HIV Care Continuum for HIV-Infected Emergency Department Patients in an Inner-City Academic Emergency Department

Evaluating Patient Perceptions on PrEP Screening and Referral in the Acute Care Setting

Pre-exposure prophylaxis (PrEP) for HIV is highly effective, yet uptake has been limited. We measured PrEP knowledge, eligibility, and referral willingness among patients receiving emergency or acute care in Washington, DC. We surveyed HIV-negative patients with STI-related complaints on HIV risk behaviors, PrEP knowledge, eligibility, and willingness for PrEP referral. Among 174 participants, 70% were PrEP unaware and 33% were PrEP eligible. Most participants (81%) supported learning more, 64% would consider taking PrEP, and 28% agreed to immediate referral. Willingness to learn more about PrEP suggests referral from non-traditional settings may increase uptake. Further evaluation of this approach is warranted.

Blood-borne virus testing in emergency departments - a systematic review of seroprevalence, feasibility, acceptability and linkage to care

BACKGROUND

Blood-borne viruses (BBVs) cause significant morbidity and mortality worldwide. Emergency departments (EDs) offer a point of contact for groups at increased risk of BBVs who may be less likely to engage with primary care. We reviewed the literature to evaluate whether BBV testing in this setting might be a viable option to increase case finding and linkage to care.

METHODS

We searched PubMed database for English language articles published until June 2019 on BBV testing in EDs. Studies reporting seroprevalence surveys, feasibility, linkage to care, enablers and barriers to testing were included. Additional searches for grey literature were performed.

RESULTS

Eight-nine articles met inclusion criteria, of which 14 reported BBV seroprevalence surveys in EDs, 54 investigated feasibility and acceptability, and 36 investigated linkage to care. Most studies were HIV-focused and conducted in the USA. Seroprevalence rates were in the range 1.5-17% for HCV, 0.7-1.6% for HBV, and 0.8-13% for HIV. For studies that used an opt-in study design, testing uptake ranged from 2% to 98% and for opt-out it ranged from 16% to 91%. There was a wide range of yield: 13-100% of patients received their test result, 21-100% were linked to care, and 50-91% were retained in care. Compared with individuals diagnosed with HIV, linkage to and retention in care were lower for those diagnosed with hepatitis C. Predictors of linkage to care was associated with certain patient characteristics.

CONCLUSIONS

Universal opt-out BBV testing in EDs may be feasible and acceptable, but linkage to care needs to be improved by optimizing implementation. Further economic evaluations of hepatitis testing in EDs are needed.

Estimating resource utilization for emergency department visits by patients' HIV seropositivity in the United States, 2009 to 2018

INTRODUCTION

The Emergency Department (ED) plays a key role in linkage to and engagement in care for people with HIV (PWH) in the United States, particularly for individuals without a routine source or schedule for care. Assessing patterns of ED resource utilization by PWH can help elucidate the role of EDs across the HIV care continuum. The aim of this study was to use visit-level data to characterize resource utilization patterns for HIV-related ED visit diagnoses compared to those of other ED visit types.

METHODS

HIV-related ED visits were identified as either having answered 'have HIV' in a survey question, been diagnosed with HIV, or had HIV noted as a reason for a visit. Weighted, pooled cross-sectional analyses were performed using the National Hospital Ambulatory Medical Care Survey (NHAMCS) for 2009-2018. ED visits were restricted to those aged 13 years and older. Both descriptive and multivariable regression analyses were performed using Stata 15.1 to measure differences in ED resource utilization.

RESULTS

A weighted total of 6.10 million ED visits occurred among PWH, representing 5.5 visits per 1000 ED visits. The rates of HIV-related ED visits (per 1000 ED visits) were higher among patients aged 50-64 years (9.1), males (7.9), African Americans (11.1), Medicaid recipients (7.8), patients in the Northeast (6.8), and patients in metropolitan areas (MSA) (6.1). HIV-related ED visits reflected higher resource utilization: including higher utilization of the ambulance, diagnostic tests, blood tests, urinalysis, HIV tests, intravenous fluids, medications, consultants, critical care units, longer visits, and hospital admissions. Multivariable regression models revealed higher ED resource utilization and showed that patients making HIV-related visits were 57% more likely to result in hospital admission, spending 17% more time compared to patients making non-HIV-related visits.

CONCLUSION

Hospitals should be prepared to meet the unique needs of PWH presenting for ED services. Continued surveillance of resource utilization patterns among PWH in EDs is important to plan successful HIV care engagement interventions in these settings.

The geography of emergency department-based HIV testing in South Africa: Can patients link to care?

BACKGROUND

Emergency Departments (EDs) can serve as clinical sites for identification of new HIV infections and their entry into care. We examined if HIV-positive patients who present to EDs in South Africa are able to successfully link to care.

METHODS

We conducted a one-year longitudinal prospective cohort study in four hospitals across the Eastern Cape, South Africa, with participants followed between July 2016 and July 2018. All adult, non-critical patients presenting to the ED were systematically approached, asked about their HIV status, and, if unknown, offered a point-of-care (POC) HIV test. All HIV-positive patients were further consented to participate in a follow-up study to assess subsequent linkage to care and distance from "home" to ED. Linkage to care was defined as self-reported linkage (telephonic) or evidence of repeated CD4/viral load testing in the National Health Laboratory System (NHLS) at either the 6- or 12-months post index ED visit.

