Annual DHAS HIV Coordinator’s Meeting 2 010

Annual DHAS HIV Annual DHAS HIV Coordinator’s MeetingCoordinator’s Meeting

22010010

PRESENTERS:PRESENTERS:

Dr. Evan CadoffDr. Evan CadoffDr. Eugene MartinDr. Eugene Martin

Joanne CorboJoanne CorboUMDNJ – Robert Wood Johnson Medical SchoolUMDNJ – Robert Wood Johnson Medical School

Somerset, NJ Somerset, NJ

Rapid HIV Testing in NJRapid HIV Testing in NJ

Common Issues on Monthly Site VisitsCommon Issues on Monthly Site Visits

Joanne CorboJoanne CorboProgram Manager, NJ HIVProgram Manager, NJ HIV

Common Issues with Record KeepingCommon Issues with Record Keeping

• Incomplete Cognition log sheets.Incomplete Cognition log sheets.

• Not entering their CLIS ID Number, and/or entering an incorrect Not entering their CLIS ID Number, and/or entering an incorrect CLIS ID Number.CLIS ID Number.

• Not writing in the comment box when entering a code – example 3 Not writing in the comment box when entering a code – example 3 or 6. If invalid or a manufacturer error please state that and why.or 6. If invalid or a manufacturer error please state that and why.

• Crossing out the lines on the log sheet and filling in above cross outCrossing out the lines on the log sheet and filling in above cross out

• Using 09 forms and rewriting over 09 to enter in the year 10 or Using 09 forms and rewriting over 09 to enter in the year 10 or writing outside the box.writing outside the box.

• Some sites are not faxing in the log sheets at the end of the monthSome sites are not faxing in the log sheets at the end of the month

Common Issues with Record KeepingCommon Issues with Record Keeping(Continued)(Continued)

• Log sheets for the month must be faxed, by the end of the month, even Log sheets for the month must be faxed, by the end of the month, even if the sheet is not completed.if the sheet is not completed.

• Do Not copy the log sheets.Do Not copy the log sheets.• Do Not send temperature log sheets and cover pages through the Do Not send temperature log sheets and cover pages through the

Cognition fax Cognition fax • numbernumber • ONLYONLY the log sheets should come through Cognition (732) 743- the log sheets should come through Cognition (732) 743-

3206 or (732) 743-3632.3206 or (732) 743-3632. • ALL OTHERALL OTHER forms forms to (732) 235-9012 or 866-238-1469. to (732) 235-9012 or 866-238-1469.

• Some Non RWJ sites are not using the log sheets at allSome Non RWJ sites are not using the log sheets at all.!! .!! Cognition Log sheets need to be usedCognition Log sheets need to be used


Discordant Analysis in Rapid HIV TestingDiscordant Analysis in Rapid HIV TestingImplementation of Rapid-RapidImplementation of Rapid-Rapid

New DirectionsNew Directions

Eugene G. Martin, Ph.DEugene G. Martin, Ph.D..Professor of Pathology and Laboratory MedicineProfessor of Pathology and Laboratory Medicine

UMDNJ – Robert W. Johnson Medical SchoolUMDNJ – Robert W. Johnson Medical School

TopicsTopics• Discordant Analysis 2009 Discordant Analysis 2009

• TrendsTrends• Rapid Test Product PerformanceRapid Test Product Performance• SpecificitySpecificity• Oraquick re-formulation of manufacturing process Oraquick re-formulation of manufacturing process

Improved product specificityImproved product specificity

• Rapid-Rapid Initiative 2009Rapid-Rapid Initiative 2009

• New Directions in Rapid TestingNew Directions in Rapid Testing • Narrowing the Detection WindowNarrowing the Detection Window

• Acute HIV InitiativeAcute HIV Initiative• New Products – Determine Combo New Products – Determine Combo


2009 2009 DISCORDANT ANALYSISDISCORDANT ANALYSIS

Trend Analysis Trend Analysis Rapid HIV Discordants

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

Dec-05 Dec-06 Dec-07 Dec-08 Dec-09T

ests

0

10

20

30

40

50

60

70

80

90

100

Dis

cord

ants

Tests Discordants

SUMMARYSUMMARY• Rapid HIV Discordants are rare eventsRapid HIV Discordants are rare events• Many factors are involved: device, operator, experienceMany factors are involved: device, operator, experience• 2009 – Dramatic decline in discordants2009 – Dramatic decline in discordants

• Is it product or training?Is it product or training?

