Routine rapid HIV testing in hospitals: another opportunity for hospitalists to improve care

Evaluation of Rapid Testing Algorithms for Venue-based Anonymous HIV Testing among Non-HIV-Positive Men Who Have Sex with Men, National HIV Behavioral Surveillance (NHBS), 2017

HIV rapid testing algorithms (RTAs) using any two orthogonal rapid tests (RTs) allow for on-site confirmation of infection. RTs vary in performance characteristics therefore the selection of RTs in an algorithm may affect identification of infection, particularly if acute. National HIV Behavioral Surveillance (NHBS) assessed RTAs among men who have sex with men recruited using anonymous venue-based sampling. Different algorithms were evaluated among participants who self-reported never having received a positive HIV test result prior to the interview. NHBS project areas performed sequential or parallel RTs using whole blood. Participants with at least one reactive RT were offered anonymous linkage to care and provided a dried blood spot (DBS) for testing at CDC. Discordant results (RT-1 reactive/RT-2 non-reactive) were tested at CDC with lab protocols modified for DBS. DBS were also tested for HIV-1 RNA (VL) and antiretroviral (ARV) drug levels. Of 6500 RTAs, 238 were RT-1 reactive; of those, 97.1% (231/238) had concordant results (RT-1/RT-2 reactive) and 2.9% (7/238) had discordant results. Five DBS associated with discordant results were available for confirmation at CDC. Four had non-reactive confirmatory test results that implied RT-1 false reactivity; one had ambiguous confirmatory test results which was non-reactive in further testing. Regardless of order and type of RT used, RTAs demonstrated high concordant results in the population surveyed. Additional laboratory testing on DBS following discordant results confirmed no infection. Implementing RTAs in the context of anonymous venue-based HIV testing could be an option when laboratory follow-up is not practicable.

Lost opportunities to identify and treat HIV-positive patients: results from a baseline assessment of provider-initiated HIV testing and counselling (PITC) in Malawi

OBJECTIVE

To assess implementation of provider-initiated testing and counselling (PITC) for HIV in Malawi.

METHODS

A review of PITC practices within 118 departments in 12 Ministry of Health (MoH) facilities across Malawi was conducted. Information on PITC practices was collected via a health facility survey. Data describing patient visits and HIV tests were abstracted from routinely collected programme data.

RESULTS

Reported PITC practices were highly variable. Most providers practiced symptom-based PITC. Antenatal clinics and maternity wards reported widespread use of routine opt-out PITC. In 2014, there was approximately 1 HIV test for every 15 clinic visits. HIV status was ascertained in 94.3% (5293/5615) of patients at tuberculosis clinics, 92.6% (30,675/33,142) of patients at antenatal clinics and 49.4% (6871/13,914) of patients at sexually transmitted infection clinics. Reported challenges to delivering PITC included test kit shortages (71/71 providers), insufficient physical space (58/71) and inadequate number of HIV counsellors (32/71) while providers from inpatient units cited the inability to test on weekends.

CONCLUSIONS

Various models of PITC currently exist at MoH facilities in Malawi. Only antenatal and maternity clinics demonstrated high rates of routine opt-out PITC. The low ratio of facility visits to HIV tests suggests missed opportunities for HIV testing. However, the high proportion of patients at TB and antenatal clinics with known HIV status suggests that routine PITC is feasible. These results underscore the need to develop clear, standardised PITC policy and protocols, and to address obstacles of limited health commodities, infrastructure and human resources.

A survey of a small sample of emergency department and admitted patients asking whether they expect to be tested for HIV routinely

OBJECTIVES

Many US HIV-positive patients are unaware of their infection. Although there are multiple studies assessing the acceptance of testing, there are none that assess the patient's expectations of routine HIV testing.

METHODS

Through a prospective, cross-sectional, unfunded, convenience sample survey, we assessed the patient's expectation of testing at a regional medical center serving an indigent population. Also, we compared the providers' predictions of the proportion of patients expecting a test.