FINDINGS

A total of 983 HIV-positive patients consented to participate in the study. In the 12 months following their ED visit, 34·1% of patients demonstrated linkage to care (335/983), 23·8% did not link to care (234/983), and 42·1% (414/983) were lost to follow-up. Though not statistically significant, a high percentage of young men (27/50, 54%) and those presenting with a trauma-related complaints (100/205, 48.8%) did not link to care. A considerable proportion of patients (105/454, 23·2%,) resided 50 or more kilometers from their index ED sites, though there was not a significant difference in linkage to care rate between those who lived closer or further from the ED.

INTERPRETATION

We have shown that strategies to improve linkage to care from the ED should consider the high rates of poor linkage among young men and those presenting to the ED with trauma. Furthermore, innovative linkage to care solutions will need to account for the unique geographical consideration of this population, given that many ED patients will need to continue care at a site distant from the diagnosis site.

FUNDING

This research was supported by the South African Medical Research Council, the Division of Intramural Research, the National Institute of Allergy and Infectious Diseases, National Institutes of Health, and the Johns Hopkins Center for Global Health.

Health-Related Social Needs Among Emergency Department Patients with HIV

Little research has examined the health-related social needs of emergency department (ED) patients who have HIV. We surveyed a random sample of public hospital ED patients and compared the social needs of patients with and without HIV. Social needs were high among all ED patients, but patients with HIV reported significantly higher levels of food insecurity (65.0% vs. 50.3%, p = 0.01) and homelessness or living doubled up (33.8% vs. 21.0%, p < 0.01) than other patients. Our findings suggest the importance of assessing social needs in ED-based interventions for patients with HIV.

Evaluation of an Emergency Department and Hospital-Based Data Exchange to Improve HIV Care Engagement and Viral Suppression

BACKGROUND

Emergency department (ED) visits and inpatient (IP) admissions may provide an opportunity to reengage poorly engaged people living with HIV and facilitate viral suppression. In 2015, Public Health Seattle and King County partnered with the University of Washington Medicine to implement a real-time data exchange to identify virally unsuppressed people living with HIV seen at the ED/IP hospital and reengage them in HIV care. We evaluated the impact of the data exchange on care engagement and viral suppression.

METHODS

Public Health Seattle and King County received a text alert on weekdays 8 AM to 6 PM for ED/IP patients previously diagnosed with HIV with a most recent viral load ≥200 copies/mL. We compared viral load testing <3 months and viral suppression <6 months after an alert-eligible visit in the 2 years after intervention and the 7 to 30 months before intervention. To account for secular trends, we used difference-in-differences models to compare patients with alert-window visits to patients with visits outside the alert window before and after intervention.

RESULTS

Patients with visits within the alert window in the postintervention period were 1.08 (95% confidence interval [CI], 0.97-1.20) times more likely to have a viral load test within 3 months after an ED visit/IP admission and 1.50 (95% CI, 1.27-1.76) times more likely to achieve viral suppression within 6 months than patients in the preintervention period. However, care engagement (difference-in-differences relative risk, 1.00; 95% CI, 0.84-1.18) and viral suppression (difference-in-differences relative risk, 1.01; 95% CI, 0.84-1.20) trends were similar among patients with visits outside the alert window.

CONCLUSIONS

Real-time data exchange with ED/IP hospitals was associated with improved viral suppression, but not increased care engagement. However, our results may reflect secular trends resulting from diverse interventions, of which ours was only one. More efforts are needed to improve the effectiveness of relinkage interventions guided by real-time data exchange.

Interprofessional collaboration associated with frequency of life-saving links to HIV continuum of care services in the urban environment of Newark, New Jersey

BACKGROUND

HIV continuum of care has been used as a strategy to reduce HIV transmission rates, with timely engagement in HIV testing being the first and most critical step. This study examines interprofessional-collaboration (IPC) after controlling for agency/ provider demographics, provider training and self-efficacy as a significant predictor of how frequently HIV service providers link their clients to HIV testing.

METHODS

Multilevel binary logistic regression analysis was conducted to examine the effects of IPC on links to HIV testing while controlling for demographic and agency information, provider training, and standardized measures of providers' feelings, attitudes, and opinions about IPC. Cross-sectional data from 142 providers in 13 agencies offering treatment and prevention services for HIV and substance-use disorders were collected via a survey.

RESULTS

Those who scored higher on the IPC scale reported significantly higher rates of linkages to HIV testing. Compared to the null model (i.e., no predictor model), the final multilevel binary logistic regression model showed a significantly improved likelihood of linkage to HIV testing by 11.4%, p. < .05. The final model correctly classified 90.2% of links to HIV testing. Providers in agencies with smaller budgets and in agencies offering substance use disorder services were more likely to link clients to HIV testing. Younger providers who received HIV training were also more likely to link clients to HIV testing.

CONCLUSIONS

Findings suggest IPC training as a potential strategy to improve linkages to HIV testing for clients at risk for HIV infection. Future research is recommended to identify specific areas of IPC that might have differential effects on links to HIV testing.