RWJ Sites ONLY

Discordant Analysis Discordant Analysis 20092009

TOTAL StatPak OQ

Blood Discordants 37 34 3

Oral Discordants 8 8

TOTAL 45 34 11

14 Non-RWJ sites

• OraquickOraquick• 8 Oral Discordants – Last one reported: 4/9/20098 Oral Discordants – Last one reported: 4/9/2009• 3 Blood Discordants – Last one reported: 5/30/093 Blood Discordants – Last one reported: 5/30/09

• 14 Non-RWJ sites REPORTED 0

5

10

15

20

25

30

35

StatPak OQ

Discordant NJ 2009

Blood Discordants 37 Oral Discordants 8

2009 Discordant 2009 Discordant AnalysisAnalysis

Prelim Pos. Oraquick OQ

SubtotalStatPa

k TOTAL

OralBloo

d

Single - Rapid 6 2 8 22 30

Rapid -Rapid 2 1 3 12 15

11 34 45

Discordant Analysis - Discordant Analysis - 20092009

PCT NUMBER RESOLUTION

15.6% 7 Discordants without follow-up (sent to NAP: success 1/7 found)

75.6% 34True False Pos. neg follow-

up EIA and NAT)

8.9% 4Confirmed Reactive by NAT

and wblot at ref lab

1

AHI likely (D43) --> initial PHEL wblot inconclusive w\ p24 only, two weeks later + NAT, bands present

2False Neg Unigolds on Rapid-

Rapids

TOTAL 45

Turn-Around-Time Initiative: Discordants

Cases Average Days

Sept 27 18.9

Nov 35 14.6

Dec 45 11.3


STATUS OF RAPID-RAPID STATUS OF RAPID-RAPID IMPLEMENTATIONIMPLEMENTATION

Status of the Rapid-Rapid Initiative

• What is ‘Rapid-Rapid’ • What is the NJ implementation process

• Volume/performance figures 2009

• The CDC Surveillance Taskforce data - two rapids verify a positive HIV test 99.2% of the time

• AHEAD: Efforts to recruit higher prevalence, non-RWJ sites to participate in the next phase of roll-out

2005 - Disposition of Confirmed 2005 - Disposition of Confirmed HIV+HIV+

• ProblemProblem• Preliminary Positive Preliminary Positive

clients fail to return clients fail to return for results (25.2%)for results (25.2%)

• NAP succeeds ONLY NAP succeeds ONLY 20% of the time in 20% of the time in locating these clientslocating these clients

• SolutionSolution• Confirmatory testing Confirmatory testing

on-site, same dayon-site, same day• Not yet accepted by Not yet accepted by

the FDAthe FDA• In use, high In use, high

prevalence areas prevalence areas worldwideworldwide

326

244

82

47

11

0

50

100

150

200

250

300

350

Number

Disposition of Confirmed HIV + Clients

Confirmed HIV + Result retuned to client Did Not Receive ResultsReferred to NAP Found by NAP

Evolving Issues in RAPID Evolving Issues in RAPID TESTINGTESTING

• Sensitivity Issues:Sensitivity Issues:• Rapid HIV Tests Measures Antibodies to Rapid HIV Tests Measures Antibodies to

HIVHIV• They DO NOT Measure HIV RNA or DNAThey DO NOT Measure HIV RNA or DNA

• How Sensitive are rapid HIV tests?How Sensitive are rapid HIV tests?• At least as sensitive as more complex At least as sensitive as more complex

EIA technology used in hospitals and EIA technology used in hospitals and laboratorieslaboratories

• In some cases more sensitive than the In some cases more sensitive than the Western blot, the so-called ‘Gold Western blot, the so-called ‘Gold Standard’ for validation. … this creates Standard’ for validation. … this creates problemsproblems

Why run a second test?Why run a second test?• Specificity of a testing algorithmSpecificity of a testing algorithm

• Builds upon the specificity of a testBuilds upon the specificity of a test• ALL laboratory tests have aALL laboratory tests have a

• A sensitivity – A sensitivity – i.e. the ability to call a true i.e. the ability to call a true positive, positivepositive, positive

• A specificity – A specificity – i.e. the ability to call a true i.e. the ability to call a true negative, negativenegative, negative

• Traditionally the Western blot, Traditionally the Western blot, improves the overall specificity of improves the overall specificity of the testing algorithm.the testing algorithm.

