i f you think
you've been discriminated against based on your HIV status.
Your counselor/dodor will talk with you about notifying your sex or needle-sharing
partners of possible exposure t o HN.
Your partners need to know that they may have been exposed to HIV so they can be
tested and get treated i f they have HIV.
If your health care provider knows the name of your spouse or other partner, he or she
must report the name to the health department unless i t would result i n harm to you.
Health department counselors can help notify your partner(s) without ever telling them
your name.
To ensure your safety, your counselor or doctor willask YOU questions about the risk of
domestic violence for each partner to be notified.
If there is any risk, the Health department will not notify partners right away and will
assist you i n getting help.
DOH-2556i 15/05) page 3
Source Patient Testing for Occupational Exposures
Checklist for Book Resident
The Book Resident (BR) is responsible for pre-test counseling and testing of
source patients involved in occupational exposures between 5 p.m. - 9 am
Monday - Friday, Saturday, Sunday and Holidays.
BR contacted by the supervisor or manager of the unit where
the exposure occurred who will identify the source patient, their location and
will provide details re: the incident. Employee will be sent to the ED by
manager or supervisor.
BR will provide pre-test counseling to the source patient and will complete
the Pre-test Counseling Form. Assess patient's ability to provide informed
consent for testing. If patient declines, STOP, testing is voluntary.
For patients who lack capacity to consent, ONLY a health care proxy,
with form present in the medical chart, can consent.
If patient or proxy consents, complete Informed Consent to Perform a
Confidential H N Test. Patient or proxy and BR must sign the consent.
BR will contact ED Attending to advise employee that source patient has
consented or not for an HIV Test. If patient consents, ED Attending will
advise employee to wait in the ED for the HIV test result. If the employee
elects to leave the ED prior to the availability of the source patient's HIV test
result, the ED Attending will obtain a telephone number where the employee
can be reached and will notify himlher of the HIV test result.
Complete a Laboratory Request form that states "RAPID TEST FOR
OCCUPATIONAL EXPOSURE." Blood shall be drawn into a speckled
top and a lavender top tube and hand delivered to the lab. The lab will be
provided with the BR pager #. Patient or proxy and BR must sign
the Lab form (see page #2)
One hour after hand delivering the blood, the BR will go to the lab to
obtain the test result. HIV test results are not available in PRISM.
You are required to perform the Post-test counseling and complete the form.
Place the Informed Consent to Perform a Confidential HIV Test Form, the
Pre-test Counseling form, Post-test counseling form, and the HIV test result in
the patient's medical record.
Provide H N test result to the ED Attending.
A copy of the Informed Consent to Perform a Confidential HIV Test Form,
the Pre-test Counseling form, Post-test counseling form, and the HIV test
result must be brought into the Chief Residents' office by 9am the next day.
The HIV counselor will pick up the forms (HIV Counseling & Testing
Department, fax # 212-420-4184), provide a copy to Employee Health, who
will follow-up with the employee on the next business day.
Book Resident's Name
Source Patient's Name
Source Patient's Medical Record Number
Date
EETI-IISRAEL
MEDICAL
CENTER
IlIV COLINSELING .4XD TESTISG SERVICES
PRE-TEST COUNSELING
TO PROVIDE PRE-TEST COUNSELING, CHECK EACH POINT WHEN DISCUSSED:
IJ Discussed prior history of HIV' counseling and testing
11Discussed nature of AlDS and HIV related illness
Reviewed benefits of HIV testing, early diagnosis, and early treatment
Reviewed HIV transmission and risk reduction
- - - - - - - - - - - - - - - -
-- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Please complete for preunant. ante-~artum.a o s t - ~ a r t u ma n d childbearina aae women /as ~ o s s i b l e )
Reviewed benefits of early diagnosis for preventing perinatal transmission (AZTis known to reduce the risk of perinatal transmission
from as high as 25% to as low as 3%,as well as provide potential protective mechanisms for the mother) and for treatment of the newborn
r
For a woman who has declined HIV testing during the prenatal period, she has been advised that she will receive
additional HIV counseling and a recommendation for expedited HIV testing on admission for delivery - Advised that if HIV testing is declined in both the prenatal and delivery settings, her newborn will be tested without
consent immediately after birth as part of the Newborn Screening Program
Discussed the riskshenefits of breastfeeding
Explained the nature and meaning of test results as they relate to:
a. Non-pregnant women
b. Pregnant woman
c. Newborns
d. Expedited Testing (Preliminary and Confirmatory)
Cl Explained that HIV testing is voluntary, except under certain circumstances
3 Discussed possible discrimination from disclosure of HIV test results and legal protec'tions against discrimination
'3 Presenfed option o f confidenftat oranonymoustesting
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- - - - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - -
'3 Discussed HIV reporting and partner notification options, including domestic violence concerns.