A Clinical Informatics Approach to Reengagement in HIV Care in the Emergency Department

Emergency department visits provide an opportunity to reengage people living with HIV (PLWH) who are out of care. We developed an electronic medical record-based algorithm to identify PLWH in the emergency department and inpatient settings and utilized a trained HIV care navigator to reengage PLWH in these settings. The algorithm identified 420 PLWH during the 14-month observation period. Of these, 56 patients were out of care. Out-of-care individuals were significantly younger than those in care (mean age: 38.6 ± 15.5 vs 46.3 ±14.8 years, P < .001) and more likely to be uninsured (7.1% [4/56] vs 1.8% [6/337], P = .02). Among out-of-care patients, 66.1% (37/56) were reengaged in care. Only 21.4% (12/56) of out-of-care patients had previously received outpatient HIV care at our institution. This project demonstrates the feasibility of using an electronic medical record alert and HIV care navigator to reengage PLWH seeking emergency medical care.

Resource utilization across the continuum of HIV care: An emergency department-based cohort study

BACKGROUND

The objective of this study was to determine the healthcare resource utilization for people living with HIV (PLWH) presenting to the emergency department (ED) across the HIV Care Continuum.

METHODS

This prospective study enrolled PLWH presenting to an urban ED between June 2016 and March 2017. Subjects were categorized as being linked to care, retained in care, on antiretroviral therapy (ART), and virally suppressed (<200 copies/ml). Data on ED visit rates, duration of stay, and hospital admission rates were compared to local metrics.

RESULTS

Overall, 94.3% of 159 enrollees had been linked to care, 75.5% retained in care, 81.1% on ART, and 62.8% virally suppressed. Compared to the general population of the city and of the ED, participants had a higher ED visit rate (3.0 v. 1.2 visits per person-per year) in the past two years, a higher median duration of ED stay (12.6 v. 7.6 h), and a higher hospital admission rate (36.5% v. 24.9%) during their index ED visit. Viral suppression was negatively associated with admission (OR = 0.35, 95% CI: 0.17, 0.72). Forty-eight (30.2%) participants who had at least eight ED visits in the past two years were more likely to have a diagnosed mental health disorder (79.2% v. 62.2%, p=0.036).

CONCLUSIONS

Our results showed that PLWH use more ED resources than the general population and a better engagement in HIV care is linked to lesser ED resource utilization for PLWH, indicating the importance of improved HIV care engagement in healthcare utilization management.

Care Continuum and Postdischarge Outcomes Among HIV-Infected Adults Admitted to the Hospital in Zambia

Background

We characterized the extent of antiretroviral therapy (ART) experience and postdischarge mortality among hospitalized HIV-infected adults in Zambia.

Methods

At a central hospital with an opt-out HIV testing program, we enrolled HIV-infected adults (18+ years) admitted to internal medicine using a population-based sampling frame. Critically ill patients were excluded. Participants underwent a questionnaire regarding their HIV care history and CD4 count and viral load (VL) testing. We followed participants to 3 months after discharge. We analyzed prior awareness of HIV-positive status, antiretroviral therapy (ART) use, and VL suppression (VS; <1000 copies/mL). Using Cox proportional hazards regression, we assessed risk factors for mortality.

Results

Among 1283 adults, HIV status was available for 1132 (88.2%), and 762 (67.3%) were HIV-positive. In the 239 who enrolled, the median age was 36 years, 59.7% were women, and the median CD4 count was 183 cells/mm³. Active tuberculosis or Cryptococcus coinfection was diagnosed in 82 (34.3%); 93.3% reported prior awareness of HIV status, and 86.2% had ever started ART. In the 64.0% with >6 months on ART, 74.4% had VS. The majority (92.5%) were discharged, and by 3 months, 48 (21.7%) had died. Risk of postdischarge mortality increased with decreasing CD4, and there was a trend toward reduced risk in those treated for active tuberculosis.

Conclusions

Most HIV-related hospitalizations and deaths may now occur among ART-experienced vs -naïve individuals in Zambia. Development and evaluation of inpatient interventions are needed to mitigate the high risk of death in the postdischarge period.

A Window Into the HIV Epidemic from a South African Emergency Department

The aim of the study was to describe the HIV care continuum in emergency department (ED) patients in the Eastern Cape region of South Africa. This is a cross-sectional, identity-unlinked serosurvey, whereby discarded/excess samples from all patients who had blood drawn during the study period for routine care and sufficient serum remaining were tested for HIV, hepatitis B virus, and hepatitis C virus infection; HIV viral load (VL); and presence of antiretroviral (ARV) drugs. We also estimated cross-sectional incidence using the Limiting-Antigen Avidity assay and HIV VL. The study was conducted between September and November 2016 at the Frere Hospital Emergency Department in East London, South Africa. The overall HIV prevalence in our study population was 26.9% [95% confidence interval (CI): 25.0-28.8; n = 2,100]. The highest prevalence was observed among females in the 30-39 years age group [60.3% (95% CI: 53.2-67.1)]. HIV prevalence was significantly higher among females compared with males in both the 20-29 years age group and 30-39 years age group (p < .05), but nearly identical to older age groups. ARV drugs were detected in 53.5% (95% CI: 48.1-58.9) of HIV-infected subjects. The frequency of HIV viral suppression (< 1,000 copies/mL) was 48.5% (95% CI: 44.3-52.7), and was not statistically different between males and females (age-adjusted prevalence ratio = 1.15, 95% CI: 0.95-1.39). The HIV incidence rate was estimated to be 2.6% (95% CI: 1.2-3.9). The Frere Hospital ED has an extremely high burden of HIV infection. The detection of ARV drugs and prevalence of viral suppression fall short of the World Health Organization 90-90-90 goals in this population. Furthermore, there were a large number of patients with recent infection in the ED. The ED is a critical venue for testing and linkage to care of high-yield population who are likely missed by current testing and linkage-to-care programs.