Western blot Limitations Western blot Limitations – NJ DATA– NJ DATA

• 7.1% of positives could not be confirmed 7.1% of positives could not be confirmed because specimens were not collectedbecause specimens were not collected

• 25.8% did not return for results of 25.8% did not return for results of confirmatory Western Blotconfirmatory Western Blot

• ONLY 70.1% of confirmed positives got ONLY 70.1% of confirmed positives got their confirmed result!!their confirmed result!!• ---------------------------------------------- ----------------------------------------------- -

• Western Blot confirmation has an Western Blot confirmation has an effectiveeffective sensitivity as low as 70.1% sensitivity as low as 70.1%

Rapid Testing AlgorithmsRapid Testing Algorithms“Rapid-Rapid”“Rapid-Rapid”

• Principle: Principle: • Two different immunoassays that Two different immunoassays that

employ different HIV antigens to employ different HIV antigens to search for HIV antibodies will verify the search for HIV antibodies will verify the HIV result >99% of the timeHIV result >99% of the time

• OutcomeOutcome• Could we potentially eliminate the Could we potentially eliminate the

western blot as a confirmatory assay western blot as a confirmatory assay and substitute a second rapid HIV and substitute a second rapid HIV test???test???

Rolling out ‘Rapid-Rolling out ‘Rapid-Rapid’Rapid’

• VALIDATION OF THE CONCEPTVALIDATION OF THE CONCEPT• SHARING THE EFFORTSHARING THE EFFORT• PRESENTATIONPRESENTATION at numerous national at numerous national

conferences: APHA, HIV Prevention, IDSA, conferences: APHA, HIV Prevention, IDSA, etc. etc.

• IMPLEMENTATION DECISION:IMPLEMENTATION DECISION: Rapid-Rapid Rapid-Rapid testing at NJ HIV sites directed by RWJMS – testing at NJ HIV sites directed by RWJMS – 2009 HIV Coordinators Conference2009 HIV Coordinators Conference

• IMPLEMENTATION PROCESS:IMPLEMENTATION PROCESS: Funding from Funding from supplemental funding from CDC, we began supplemental funding from CDC, we began the roll-out in December, 2009.the roll-out in December, 2009.

Validation Studies – 2004-8Validation Studies – 2004-8

• Goal – To satisfy ourselves that a second, Goal – To satisfy ourselves that a second, independent rapid HIV test could reliably identify independent rapid HIV test could reliably identify false positive HIV tests false positive HIV tests • 2004 – Using residual serum, we confirmed all Western 2004 – Using residual serum, we confirmed all Western

blot positive sera obtained in the previous year and blot positive sera obtained in the previous year and available at the Public Health Labsavailable at the Public Health Labs

• 2005-8: 2005-8: • Using residual sera and plasma samples to confirm Using residual sera and plasma samples to confirm

that a second independent rapid HIV test could that a second independent rapid HIV test could reliably identify false positive HIV testsreliably identify false positive HIV tests

Rapid confirmation Rapid confirmation trialtrial

Negative WB Pos Discordant

• 15,923 OraQuick tests 15,923 OraQuick tests statewidestatewide

• 363 prelim positive 363 prelim positive samples to state lab samples to state lab for confirmatory for confirmatory testingtesting

• 355 Western Blot 355 Western Blot positivepositive

• 8 Western Blot 8 Western Blot negativenegative

• A second rapid test – Unigold A second rapid test – Unigold identified all 8 false positive identified all 8 false positive rapidsrapids

July 1, 2004 through April 19, 2005

History of our RTA SelectionHistory of our RTA Selection

1.1. Oraquick (Oral or Fingerstick) were both in use in NJ from 2004 on. Oraquick (Oral or Fingerstick) were both in use in NJ from 2004 on. 2.2. StatPak was introduced in NJ at a significant number of sites 2008 StatPak was introduced in NJ at a significant number of sites 2008

INITIAL SCREENINGINITIAL SCREENING: EITHER OraQuick (FS or O) or StatPak: EITHER OraQuick (FS or O) or StatPak

VERIFICATION: VERIFICATION: Trinity Unigold Trinity Unigold

1.1. Two stage process to minimize:Two stage process to minimize:• Issues of trainingIssues of training• Issues of competency assessment Issues of competency assessment • Issues of required QCIssues of required QC• A discordant situation in stage two would immediately bring the specimen and the A discordant situation in stage two would immediately bring the specimen and the

client to the attention of clinicians for definitive follow-upclient to the attention of clinicians for definitive follow-up• Healthcare linkage could be achieved on the basis of two tests taking less than ½ hr.Healthcare linkage could be achieved on the basis of two tests taking less than ½ hr.