RESULTS

Of the 69 patients, 23% expected a test. The only factor that correlated with this was their desire to be tested (P = .004). Providers' (N = 59) mean prediction was that 21% of the patients expected a test (range: 0%-100%). The proportion of emergency department (ED) patients wanting a test was 52% (of 30) and internal medicine inpatients were 44% (of 39).

CONCLUSIONS

Nearly a quarter of patients expected routine HIV testing. This finding should encourage a review of policies promoting HIV testing, especially within the ED.

HIV screening practices in U.S. hospitals, 2009-2010

OBJECTIVE

A 2004 national survey of hospitals showed that 23.4% of hospitals screened for HIV in at least one department, most frequently in labor and delivery departments. However, less than 2% of these hospitals screened patients in inpatient units, urgent care clinics, or emergency departments. In 2006, the Centers for Disease Control and Prevention (CDC) recommended HIV screening for all individuals 13-64 years of age in health-care settings. We determined the frequency of hospital adoption of these CDC recommendations.

METHODS

We surveyed hospital infection-control personnel at a randomly selected sample of U.S. general medical and surgical hospitals in 2009-2010.

RESULTS

Of the 1,476 hospitals selected for the survey, 754 (51.1%) responded to the survey; of those responding, 703 (93.2%) offered HIV tests for patients at the hospital and 206 (27.3%) screened for HIV in at least one department. Screening was most common in larger hospitals (45.7%), hospitals in large metropolitan areas (50.5%), and teaching hospitals (44.4%); it was least common in public hospitals (19.1%). By department, screening was most common in labor and delivery departments (34.6%) and substance abuse clinics (20.7%); it was least common in emergency departments (11.9%), inpatient units (9.6%), and psychiatry/mental health departments (9.4%). More than half of hospitals were not considering implementing CDC's recommendations within the next 12 months.

CONCLUSIONS

Since 2004, HIV screening in hospitals increased overall and by department. However, the majority of U.S. hospitals have not adopted the CDC recommendations.

Greater acceptance of routine HIV testing (opt-out) by patients attending an infectious disease unit in Spain

OBJECTIVE

Our objective was to determine attitudes and opinions of patients seen in our ID Unit on conducting HIV testing universally.

METHODS

The survey was conducted in patients between 18 and 65 years without known HIV infection. Requested information about the test was previous embodiment, reasons for rejection, opinion on the universal realization, benefits and/or drawbacks, possible test performance, and availability of results "test negative stigma."

RESULTS

We surveyed 91 patients (54.9% males). Surprisingly, up to 18.7% of patients mistakenly believed that HIV testing is routinely performed without consent. A great majority (98.9%) felt that universal performance on the test would benefit mainly in early diagnosing and/or preventing transmission. Patients younger than 42 years were significantly more prone to doing the test as a routine procedure. Only 4 (4.4%) patients did not participate because they believed they were "not infected." A vast majority (80.5%) of respondents would prefer to have results within the first 24 hours. In addition, 20.7% would have a problem with confidentiality if HIV serology testing was done.

CONCLUSIONS

In summary, the vast majority (95.6%) of the surveyed patients had a fair opinion about universal HIV testing. Only 4 patients (4.4%) would not consent to HIV testing (because of low-risk perception). Availability of rapid HIV tests can facilitate fast result delivery, facilitating linkage to care. Considering favorable patients' opinion, recent opt-out screening recommendations, highest HIV prevalence in admitted patients, and cost-effectiveness, studies favor universal HIV testing.