Missed Opportunities for Engagement in the Prevention Continuum in a Predominantly Black and Latino Community in New York City

Even though over the last 25 years, the Centers for Disease Control and Prevention recommendations for HIV screening have expanded to encompass population-wide screening in all healthcare settings, and despite the availability of pre-exposure prophylaxis (PrEP), a large proportion of individuals at risk of infection are not linked to prevention care. We evaluated missed opportunities for HIV screening and linkage to PrEP from 2006 through 2017 at an urban academic medical center serving a predominantly minority community. A missed opportunity for HIV screening was a provider visit that did not include HIV testing and occurred within the 12 months before the first positive HIV test. A missed opportunity for prevention was a visit after 2012 that included a negative HIV test, no evaluation for PrEP, and was followed by a positive HIV test. Univariate analysis was performed to assess characteristics of individuals with missed opportunities for screening and prevention services. Between 2006 and 2017, 721 patients were newly diagnosed with HIV. Two hundred forty-seven diagnoses were made in the early period (2006-2010), 236 in the middle period (2010-2013), and 238 in the late period (2014-2017). Overall 60% of patients had at least one missed opportunity, 36% for HIV screening, and 42% for PrEP. There was no improvement in the rates of individuals with a missed opportunity for HIV screening over time. Ending the HIV epidemic will require concerted efforts to bolster access to testing and ensure that all individuals are offered screening, counseling, and linkage to prevention and care services.

The Facility-Level HIV Treatment Cascade: Using a Population Health Tool in Health Care Facilities to End the Epidemic in New York State

Background

The HIV treatment cascade is a tool for characterizing population-level gaps in HIV care, yet most adaptations of the cascade rely on surveillance data that are ill-suited to drive quality improvement (QI) activities at the facility level. We describe the adaptation of the cascade in health care organizations and report its use by HIV medical providers in New York State (NYS).

Methods

As part of data submissions to the NYS Department of Health, sites that provide HIV medical care in NYS developed cascades using facility-generated data. Required elements included data addressing identification of people living with HIV (PLWH) receiving any service at the facility, linkage to HIV medical care, prescription of antiretroviral therapy (ART), and viral suppression (VS). Sites also submitted a methodology report summarizing how cascade data were collected and an improvement plan identifying care gaps.

Results

Two hundred twenty-two sites submitted cascades documenting the quality of care delivered to HIV patients presenting for HIV- or non-HIV-related services during 2016. Of 101 341 PLWH presenting for any medical care, 75 106 were reported as active in HIV programs, whereas 21 509 had no known care status. Sites reported mean ART prescription and VS rates of 94% and 80%, respectively, and 60 distinct QI interventions.

Conclusions

Submission of facility-level cascades provides data on care utilization among PLWH that cannot be assessed through traditional HIV surveillance efforts. Moreover, the facility-level cascade represents an effective tool for identifying care gaps, focusing data-driven improvement efforts, and engaging frontline health care providers to achieve epidemic control.

Implementing emergency department-based HIV testing in a low-resource setting: The value of a structured feasibility assessment tool

Introduction

HIV is a worldwide health problem with continuing high rates of new infections in many parts of the world. This lack of progress in decreasing overall incidence rates has sparked innovative HIV testing strategies, including expansion of testing into the emergency department (ED) setting. Emergency departments have been shown to be high-yield testing venues in the United States and other developed world settings. The feasibility of expanding public health HIV services in the ED in limited-resource countries is unclear.

Methods

We performed a cross-sectional feasibility assessment of a convenience sample of four hospitals in the Eastern Cape, South Africa. We administered three adapted interview tools from a previously field-tested survey instrument at each facility (total of 10 interviews) to gather an overview of the health facility, their HIV counselling and testing services, and their laboratory services.

Results

All of the health facilities had access to basic commodities such as water and electricity. Many had severe human resource limitations and provided care to wide population catchment areas. In addition, there was little integration of HIV testing into current daily ED operations. Hospital staff identified numerous barriers to future ED testing efforts.

Conclusions

Although control of the HIV epidemic requires innovative testing strategies and treatment, specific assessments are warranted on how to incorporate routine HIV testing into an acute care facility like the ED, which typically has many competing priorities. The use of a prospective structured tool incorporating both barriers and benefits can provide valuable field-tested guidance for increased programme planning for HIV testing.

Shifting the HIV Paradigm from Care to Cure: Proceedings from the Caribbean Expert Summit in Barbados, August 2017

The CCAS EXPERT SUMMIT convened an array of international experts in Barbados on August 27-31, 2017 under the theme "From Care to Cure-Shifting the HIV Paradigm." The Caribbean Cytometry & Analytical Society (CCAS) partnered with the Joint United Nations Programme on HIV/AIDS (UNAIDS) to deliver a program that reviewed the advances in antiretroviral therapy and the public health benefits accruing from treatment as prevention. Particular emphasis was placed on reexamining stigma and discrimination through a critical appraisal of whether public health messaging and advocacy had kept pace with the advances in medicine. Persistent fear of HIV driving discriminatory behavior was widely reported in different regions and sectors, including the healthcare profession itself; continued fear of the disease was starkly misaligned with the successes of new medical treatments and progress toward the UNAIDS 90-90-90 targets. The summit therefore adopted the mantra "Test-Treat-Defeat" to help engage with the public in a spirit of optimism aimed at creating a more conducive environment for persons to be tested and treated and, thereby, help reduce HIV disease and stigma at the individual and community levels.