2.2. Since UniGold was not labeled for HIV-2 detection, we opted to initially screen Since UniGold was not labeled for HIV-2 detection, we opted to initially screen by Oraquick or StatPak and verify by UniGold. If it turned out that there was a by Oraquick or StatPak and verify by UniGold. If it turned out that there was a problem due to HIV-2 detection, it would have triggered central supportproblem due to HIV-2 detection, it would have triggered central support..

First rapid HIV -

Negative

Negative for HIV Antibodies

First rapid HIV +

PRELIMINARY POSITIVE

PERFORM2nd Rapid –

Trinity Unigold

DISCORDANT PROCESS

2nd rapid HIV +

HIV Verified – Refer to Care IMMEDIATELY

2nd rapid HIV -

Notify NJ HIV Clinicians for follow-

up

White top tubes picked up ->

Reference Lab

Perform 1st Rapid:

Oraquick OR StatPak

GOAL: 20 MIN VERIFIED

RESULT SAME DAY REFERRAL

GOAL: 96 HR. DISCORDANT RESOLUTION

Collect Blood for HIV-1 Western blot

(NJ PHEL)

White top tube for possible NAAT: spin/

freeze

NJ HIV Techs pickup

process and follow-up

NJ R

APID

TES

TIN

G

ALG

OR

ITH

M

Rapid-Rapid ImplementationRapid-Rapid Implementation

• PLAN:PLAN:• December, 2008: 3 pilot sites began the ‘roll-out’ December, 2008: 3 pilot sites began the ‘roll-out’ • Sites of high prevalence first, lower prevalence laterSites of high prevalence first, lower prevalence later• Policies, Procedures, Counseling Messages and Forms were completed for Policies, Procedures, Counseling Messages and Forms were completed for

the entire system available before trainingthe entire system available before training• Available on the ‘web’: Available on the ‘web’: http://www.njhiv1.orghttp://www.njhiv1.org

• EXPECTATIONS: EXPECTATIONS: • Doesn’t eliminate Western blot confirmation, BUT allow immediate linkage to Doesn’t eliminate Western blot confirmation, BUT allow immediate linkage to

care reliably!care reliably!• Less than 1 in 100 would later be removed from care because of a failure to Less than 1 in 100 would later be removed from care because of a failure to

confirmconfirm

• UNKNOWNS: What will be the real world performance of a rapid test in a UNKNOWNS: What will be the real world performance of a rapid test in a confirmatory setting?confirmatory setting?

• Does reducing the delay really improve the linkage to care?Does reducing the delay really improve the linkage to care?

http://www.njhiv1.org/

Training

04/22/23

NJ HIV – May, 2009

LEGEND TRADITIONAL RAPID TESTING ALGORITHM

Rapid Testing PROGRAM

COMMUNITY BASED ORG. (CBO)

MEDICAL CTR. ER

MOBILE VAN

PRISONS

Diversity of sites using an RTA

Timeline - RTA Implementation

2009 – NJ RTA – Testing 2009 – NJ RTA – Testing VolumesVolumes

Rapid Test 1 Tests PCT

StatPak 12389 72.5%

Oraquick Oral 2466 14.4%

Oraquick Finger Stick 2240 13.1%

Rapid Test 2 RTA Total Tested:

Unigold 149 .87% 17095

Outcome Analysis – RTA Outcome Analysis – RTA 20092009

WB Results1st Rapid

Positive2nd Rapid

Positive2nd Rapid

Negative

Total WB results 142 131 10

Pct WB POS 93.7% 99.2% 20.0%

Pct WB Neg orIndeterminant 6.3% 0.8% 80.0%

Pct Refused WB 7 - 4.9%

Who Gets Linked to Care

0

10

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30

40

50

60

70

80

90

Nu

mb

er

Prelim. Pos UniGold Confirmed Same Day Connected toCare

Rapid-Rapid NJ 2009 • 74% of ‘verified’ HIV positives 74% of ‘verified’ HIV positives receive appts on the same dayreceive appts on the same day

• 26% DID NOT receive appts on the 26% DID NOT receive appts on the same day!! same day!!