O
Assessed for suicidal history and current coping skills
Determined capacity to consent
Cl Obtained written informed consent and provided a copy of NYS DOH consent form (DOH-2556)
3 Provided or referred for emotional support during waiting period as needed
3
DISPOSITION
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COUNSELED. REFUSED TESTING
Stale Reason:
REFUSED COUNSELING
State Reason:
COUNSELED. DEFERRED TESTING
State Reason:
COUNSELED, CONSENT SIGNED &TESTING PERFORMED
UNABLE TO PARTICIPATE IN INFORMED CONSENT
State Reason:
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REFERRALS PROVIDED
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Pediatric AIDS Program
Peter Krueger Clinic (420-2620)
Mental Health Counseling
Substance Abuse Counseling
Domestic Violence Counseling
Partner Notification (693-141 9)
Clinical Trials Unit (420-4519)
Women's Project (420-2326)
Other: Please state:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Comments:
SignaturelDate:
60835 (01103)
Provider #
DATE
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DOPI.
Informed Consent to Perform a Confidential* HIV Test and
Authorization for Release of HIV Related Information for Purposes
of Providing Post-Exposure Care to a Health Care Worker
Exposed to a Patient's Blood or Body Fluids
New
-- York S t a t e D e p a r t m e n t of Health AIDS Institute
AIIemploye~has been exposed to your blood or a body fluid in a manner which may pose a risk for transmission of a
blootlbomc infection. Many individuals may not know whether they have a bloodborne infection because people can carry
these viruscs without having any symptoms. We therefore are asking for your consent to test for the presence of human
im~i~unodeficicncy
virus (HIV). You will also be tested for hepatitis B virus (HBV) and hepatitis C virus (HCV).
Ulltler New Yorlc State law, HIV testing is voluntary and requires your consent in writing. (Consent can be withdrawn for the
tcst ; ~any
t time.) Thcre are a number of tests that can be done to show if you are infected with HIV. Your provider or
coi~nselorC;III plnvicle specific information on these tests. These tests involve collecting and testing blood, urine o r oral fluid.
Tlic most common test for HIV is the HIV antibody test. In this circumstance, the test result will be used to help determine
whether the exposcrl health care worker is now at risk for HIV and needs treatment for that exposure. Additional testing also
will tell wlietlier yo11are carrying HBV or HCV.
I
Mei~ningof HlV Test Results:
* A llegative result on the HIV antibody test most likely medns that yourarenot infected with HIV, but Aay not show recent
I
been exposed to HIV, you shoi~lddiscuss this with the person requesting your consent for
infection. If you think ~ O Lhave
tllV testing ant1 you should take the test again three months after the last possible exposure.
e A pos~tiveresult on the test means that you are infected with HIV and can infect others.
a Soliletirnes the HIV antibody test result is not clearly positive or negative. Your provider or counselor will explain this
I . ~ s Land
I ~ ~may
. ilsk that you give your consent for further testing.