Which Patients in the Emergency Department Should Receive Preexposure Prophylaxis? Implementation of a Predictive Analytics Approach

Emergency Departments (EDs) have the potential to play a crucial role in HIV prevention by identifying and linking high-risk HIV-negative clients to preexposure prophylaxis (PrEP) care, but it is difficult to perform HIV risk assessment for all ED patients. We aimed to develop and implement an electronic risk score to identify ED patients who are potential candidates for PrEP. Using electronic medical record (EMR) data, we used logistic regression to model the outcome of PrEP eligibility. We converted the model into an electronic risk score and incorporated it into the EMR. The risk score is automatically calculated at triage. For patients whose risk score is above a given threshold, an automated electronic alert is sent to an HIV prevention counselor who performs real time HIV prevention counseling, risk assessment, and PrEP linkage as appropriate. The electronic risk score includes the following EMR variables: age, gender, gender of sexual partner, chief complaint, and positive test for sexually transmitted infection in the prior 6 months. A risk score ≥21 has specificity of 80.6% and sensitivity of 50%. In the first 5.5 months of implementation, the alert fired for 180 patients, 34.4% (62/180) of whom were women. Of the 51 patients who completed risk assessment, 68.6% (35/51) were interested in PrEP, 17.6% (9/51) scheduled a PrEP appointment, and 7.8% (4/51) successfully initiated PrEP. The measured number of successful PrEP initiations is likely an underestimate, as it does include patients who initiated PrEP with outside providers or referred acquaintances for PrEP care.

Undiagnosed HIV and HCV Infection in a New York City Emergency Department, 2015

OBJECTIVES

To measure undiagnosed HIV and HCV in a New York City emergency department (ED).

METHODS

We conducted a blinded cross-sectional serosurvey with remnant serum from specimens originally drawn for clinical indications in the ED. Serum was deduplicated and matched to (1) the hospital's electronic medical record and (2) the New York City HIV and HCV surveillance registries for evidence of previous diagnosis before being deidentified and tested for HIV and HCV.

RESULTS

The overall prevalence of HIV was 5.0% (250/4990; 95% confidence interval [CI] = 4.4%, 5.7%); the prevalence of undiagnosed HIV was 0.2% (12/4990; 95% CI = 0.1%, 0.4%); and the proportion of undiagnosed HIV was 4.8% (12/250; 95% CI = 2.5%, 8.2%). The overall prevalence of HCV (HCV RNA ≥ 15 international units per milliliter) was 3.9% (196/4989; 95% CI = 2.8%, 5.1%); the prevalence of undiagnosed HCV was 0.8% (38/4989; 95% CI = 0.3%, 1.3%); and the proportion of undiagnosed HCV was 19.2% (38/196; 95% CI = 11.4%, 27.0%).

CONCLUSIONS

Undiagnosed HCV was more prevalent than undiagnosed HIV in this population, suggesting that aggressive testing initiatives similar to those directed toward HIV should be mounted to improve HCV diagnosis.

HIV testing in a South African Emergency Department: A missed opportunity

BACKGROUND

South Africa has the largest HIV epidemic in the world, with 19% of the global number of people living with HIV, 15% of new infections and 11% of AIDS-related deaths. Even though HIV testing is mandated in all hospital-based facilities in South Africa (SA), it is rarely implemented in the Emergency Department (ED). The ED provides episodic care to large volumes of undifferentiated who present with unplanned injury or illness. Thus, the ED may provide an opportunity to capture patients with undiagnosed HIV infection missed by clinic-based screening programs.

METHODS AND FINDINGS

In this prospective exploratory study, we implemented the National South African HIV testing guidelines (counselor initiated non-targeted universal screening with rapid point of care testing) for 24-hours a day at Frere Hospital in the Eastern Cape from September 1st to November 30th, 2016. The purpose of our study was to quantify the burden of undiagnosed HIV infection in a South African ED setting. Furthermore, we sought to evaluate the effectiveness of the nationally recommended HIV testing strategy in the ED. All patients who presented for care in the ED during the study period, and who were clinically stable and fully conscious, were eligible to be approached by HIV counseling and testing (HCT) staff to receive a rapid point-of-care HIV test. A total of 2355 of the 9583 (24.6%) patients who presented to the ED for care during the study period were approached by the HCT staff, of whom 1714 (72.8%) accepted HIV testing. There was a high uptake of HIV testing (78.6%) among a predominantly male (58%) patient group who mostly presented with traumatic injuries (70.8%). Four hundred (21.6%) patients were HIV positive, including 115 (6.2%) with newly diagnosed HIV infection. The overall prevalence of HIV infection was twice as high in females (29.8%) compared to males (15.4%). Both sexes had a similar prevalence of newly diagnosed HIV infection (6.0% for all females and 6.4% for all males) in the ED.

CONCLUSIONS

Overall there was high HIV testing acceptance by ED patients. A non-targeted testing approached revealed a high HIV prevalence with a significant burden of undiagnosed HIV infection in the ED. Unfortunately, a counselor-driven HIV testing approach fell short of meeting the testing needs in this setting, with over 75% of ED patients not approached by HCT staff.