• Site Specific Issues - Ongoing Site Specific Issues - Ongoing • How to improve linkageHow to improve linkage

Linkage to Care - Survey

APPT Site of Rapid-RapidSame Day Appt FQHC HD

Med. Sch. CBO

>90% 4 1 1>75-90%

>50<75% 1 2 110 <25%>10%

PHYSICIAN Site of Rapid-RapidSame Day Visit FQHC HD

Med. Sch. CBO

>90% 2 1>75-90% 1

>50<75% 1 110 <25% 1>10% 1 1 1

• It’s not too difficult in NJ to schedule a physician appointment – 6/10 sites could It’s not too difficult in NJ to schedule a physician appointment – 6/10 sites could schedule appt 90% of time on same day as RTA positiveschedule appt 90% of time on same day as RTA positive

• Obtaining an appointment on the same day was more difficult --- only 3/10 sites Obtaining an appointment on the same day was more difficult --- only 3/10 sites were able to accomplish this linkage.were able to accomplish this linkage.

The Next PhaseThe Next Phase

• Expand Rapid-Rapid TestingExpand Rapid-Rapid Testing• Seeking non-RWJ sites to implement Rapid-Rapid. Seeking non-RWJ sites to implement Rapid-Rapid. • Goal:Goal: Linkage to care on the day HIV result is verified. Linkage to care on the day HIV result is verified.

• Possible Possible Elimination of the Confirmatory Western blotElimination of the Confirmatory Western blot• Current surveillance definition requires IFA, Western blot or Current surveillance definition requires IFA, Western blot or

RNA testing – a CDC taskforce is addressing this issue. – it RNA testing – a CDC taskforce is addressing this issue. – it matters because funding is influenced!!matters because funding is influenced!!


Future DirectionsFuture Directions

Rapid Diagnostic HIV Rapid Diagnostic HIV AssaysAssays

• LIMITATIONS:LIMITATIONS:1.1. Detects HIV antibodies, not the HIV Detects HIV antibodies, not the HIV

virusvirus

2.2. Western Blot Confirmation or IFA Western Blot Confirmation or IFA MUST BE performed. MUST BE performed.

• As rapid tests become more sensitive, As rapid tests become more sensitive, wblot confirmation becomes more wblot confirmation becomes more problematic. problematic. More discordant resultsMore discordant results

3.3. Client message: PRELIMINARY Client message: PRELIMINARY POSITIVE on 1POSITIVE on 1stst Visit or NEGATIVE Visit or NEGATIVE

• Ramp-up ViremiaRamp-up Viremia DoublingDoubling TimeTime = = 21.5 hrs21.5 hrs

• Peak ViremiaPeak Viremia101066 – 10 – 1088 gEq/mL gEq/mL

• Viral set-pointViral set-point101022 – 10 – 1055 gEq/mL gEq/mL

• WINDOWWINDOW• Antibody – 22 DaysAntibody – 22 Days• Antigen – 16 DaysAntigen – 16 Days• Pooled NAT – 14 DaysPooled NAT – 14 Days• Individual NAT – 11 DaysIndividual NAT – 11 Days

HIV ANTIBODY WINDOW is the problemHIV ANTIBODY WINDOW is the problem

0 10 16 22 DAYS

Individual NAT 11 Days

Pooled NAT14 Days

P24 Ag 16 Days

HIV Antibody – 3rd Generation 22 Days

ANTIBODY WINDOW

Opportunity SummaryOpportunity Summary

1.1. ~ 55,000~ 55,000 new new HIV infectionsHIV infections per year in the US per year in the US2.2. Reaching and testing those at riskReaching and testing those at risk

• ~ 25%~ 25% of the 850,000 - 950,000 HIV+ people in the of the 850,000 - 950,000 HIV+ people in the United States are United States are unaware of their statusunaware of their status

• ~ 30% or more who test positive for HIV by conventional ~ 30% or more who test positive for HIV by conventional testing do not receive their results!!testing do not receive their results!!

3.3. Stop the cycle by interfering with transmissionStop the cycle by interfering with transmission• More than 50% of transmission occurs in the earliest stagesMore than 50% of transmission occurs in the earliest stages of of

an HIV infection!an HIV infection!• If we detect infections at the earliest stages possibility of If we detect infections at the earliest stages possibility of

interrupting the cycle of transmission.interrupting the cycle of transmission.• Once the antibody appears, infectivity is diminishingOnce the antibody appears, infectivity is diminishing

4.4. How to detect early infections in a simpler, more How to detect early infections in a simpler, more economical mannereconomical manner

Natural History - HIV InfectionNatural History - HIV Infection

Couthino et al., Bulletin of Mathematical Biology 2001

Future – p24 Ag Future – p24 Ag detection Point-of-care detection Point-of-care devicedevice

Detecting HIV virus before HIV antibody appearsDetecting HIV virus before HIV antibody appears• Pooled NAT on antibody negative bloodPooled NAT on antibody negative blood

• Blood donor facilities use to protect blood recipients since the Blood donor facilities use to protect blood recipients since the late 1990’s.late 1990’s.