The benefits to you of having an HIV test, and your confidentiality protections and discrimination issues under the law are
explained on the reverse side of this form. You also are being asked to authorize the release of confidential HIV-related
infonilation ]-elated lo this request to the health professional, named below, who is treating the exposed health care worker
iuitlior tlirectly to thc exposed healtli care worker. This will facilitate appropriate care and counseling about the risk of
beco~nrnginfectecl ancl possibly infecting others. Under New York State law, except for certain people, confidential HIVI.CI;I~CLIinformation can only be given to persons you allow to have it by signing a release. These individuals are prohibited by
la\v fru117s ~ ~ b s e q i ~ e ~clisclosing
itly
these test results in a way that could reveal your identity. The section on the reverse side of
this form titled, Col~ficlcntiulityof HIVInformution, lists those people who can be given confidential HIV-related information
without a release fonn.
of exlloscd employee's health care provider
N:IIIIC
to uhnm I l l V 1cs1result will be disclosetl
(Optional) Name of exposed health care worker
to whom HTV test result will be disclosed
Prior to executing this consent, you must be counseled about the implications of HIV testing and your confidentiality
protections undcr the law.
I t ~ l ~ t l e r s t atile
~ ~ tpurpose
l
f o r wliicli 1 am being asked to submit a specimen for HIV testing. bIy questions a b o u t t h e
tllV test were answered. I agree to be tested for HIV and 1 authorize release of this information to the exposed health
cnrc wnrltw and Iiisllier health care providers. Tliis release is effective for one year after the d a t e listed below.
Date
I'rin~name al'the person to be tested
S~g~~ature
ol'tlie pcl-son io he tested or of the person consenting if different from the person to be tested
I provitled pretest counseling in accordance with Article 27-F of the New York State Public Health Law. 1 answered
thc nl~nvei~~divicl~lal's
questions about the test and offered himlher an unsigned copy of this form.
7
L;:*:~~:tt~~rc.-
Title
~;~cilit~/l'l-c;%lcr
N;lnic
" A I I I I I I I I ; ~c ~o ~ ~ t i ( I e ~rcstill;
l t ~ ; ~ l with iclrtltitiers is aecrssclry for occuparional exposure. Piew York State I:lw reqwres that you he infornlcd t l l ~ tHIV train:: can be
pcliiirtnecl n ~ l o ~ ~ y ~ m i uFor
s l y;.l list o f anonymous sltes. call 1-800-541-2437,
1101-1-4054 (I<cv.0/00) P. 1 o f 2
3
BETI-IISRAELMEDICAL
CENTER
Im' COLINSELINC AND TESTISG SERVICES
POST-TEST COUNSELING
DOCUMENTATION FORM
ADDRESSOGRAPH
TO PROVIDE POST-TEST COUNSELING, CHECK EACH POINT WHEN DISCUSSED:
\
FOR PATIENTS WlTH NEGATIVE TEST RESULTS
Discussed the meaning of the test result
Discussed the possibility of HIV exposure during the past three months and the need to consider retesting
Emphasized that a negative test result does not imply immunity to future infection
11Reinforced personal risk reduction strategies
FOR PATIENTS WlTH POSITIVE TEST RESULTS
Discussed the meaning of the test result
Discussed the availability of medical care including prophylaxis for opportunistic infections and antiretroviral therapy
3 With pregnant patients, discussed and recommended use of ZDV, consistent Mth.tlinical::praCtice guideli?es, to reduce the risk
of maternal-child transmission; discussed the risk of HIV transmission through breast feeding
---.-- .
Provided counseling for the following:
--.
coping with the emotional consequences of the test results;
regarding discrimination that disclosure of result could cause;
for behavior change to prevent transmission of HIV infection;
provided or referred to needed medical support and services
3 Encouraged partnerlcontact notification. Explained that provider must report partners to NYCDOH and discussed options including
self notification; clinician-assisted notification; use of CNAPIPNAP; and that there is no penalty, should s/he choose not to
cooperate with partner notification.