A systematic review of emergency department based HIV testing and linkage to care initiatives in low resource settings

INTRODUCTION

Only 45% of people currently living with HIV infection in sub-Saharan Africa are aware of their HIV status. Unmet testing needs may be addressed by utilizing the Emergency Department (ED) as an innovative testing venue in low and middle-income countries (LMICs). The purpose of this review is to examine the burden of HIV infection described in EDs in LMICs, with a focus on summarizing the implementation of various ED-based HIV testing strategies.

METHODOLOGY AND RESULTS

We performed a systematic review of Pubmed, Embase, Scopus, Web of Science and the Cochrane Library on June 12, 2016. A three-concept search was employed with emergency medicine (e.g., Emergency department, emergency medical services), HIV/AIDS (e.g., human immunodeficiency virus, acquired immunodeficiency syndrome), and LMIC terms (e.g., developing country, under developed countries, specific country names). The search returned 2026 unique articles. Of these, thirteen met inclusion criteria and were included in the final review. There was a large variation in the reported prevalence of HIV infection in the ED population ranging from to 2.14% in India to 43.3% in Uganda. The proportion HIV positive patients with previously undiagnosed infection ranged from 90% to 65.22%.

CONCLUSION

In the United States ED-based HIV testing strategies have been front and center at curbing the HIV epidemic. The limited number of ED-based studies we observed in this study may represent the paucity of HIV testing in this venue in LMICs. All of the studies in this review demonstrated a high prevalence of HIV infection in the ED and an extraordinarily high percentage of previously undiagnosed HIV infection. Although the numbers of published reports are few, these diverse studies imply that in HIV endemic low resource settings EDs carry a large burden of undiagnosed HIV infections and may offer a unique testing venue.

Trends and Comparisons of Utilization of Emergency Departments Due to Traumatic or Non-Traumatic Causes among the HIV-Positive Population in Taiwan, 2006-2011

It is important that the utilization of emergency departments (EDs) among people living with the human immunodeficiency virus (HIV) be epidemiologically evaluated in order to assess and improve the HIV care continuum. All participants newly-diagnosed with HIV in Taiwan registered in the National Health Insurance Database from 2000 to 2005 were enrolled in this study and followed-up from 2006 to 2011. In total, 3500 participants newly-diagnosed with HIV in 2000–2005 were selected as a fixed-cohort population and followed-up from 2006 to 2011. Overall, 704, 645, 591, 573, 578, and 568 cases made 1322, 1275, 1050, 1061, 1136, and 992 ED visits in 2006, 2007, 2008, 2009, 2010 and 2011, respectively, with an average number of ED visits ranging from 1.75 to 1.98 per person, accounting for 20.1–22.6% of the whole HIV-positive population. Fewer ED visits were due to traumatic reasons, accounting for 19.6–24.4% of all cases. The incidence of traumatic and non-traumatic ED visits among the HIV-positive participants ranged from 7.2–9.3 and 27.0–33.9 per 100 people, respectively. The average direct medical cost of traumatic and non-traumatic ED visits ranged from $89.3–112.0 and $96.6–120.0, respectively. In conclusion, a lower incidence of ED visits for all reasons and fewer ED visits owing to traumatic causes were observed in the population living with HIV in comparison with the general population; however, the direct medical cost of each ED visit owing to both traumatic and non-traumatic causes was greater among those living with HIV than in the general population.

High Feasibility of Empiric HIV Treatment for Patients With Suspected Acute HIV in an Emergency Department

Earlier intervention in acute HIV infection limits HIV reservoirs and may decrease HIV transmission. We developed criteria for empiric antiretroviral therapy (ART) in an emergency department (ED) routine HIV screening program. We assessed the feasibility and willingness of patients with suspected acute HIV infection in the ED to begin ART. A suspected acute HIV infection was defined as a positive HIV antigen antibody combination immunoassay with pending HIV-antibody differentiation test results and HIV RNA viral load. During the study period, there were 16 confirmed cases of acute HIV infection: 11 met our criteria for empiric ART and agreed to treatment, 10 were prescribed ART, and 1 left the ED against medical advice without a prescription for ART. Eight patients completed at least one follow-up visit. Empiric HIV treatment in an ED is feasible, well received by patients, and offers a unique entry point into the HIV care continuum.

Evaluation of a Client-Centered Linkage Intervention for Patients Newly Diagnosed with HIV at an Urban United States LGBT Center: The Linkage to Care Specialist Project

Linkage to care (LTC) is a key element of the HIV care continuum, and a crucial bridge from testing and diagnosis to receipt of antiretroviral therapies and viral suppression. In 2012, the Los Angeles LGBT Center hired a full-time LTC specialist (LTC-S), who developed a unique client-centered approach to LTC. This single-arm demonstration project was designed to systematically evaluate the LTC-S intervention. Individuals who were newly diagnosed with HIV between March 2014 and September 2015 were eligible for enrollment. The LTC-S draws heavily from principles of motivational interviewing and strengths-based case management, helping to normalize fears while guiding clients at a pace that reflects individual needs and resources. These tailored, targeted methods facilitate the rapid development of rapport, enabling the LTC-S to help clients address particular reactions and barriers to care more effectively. Of the 118 newly HIV-diagnosed individuals who enrolled, 111 (94.1%) saw an HIV primary care provider within 3 months of diagnosis; the LTC-S spent an average of 2.1 h working with each participant. Enrolled clients were a racially diverse, urban group composed primarily of young men who have sex with men. The LTC-S intervention was effective in promoting LTC among this sample. Our results demonstrate that client-centered, resiliency-based LTC services can be seamlessly integrated into an existing HIV testing program, thereby increasing the chances that newly diagnosed individuals will link to care.