• Concept – If you’re in the window phase, you have no Concept – If you’re in the window phase, you have no antibody, you may have no p24 Ag, but you still have the antibody, you may have no p24 Ag, but you still have the virusvirus

• As of 2001, 100% of the US blood supply was tested by As of 2001, 100% of the US blood supply was tested by pooled NAT. Yield: 8 HIV antibody negative infected units in pooled NAT. Yield: 8 HIV antibody negative infected units in 23 million tested units. 2 p24 Ag+ units also detected. 23 million tested units. 2 p24 Ag+ units also detected. (~1:3,292,400)(~1:3,292,400)

• Between 2003-7 discussions in the HIV community regarding Between 2003-7 discussions in the HIV community regarding the use of pooled NAT in high risk individuals. the use of pooled NAT in high risk individuals.

• Expensive Expensive • Cases eventually demonstrate antibody, so…Cases eventually demonstrate antibody, so…• Why bother?Why bother?

• Crucial bit of information missing to justify pooled NAT!Crucial bit of information missing to justify pooled NAT!

The missing linkThe missing link

• More than 50% of transmission occurs More than 50% of transmission occurs in the earliest stagesin the earliest stages of an HIV of an HIV infection!infection!

• If we detect infections at the earliest If we detect infections at the earliest stages, there is the possibility of stages, there is the possibility of interrupting the cycle of transmission.interrupting the cycle of transmission.

• Once the antibody appears, infectivity Once the antibody appears, infectivity is already diminishingis already diminishing

The QuestionThe Question• If we have the capacity to check p24 Ag with a rapid test and it narrows the If we have the capacity to check p24 Ag with a rapid test and it narrows the

window for detection by 6 days is that good enough?window for detection by 6 days is that good enough?

• We have implemented pooled NAT testing from antibody negative blood at We have implemented pooled NAT testing from antibody negative blood at high prevalence sites where individuals who are recently infected might high prevalence sites where individuals who are recently infected might logically go, if they were feeling poorly.logically go, if they were feeling poorly.

• University HospitalUniversity Hospital• St. Michael’sSt. Michael’s

• In San Francisco, last year they identified 39 individuals with Acute HIV In San Francisco, last year they identified 39 individuals with Acute HIV infection, but the majority WOULD have been identified with access to p24 Ag infection, but the majority WOULD have been identified with access to p24 Ag testing!testing!

• What about New Jersey?What about New Jersey?

New Jersey HIVNew Jersey HIV

We’ll let you know…We’ll let you know…

Next year!Next year!

And Most ImportantlyAnd Most Importantly

Thanks for all you do!Thanks for all you do!

Thanks To:Thanks To:

RWJMSRWJMS• Evan Cadoff, MDEvan Cadoff, MD• Eugene Martin, Ph.D.Eugene Martin, Ph.D.• Gratian Salaru, MDGratian Salaru, MD

• Joanne Corbo, MBA, MT (ASCP)Joanne Corbo, MBA, MT (ASCP)• Claudia Carron, MSN, RNClaudia Carron, MSN, RN• Franchesca Jackson, BS (Biology)Franchesca Jackson, BS (Biology)• Nisha Intwala, BS, MT (ASCP)Nisha Intwala, BS, MT (ASCP)• Aida Gilanchi, BS, MT Aida Gilanchi, BS, MT • Mary Ann Garrihy, BS, MT (ASCP)Mary Ann Garrihy, BS, MT (ASCP)• Patricia Riberio, BS, MT (ASCP)Patricia Riberio, BS, MT (ASCP)• Lisa MayLisa May• Karen WilliamsKaren Williams

NJDHSS/DHASNJDHSS/DHAS• Sindy Paul, MD, MPH*Sindy Paul, MD, MPH*• Linda Berezny, RNLinda Berezny, RN• Maureen Wolski, BSMaureen Wolski, BS• Aye Maung MaungAye Maung Maung

NJDHSS/PHELNJDHSS/PHEL

All site coordinators and counselorsAll site coordinators and counselors throughout New Jerseythroughout New Jersey

Documents

Annual DHAS HIV Coordinator’s Meeting 2 010