With patients choosing to participate i n partnerlcontact notification,
conducted and documented a domestic violence screening for each identified partnerlcontact
a
FOR PATIENTS WlTH INDETERMINATETEST RESULTS
Discussed the meaning of test results
!El Encouraged re-testing
3 Discussed the availability of appropriate medical follow-up
Reinforced personal risk reduction strategies
a
a
REFERRALS PROVIDED
DISPOSITION
COUNSELED, HIV POSITIVE
Completed and submitted Medical Provider HIVIAIDS &
Pediatric AIDS PROGRAM
PartnerlContact Report Form
Peter Krueger Clinic (420-2620)
Mental Health Counseling
Indicate patient's choice for partnerlcontact notification
Self-notification (Date:
)
Substance Abuse Counseling
Clinician-assisted notification (Date:
)
Domestic Violence Counseling
Use of CNAPIPNAP (Date:
)
Partner Notification (693-141 9)
Declined partic~pationin partnerlcontact notification
Other:
O COUNSELED, HIV NEGATIVE
Clinical Trials Unit (420-4519)
5 Women's Project (420-2326)
Cl Other: Please state:
COUNSELED, HIV INDETERMINATE
Comments:
SignatureIDate:
60835 (01103)
Provider #
DATE
I
I
NAME (LAST, FIRST)
I
I
INSUREDPATIENT'S ADDRESS
I ClrY
ISTATE
I
TEL # (DAY)
DATE OF BIRTH (WON)
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MALE
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PATIENT'S SOCIAL SECURITY NUMBER
?: .
PHYSICIAN NAME
O FEMALE
MEDICAID
INSURED'S NAME
SECONDARY INSURED NAME
SECONDARY INSURANCE
POLICY #
ADDRESS
DATE COLLECTED
I
TIME COLLECTED
ICD 9 Diagnostics.Select
All That Aoolv
t 1'
AM
COLLECTED BY
1
I
I
SPECIMEN INFORMATIIl
I
DIAGNOSTIC testing means the performance of HIV testing for purposes of making a diagnosis of HIV infection. PROGNOSTIC testing means the performance
of HIV tests for clinical management of patients who have been diagnosed as having HIV infection.
Please (x) Desired Test(s).
IDIAGNOSTICTESTS: Supplemental testlng for contirmatlon wlll be performed when indlceted.
I
I
I HIV-1 Antibody Screen (Confirmation of positive results by Western Blot)
I
IPROGNOSTICTESTS:
I I HIV-I RNA, bDNA, Quantitative Assay
I
I
I I
I
I
I I
' HIV-1 RNA, PCR, Quantitative Assay, 1st Generation
*
HIV-1 RNA, PCR. Quantitative Assay, 2nd Generation, Ultra Sensitive
For Diagnostic Tests Only
New York regulations require an authorized signature (submitting physician or designee).
By signature below, the submitting physician or designee confirms that pre-test counseling has been provided, post-test counseling will be provided and that the
patient has given informed consent for the HIV AntibodyIAntigen test(s) based on a full explanation of the test(s) and subsequent ramifications including,
without limitation, the following:
1. The test is to determine the presence or absence of antibodytantigen to Human lmmunodeficlency Virus (HIV).
2. The test for HIV AntibodyfAntigen is VOLUNTARY.
3. This test is not diagnostic for AIDS. Though most patients with AlDS or AlDS Related Complex have antibody to HIV, the reverse is
not necessarily true. You may have antibody and not develop AIDS.
4. Repeatedly reactive HIV ELlSA screening tests may be evidence of infection and may imply risk to develop AIDS or ARC. All
reactive ELlSA tests will be confirmed by Western Blot.
I
Date
Authorized Signature (submitting physician or designee)
I
Information R e l e a ~Authorization
t
ADVANCED BENEFICIARY NOTICE (ABN)
I have been inlormed that Medicare will only pay for services that it determines to be I authorize the release to my insurance carrier of any medlcal lnformatlon necessary to process
"reasonable and necessary" under sectlon 1862(a)(l)of the Medicare law. I have been this claim, and I authorize payment of medlcal benefits dlrectly to Beth Israel Laboratory.
not~fiedon the date ~ndlcatedabove that Medicare is likely to deny payment for the test@)
denoted (') because Medlcare usually does not pay for this service for my condition. If
Medicare denies payment. I agree to be personally and fully responsible for payment
Signature (Medicare Beneficiary). X
Signature (Medcare Beneflclary) X
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PHYSICIAN COPY
Post exposure prophylaxis-Reference-Up to date, unless otherwise specified.