HIV Prevention and Treatment: The Evolving Role of the Emergency Department

Historically, the role of the emergency physician in HIV care has been constrained to treating sick patients with opportunistic infections and postexposure prophylaxis for occupational exposures. However, advances in HIV care have led to medications that have substantially fewer issues with toxicity and resistance, opening up an exciting new opportunity for emergency physicians to participate in treating the HIV virus itself. With this new role, it is crucial that emergency physicians be familiar with the advances in testing and medications for HIV prevention and treatment. To our knowledge, to date there has not yet been an article addressing this expansion of practice. We have compiled a summary of what the emergency physician needs to know, including misconceptions associated with antiretroviral therapy, medication complexity, toxicity, resistance, and usability. Additionally, we review potential indications for prescribing these drugs in the emergency department, including the role of the emergency physician in postexposure prophylaxis, preexposure prophylaxis, and treatment of acute HIV, as well as how emergency physicians can engage with chronic HIV infection.

Factors associated with patients who prefer HIV self-testing over health professional testing in an emergency department-based rapid HIV screening program

Kiosk-facilitated HIV self-testing has been shown to be accurate and well accepted by emergency department (ED) patients. We investigated factors associated with patients who preferred self-testing over testing performed by health professionals in an ED-based HIV screening program. This opt-in program evaluation studied 332 patients in an inner-city academic ED from February 2012 to April 2012, when a kiosk-based HIV self-testing program was standard of care. The first kiosk in the 2-stage system registered patients and assessed their interest in screening, while the second kiosk gathered demographic and risk factor information and also provided self-testing instructions. Patients who declined to self-test were offered testing by staff. Broad eligibility included patients aged 18-64 years who were not critically ill, English-speaking, able to provide informed consent, and registered during HIV program operational hours. Data were analyzed using descriptive statistical analysis and Chi squared tests; 160 (48.2%) of 332 patients consenting to testing chose to use a kiosk to guide them performing self-testing. Patients aged 25-29 years and those whose primary ED diagnosis was not infectious disease-related were more likely to prefer HIV self-testing (OR = 2.19, 95% CI: 1.17-4.10; OR = 1.79, 95% CI: 1.03-3.12). HIV self-testing in the ED could serve as a complementary testing approach to the conventional modality.

Parallel declines in HIV and hepatitis C virus prevalence, but not in herpes simplex virus type 2 infection: A 10-year, serial cross-sectional study in an inner-city emergency department

BACKGROUND

The Johns Hopkins Hospital Emergency Department (JHHED) has served as an observational window on the HIV epidemic in a socioeconomically depressed, urban population. We previously reported that HIV incidence among JHHED patients is decreasing and that prevalence has declined from 11.4% in 2003-5.6% in 2013.

OBJECTIVES

This study sought to observe temporal trends in hepatitis C virus (HCV) and herpes simplex virus type 2 (HSV-2) seroprevalence, which are surrogate markers for parenteral and sexual risk behavior, respectively.

STUDY DESIGN

Identity unlinked-serosurveys were conducted over 6-8 weeks in the adult JHHED in 2003, 2007, and 2013. Excess sera from 10,274 patients, previously tested for HIV, were assayed for HSV-2 and HCV antibodies.

RESULTS

Overall HCV seroprevalence declined steadily from 22.0% in 2003-13.8% in 2013 (Ptrend<0.01), and was significant by all gender and race strata. Overall HSV-2 prevalence declined from 55.3% in 2003-50.0% in 2013 (Ptrend<0.01), but was non-significant after adjustment for demographics. Among HIV+ individuals<45years of age, there was a significant decrease in the proportion of individuals with HCV co-infection [without HSV-2] (Ptrend=0.02) from 2003 to 2013, however, there was an increase in individuals with HSV-2 co-infection [without HCV] (Ptrend < 0.01).

DISCUSSION

Little change in age-specific HSV-2 prevalence suggests the decrease in HIV prevalence was likely not associated with changes in sexual risk behavior. In addition to clinical interventions, strategies to address sexual health disparities and continued parenteral harm-reduction efforts are needed to further drive the decline in HIV.

Effectiveness of hepatitis B rapid tests toward linkage-to-care: results of a randomized, multicenter study

OBJECTIVES

Worldwide, many infected individuals are unaware of their hepatitis B virus (HBV) status. We evaluated the effectiveness of HBV rapid testing in promoting linkage-to-care.

METHODS

In 2012, volunteers were recruited from five Parisian centers. Participants were randomized 1 : 1 to receive standard serology (S) or rapid testing (VIKIA-HBsAg/Quick Profile anti-HBsAb) with confirmatory serology (R+S). The primary endpoint was percentage of individuals with appropriate linkage-to-care (nonimmunized individuals starting vaccination or HBsAg-positive individuals receiving medical evaluation). The secondary outcomes were percentage receiving HBV-test results and performance of HBV rapid tests.