Causes of hospitalization and perceived access to care among persons newly diagnosed with HIV infection: implications for HIV testing programs

There has been little research on the causes of hospitalization when patients are first diagnosed with HIV in the hospital. Reduced access to care could partially explain inpatient diagnosis. We sought to determine if the patients diagnosed as inpatients are hospitalized due to a HIV-related cause versus some other causes, to compare access to care of patients diagnosed with HIV in hospital and outpatient settings, and to determine factors associated with access to care. Participants were newly diagnosed with HIV and recruited between January 2006 and August 2007. The reason for hospitalization was classified as HIV-related, other infectious cause, noninfectious cause, or miscellaneous cause. Access to care was self-reported using a six-item scale and scores were compared with the t test. Multivariate linear regression determined factors associated with improved access to care. Of 185 participants in the study, 78 were diagnosed in hospital and 107 in outpatient settings. Thirty-two percent of participants were female, 90% were racial/ethnic minority, 45% had no high school diploma, and 85% were uninsured. HIV-related conditions accounted for 60% of admissions, followed by non-infectious causes (20%) and other infectious causes (17%). Inpatients did not report less access to care than patients diagnosed while outpatients. Multivariate analysis demonstrated improvement in access to care with better health insurance (p = 0.01) and greater education (p = 0.08). HIV-related preventable conditions account for many hospitalizations when patients are first diagnosed with HIV. While socioeconomic factors are associated with perceived access to care, persons diagnosed in the inpatient setting do not report lower perceived access to care than persons diagnosed as outpatients, suggesting other barriers to earlier diagnosis.

The performance of the VIKIA(®) HIV1/2 rapid test-evaluation of the reliability and sensitivity

The use of rapid human immunodeficiency virus (HIV) antibody tests can help reduce the number of individuals positive for HIV who are unaware of their infection. Although several studies have demonstrated that the sensitivity and specificity of rapid HIV tests are comparable to those of enzyme immunoassays, none have addressed the rapidity with which these tests can yield a result and the reliability of such results. In this study, we investigated the performance of VIKIA(®) HIV1/2 rapid tests regarding early reactive results and the stability of these results after sample addition. The results showed that using HIV-1 or HIV-2 positive samples, a positive result could be observed as early as 1 min after the addition of the sample. The ability of this test to detect early HIV-1 primary infection was also assessed using seroconversion specimens. The results demonstrate the high sensitivity of this test, and its suitability for the identification of seroconversion samples in the context of primary infection with HIV-1.

[Meta-analysis for the pooled sensitivity and specificity of anti-human immunodeficiency virus Ab rapid tests]

BACKGROUND

Many immunochromatography (ICA) kits for anti-human immunodeficiency virus type (HIV) antibody (Ab) have been introduced to improve the accessibility of HIV Ab tests. However, qualified evaluation reports for HIV rapid tests are not enough to validate their performances. Meta-analysis for the performances of the HIV Ab rapid tests was performed in this study.

METHODS

PubMed database was searched with combination of search terms, 'human immunodeficiency virus', 'HIV Ab', 'rapid test', 'immunochromatography', 'performance', 'sensitivity', and 'specificity'. Criteria of inclusion were performance studies for HIV ICA kits with serum or EDTA whole blood. Methodological qualities were evaluated with standards for reporting of diagnostic accuracy studies (STARD) checklists by two investigators. Homogeneity among selected studies was evaluated and then pooled sensitivity and specificity were calculated. Positive and negative predictive values were simulated with presumed HIV prevalence in Korea.

RESULTS

Twenty-three studies were selected from 12 high-qualified papers with STARD checklists. The performance of 23 studies were found to be heterogeneous (P<0.1) and random effect model was used. Pooled sensitivity was 99.71% (95% CI: 99.45-99.97%) and pooled specificity was 99.27% (95% CI: 98.83-99.70%). With HIV prevalence of 0.03%, positive and negative predictive values were presumed to be 3.936% and 99.999%, respectively.

CONCLUSIONS

This meta-analysis for HIV ICA rapid tests showed good performance. In consideration of low positive predictive values of HIV rapid tests, confirmation by enzyme immunoassay or Western blot is still needed. This study would be helpful in evaluating and establishing proper performance guideline for those kits not fully evaluated.

Patient risks, outcomes, and costs of voluntary HIV testing at five testing sites within a medical center

OBJECTIVES

The Centers for Disease Control and Prevention (CDC) recommends offering human immunodeficiency virus (HIV) testing to all patients in all high HIV-prevalence clinical settings. We evaluated programmatic aspects of HIV testing across multiple clinical settings within a single medical center.