(Prepared by Robert Navarro in April, 2007)
HIV:
Body fluids of concern include:
•
•
•
Implicated in the transmission of HIV: semen, vaginal secretions, other body
fluids contaminated with visible blood.
Potentially infectious (undetermined risk for transmitting HIV): cerebrospinal,
synovial, pleural, peritoneal, pericardial, and amniotic fluids.
Fluids that are not considered infectious unless they contain blood include:
feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus.
The risk of becoming infected with HIV after exposure to body fluids from an
HIV-infected patient is extremely low. A review of 23 studies of needlestick injuries
to HCWs exposed to an HIV-infected source in the era before the introduction of
highly active antiretroviral therapy (HAART) found the following [1]:
•
•
•
HIV transmission occurred in 20 of 6135 cases (0.33 percent) (needlestick)
One case of HIV was transmitted out of 1143 exposures (0.09 percent) on the
mucosa of the healthcare worker (mucosal exposure)
There were no cases after 2712 intact skin exposures
A similar frequency of HIV seroconversion after needlestick injury (0.36 percent) was
found in a later report from the CDC Cooperative Needlestick Surveillance Group [2].
Risk factors for seroconversion — A case-control study of needlestick injuries from
an HIV-infected source by the Centers for Disease Control and Prevention included
33 cases who seroconverted and 655 controls from the United States, the United
Kingdom, France, and Italy [5]. The study found that the following factors, each of
which presumably reflected exposure to a higher number of viral particles, increased
the risk of acquiring HIV after a needlestick injury:
•
•
•
•
Deep injury (odds ratio [OR] 15)
A device visibly contaminated with the patient's blood (OR 6.2)
Needle placement in a vein or artery (OR 4.3)
Terminal illness in the source patient (OR 5.6)
HIV viral load is an important variable based upon the studies of sexual transmission
in discordant couples and rates of perinatal transmission [6-9]. The studies cited
above did not directly address this issue because they were based upon data
obtained before viral load measurement was routinely available [2,5].
Determining the need for prophylaxis — In all cases, the decision to administer PEP
must weigh the risk of infection with HIV against the toxicity and inconvenience of
PEP. The individual preferences of the exposed HCW will generally determine the
decision about whether to proceed with post-exposure prophylaxis (PEP.)
HCWs with an exposure via intact skin do not require PEP. The CDC has published
recommendations for who should receive PEP based on whether the exposure is
percutaneous (show table 1) or to mucous membranes or nonintact skin (show table
2), and that take into account the likelihood that the source is HIV infected, and if
infected the stage of HIV infection.
Table 1
Recommended HIV postexposure prophylaxis for percutaneous injuries
Infection status of Exposure type
source
Less severe*
More severe
HIV-Positive
class 1
Recommend basic 2-drug PEP
Recommend expanded 3-drug
PEP
HIV-Positive
class 2
Recommend expanded 3-drug
PEP
Recommend expanded 3-drug
PEP
Source of
unknown
HIV status
Generally, no PEP warranted;
however consider basic 2-drug
PEP§ for source with HIV risk
factors¥
Generally, no PEP warranted;
however consider basic 2-drug
PEP§ for source with HIV risk
factors¥
Unknown
Source
Generally, no PEP warranted;
however, consider basic 2-drug
PEP§ in settings where exposure
to HIV-infected persons is likely
Generally, no PEP warranted;
however, consider basic 2-drug
PEP§ in settings where exposure
to HIV-infected persons is likely
HIVNegative
No PEP warranted
No PEP warranted
* Less severe (eg, solid needle and superficial injury).
More severe (eg, large bore hollow needle, deep puncture, visible blood on device, or needle used
in patient's artery or vein).
HIV-Positive, Class 1: asymptomatic HIV infection or known low viral load (eg, <1500 RNA
copies/mL); HIV-Positive, Class 2: symptomatic HIV infection, AIDS, acute seroconversion, or
known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of
postexposure prophylaxis (PEP) should not be delayed pending expert consultation, and, because
expert consultation alone cannot substitute for face-to-face counseling, resources should be
available to provide immediate evaluation and follow-up care for all exposures.
Source of unknown HIV-status (eg, deceased source person with no samples available for HIV
testing).
§ The designation, "consider PEP," indicates that PEP is optional and should be based on an
individualized decision between the exposed person and the treating clinician.
¥ If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be
discontinued.
Unknown source (eg, needle from a sharps disposal container).
Table 2
Recommended HIV postexposure prophylaxis for mucous membrane exposures and nonintact skin*
exposures
Infection status of Exposure type
source
Small volume
Large volume
HIV-Positive
class 1
Consider basic 2-drug PEP§
Recommend basic 2-drug PEP
HIV-Positive
class 2
Recommend basic 2-drug PEP
Recommend expanded 3-drug
PEP
Source of
unknown HIV
status¥
Generally, no PEP warranted;
however consider basic 2-drug
PEP§ for source with HIV risk
factors
Generally, no PEP warranted;
however consider basic 2-drug
PEP§ for source with HIV risk
factors
Unknown
Source**
Generally, no PEP warranted;
however, consider basic 2-drug
PEP¥ in settings where exposure
to HIV-infected persons is likely
Generally, no PEP warranted;
however, consider basic 2-drug
PEP¥ in settings where exposure
to HIV-infected persons is likely
HIV-Negative
No PEP warranted
No PEP warranted
* For skin exposures, follow-up is indicated only if there is evidence of compromised skin integrity
(eg, dermatitis, abrasion, or open wound).
Small volume (ie, a few drops).
Large volume (ie, major blood splash)
HIV-Positive, Class 1: asymptomatic HIV infection or known low viral load (eg, <1500 RNA
copies/mL); HIV-Positive, Class 2: symptomatic HIV infection, AIDS, acute seroconversion, or
known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of
postexposure prophylaxis (PEP) should not be delayed pending expert consultation, and, because
expert consultation alone cannot substitute for face-to-face counseling, resources should be
available to provide immediate evaluation and follow-up care for all exposures.
§ The designation, "consider PEP," indicates that PEP is optional and should be based on an
individualized decision between the exposed person and the treating clinician.
¥ Source of unknown HIV-status (eg, deceased source person with no samples available for HIV
testing).
If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be
discontinued.
** Unknown source (eg, splash from inappropriately disposed blood).
The presence of HIV infection in the source should be confirmed, but this should not
delay PEP. Most states in the US require informed consent for HIV serologic testing,
but many waive this requirement in the event of occupational exposure. If the source
is found to be HIV negative, PEP should be discontinued.
Timing — PEP should be initiated as quickly as possible. The goal is to start within
one to two hours or earlier after exposure, often using a "starter pack" with
appropriate drugs that are immediately available.
For occupational exposures with a low risk source, it may be more reasonable to
perform a rapid test for HIV on the source patient, provided the results will be
available within two hours. PEP should be offered if the rapid test is positive, but the
result should be considered provisional until confirmed by Western Blot.
Side effects — Side effects are reported by about half of patients who receive PEP
[22-26]. Most side effects are mild, but about one-third of patients discontinue
treatment because of side effects [22,26,27]. The most common side effects are
nausea and fatigue; headache, vomiting, and diarrhea are also common [22-26].
Rare but serious side effects include nephrolithiasis (with IDV), hepatitis,
hyperglycemia, fevers, rashes, and pancytopenia [22,26]. PEP with NVP has resulted
in some severe adverse events including at least one case of hepatotoxicity requiring
liver transplantation and three confirmed or possible cases of Stevens-Johnson
syndrome
Hepatitis C:
Transmission-
Transmission of HCV resulting from exposures to body fluids other than blood has not
yet been documented, presumably because viral titers in these fluids are substantially
lower than in blood. (Clinical Microbiology Reviews, July 2003, p. 546-568, Vol. 16, No. 3)
Risk after exposure-The average incidence of seroconversion to HCV after
unintentional needle sticks or sharps exposures from an HCV-positive source is 1.8
percent (range, 0-7 percent) [27].