METHODS

We analyzed programmatic data of HIV testing in the Urgent Care Center (UCC), inpatient floors, outpatient primary care, a non-clinical Drop-In Center, and Emergency Department (ED). HIV testing was by oral mucosal transudate, venous blood samples, or rapid testing fingersticks, with Western blot confirmation. We compared the sociodemographics and behavioral risks of individuals undergoing HIV testing across the five sites and estimated costs per person tested and per HIV-positive test result.

RESULTS

From 2002 to 2004, 16,750 HIV tests were conducted, with 229 (1.4%) previously unreported HIV infections diagnosed among 16,696 valid test results. HIV-positive prevalence was 1.5% for the UCC, 1.5% at the Drop-In Center, 1.4% for primary care, 1.2% for inpatient, and 0.6% in the ED. Behavioral risks were most prevalent in the UCC and the Drop-In Center. The cost per test was lowest in the UCC and highest in the Drop-In Center. The cost per previously unreported HIV infection was lowest in the UCC ($1,980) and highest in the ED ($9,724).

CONCLUSIONS

Although a significant number of HIV infections were identified, the number of tests performed represents < 10% of all clinical visits. Due to personnel and time constraints, offering HIV testing to patients hierarchically in some settings of a high-volume medical center merits evaluation.

The utilization of testing and counseling for HIV: a review of the social and behavioral evidence

Against the background of debates about expanding HIV testing and counseling, we summarize the evidence on the social and behavioral dimension of testing and its implications for programs. The discrepancy between acceptance of testing and returning for results and the difficulties of disclosure are examined in light of research on risk perceptions and the influence of gender and stigma. We also summarize the evidence on the provision of testing and counseling, the implementation of practices regarding confidentiality and consent, and the results of interventions. We demonstrate that social factors have a considerable impact on testing, show that the services linked to testing are key determinants of utilization, and consider the implications of these findings for HIV testing programs.

Expanding the roles of hospitalist physicians to include public health

Several years after the inception of the hospitalist movement, hospitalist roles have evolved in breadth and sophistication. Although public health is not formally recognized or previously described as an arena for hospitalists, hospitalists are often engaged in public health practice. This article attempts to alert hospitalists to the potential to make contributions to the field of public health and defines the public health skills that can positively affect the lives of their patients and the communities they serve. In a public health role, hospitalists may improve the quality of inpatient care. This article reviews how public health and hospital-based practices have already intersected and proposes further development within this discipline. In our ever-changing health care system, hospitalists play key roles in the central public health domains of assessment, assurance, and policy development. Insightful hospitalists will recognize and embrace these responsibilities in caring for patients and society.

Approaching the CDC's guidelines on the HIV testing of inpatients: physician-referral versus nonreferral-based testing

Despite ongoing evidence that one quarter of HIV-infected people in the United States are unaware of their infection, widespread implementation of the Centers for Disease Control and Prevention's 1993 recommendations regarding routine inpatient HIV testing has not occurred. This study compares two HIV testing strategies: the initial phase of inpatient HIV testing (1999-2001) utilized a physician-referral-based system. The second phase (2001-2003) included the first 2 years' experience with having trained HIV counselors directly approach inpatients regarding their willingness to undergo voluntary HIV counseling and testing (VCT) without physician referral. This latter phase was prompted by a patient attitude survey demonstrating favorable responses to unsolicited approaches by staff regarding HIV testing. Barriers to implementing the latter strategy are discussed and initial experience with rapid HIV testing on this service is also presented. Referral-based testing yielded 2.3 patient referrals (6.4% of total admissions) resulting in 1.2 HIV tests and 0.7 counseling only sessions per day. Nonreferral based testing resulted 6.2 HIV tests and another 3.0 counseling-only sessions per day. HIV VCT on an inpatient service is feasible but challenging. Most patients respond favorably to being approached for VCT. Routinely offering HIV tests to inpatients yields higher testing rates than physician referral-based systems and increases the number of patients who know their HIV status. Recommendations for implementing routing HIV testing on an inpatient service are made.