Transmission after mucous membrane exposure-is very rare. There has been one
case report of apparent transmission of HCV by a blood splash to the conjunctiva
[20].
One study reported no instances of HCV seroconversion in 85 exposures with blood or
other risk-prone body materials. (Am J Infect Control. 1995 Oct;23(5):273-7.)
PREEXPOSURE PROPHYLAXIS — Currently preexposure prophylaxis for HCV is not
available. Immune globulin is not effective as postexposure prophylaxis and is
therefore not recommended [17]. There are no data regarding the use of antiviral
agents such as interferon following exposure, and this is not recommended unless
acute infection develops.
Hepatitis B:
Transmission-(info from http://www.metrokc.gov/health/prevcont/hepbfactsheet.htm)
The amount of virus is highest in blood and serous fluid (yellowish or clear fluid that drains from
cuts/sores) but is also present in smaller amounts in semen, vaginal fluids, and menstrual blood.
Although small amounts of virus can be found in saliva, saliva is not likely to spread hepatitis B, unless
saliva from an infected person gets into a cut or sore, for example, following a bite.
-Hepatitis B is not spread by kissing or sneezing.
Risk after exposure-A healthcare worker who sustains a needlestick with blood
from a known HBV-infected patient has between a 6 and 30 percent chance of
developing HBV.
Postexposure prophylaxis with HBIG and/or vaccine should be used when
indicated (eg, after percutaneous or mucous membrane exposure to blood known or
suspected to be HBsAg positive) (show table 3). Needlestick or other percutaneous
exposures of unvaccinated HCWs should lead to initiation of the hepatitis B vaccine
series regardless of the HBV status of the source patient. Postexposure prophylaxis
should be considered for any percutaneous, ocular, or mucous membrane exposure
to blood in the workplace and is determined by the HBsAg status of the source and
the vaccination and vaccine-response status of the exposed person.
If the source patient is HBsAg positive and the exposed person is unvaccinated, HBIG
also should be administered as soon as possible after exposure (preferably within 24
hours) and the vaccine series started. The effectiveness of HBIG when administered
more than seven days after percutaneous or permucosal exposures is unknown. If
the exposed person had an adequate antibody response (>10 mIU/mL) documented
after completion of an HBV vaccination series, no testing or treatment is needed,
although some experts would consider administration of a booster dose of vaccine.
When the source is unavailable but is at high risk for HBV infection (eg, current or
former injecting drug user), some clinicians would assume that the source is HBsAg
positive and provide postexposure prophylaxis based on this assumption.
Table 3
Recommended postexposure prophylaxis for percutaneous or permucosal exposure to hepatitis B
virus
Treatment when source is:
HBsAg* positive
HBsAg negative
Not tested or unknown
Vaccination and antibody response status of exposed person
Unvaccinated
HBIG x 1; initiate HB
vaccine series
Initiate HB
vaccine series
Initiate HB vaccine series
Previously vaccinated
Known responder
No treatment
No treatment
No treatment
Known nonresponder
HBIG x 2 or HBIG x 1
and initiate
revaccination
No treatment
If known high-risk source,
treat as if source were
HBsAg positive
Test exposed person for antiTest exposed person for antiHBs
HBs
If adequate§, no treatment No treatment
If adequate§, no treatment
If inadequate§, initiate
If inadequate§, HBIG x 1 and
revaccination
vaccine booster
* Hepatitis B surface antigen.
Hepatitis B immunoglobulin; dose 0.06 mL/kg IM.
Hepatitis B vaccine.
Antibody to hepatitis B surface antigen.
§ Responder is defined a person with adequate levels of serum antibody to hepatitis B surface
Antibody
response
unknown
antigen (ie,
mlU/mL.
10mlU/mL); inadequate response to vaccination defined as serum anti-HBs <10