RESULTS

In total, 995 individuals were screened. Among the HBV-infection groups included in the primary endpoint (n=409), 20 (4.9%) received appropriate linkage-to-care, with no difference between S and R+S groups (5.7 vs. 4.1%, P=0.5). Two of eight HBsAg-positive participants had a medical visit (1/6 and 1/2 in the S and R+S groups, respectively) and 18/401 (4.5%) nonimmunized participants initiated HBV-vaccination (11/205 and 7/196). Factors that tended to be associated with linkage-to-care were female sex, birth country of high HBV prevalence, and extended medical stay. Test results were not obtained in 4.7% of participants, which was significantly higher in the S arm (P=0.02). Both sensitivity and specificity were 100% for the VIKIA-HBsAg rapid test and 94.4 and 80.8%, respectively, for the anti-HBsAb Quick Profile rapid test.

CONCLUSION

Despite a higher proportion of participants obtaining their results in the R+S arm and better performance of anti-HBsAb rapid tests than described previously, we found no evidence that HBV screening based initially on rapid tests leads to increased HBV-vaccination rates or medical evaluation. This strategy should be evaluated in more hard-to-reach populations.

Missed Opportunities for HIV Prophylaxis Among Emergency Department Patients With Occupational and Nonoccupational Body Fluid Exposures

STUDY OBJECTIVE

Exposures to HIV are frequently managed in the emergency department (ED) for assessment and potential initiation of HIV postexposure prophylaxis. Despite established guidelines, it is unclear whether patients with a nonoccupational exposure are managed similarly to patients with an occupational exposure.

METHODS

This retrospective study used an administrative database to identify consecutive patients at a single ED with a discharge diagnosis of "blood or body fluid exposure" without sexual assault from April 1, 2007 to June 30, 2013. Patient exposure details and physician management were ascertained according to predefined guidelines. The primary outcome was the proportion of patients with high-risk exposures who were correctly given HIV prophylaxis; the secondary outcome was the proportion of patients with low-risk exposures who were correctly not given HIV prophylaxis. Other outcomes included the proportion of patients who had a baseline HIV test in the ED, the proportion who followed up with an HIV test within 6 months, and the number of seroconversions in this group. All outcomes were compared between nonoccupational and occupational exposure.

RESULTS

Of 1,972 encounters, 1,358 patients (68.9%) had an occupational exposure and 614 (31.1%) had a nonoccupational exposure. In the occupational exposure group, 190 patients (14.0%) were deemed high risk, with 160 (84.2%; 95% confidence interval [CI] 78.1% to 88.9%) appropriately given prophylaxis. In the nonoccupational exposure group, 287 patients (46.7%) had a high-risk exposure, with 208 (72.5%; 95% CI 66.8% to 77.5%) given prophylaxis, for a difference of 11.7% (95% CI 3.8% to 19.1%). For low-risk exposures, appropriate management of both occupational and nonoccupational exposure was similar (92.4% versus 93.0%). At the index ED visit, 90.5% of occupational exposure patients and 76.7% of nonoccupational exposure patients received HIV testing, for a difference of 13.8% (95% CI 10.1% to 17.7%). At 6 months, 25.4% of patients with an occupational exposure and 35.0% of patients with a nonoccupational exposure had a follow-up test, for a difference of -9.6% (95% CI -14.2% to -5.1%). Of patients who had follow-up testing within 6 months, 4 of 215 (1.9%) in the nonoccupational exposure group tested newly positive for HIV, whereas 0 of 345 (0%) in the occupational exposure group tested positive.

CONCLUSION

For ED patients with blood or body fluid exposures, those with high-risk nonoccupational exposures were not given HIV prophylaxis nearly twice as often as those with high-risk occupational exposure. Although 6-month follow-up testing rates were low, 1.9% of high-risk nonoccupational exposure patients seroconverted.

Comparison of HIV Testing Uptake in an Urban Academic Emergency Department Using Different Testing Assays and Support Systems

Despite 2006 recommendations by the Centers for Disease Control and Prevention for opt-out HIV testing in all healthcare settings, Emergency Department (ED) testing has been limited. We conducted an observational cohort study to assess the impact of two workflow interventions on the proportion of HIV tests ordered in an urban academic ED. First, a 4(th)-generation HIV antigen/antibody combination test replaced the existing assay, and ED staff continued to notify patients of their reactive tests. Six months later, the HIV Rapid Diagnosis Team, composed of an Infectious Diseases (ID) physician and the HIV Advanced Practice Nurse, immediately assisted with disclosure of positive results to the patients and facilitated linkage to outpatient care. The new assay did not change the proportion of HIV tests ordered (0.14-0.11%, χ2, p = 0.2). However, ID support was associated with a statistically significant increase in the proportion of HIV tests ordered (0.14-0.43%, χ2, p < 0.00010) and a nonstatistically significant increase in the proportion of new HIV diagnoses (1.6-6.8%, Fisher exact test = 0.113). Male gender and lack of insurance were associated with a reactive HIV test. Reduction of barriers to linkage to outpatient HIV care through a collaborative relationship between the ED and ID team increased HIV testing and diagnosis. The role of this model as a component of a universal HIV screening program will need to be further assessed.

Moving Beyond Screening: How Emergency Departments Can Help Extinguish the HIV/AIDS Epidemic

While great strides have been made in diagnostic and treatment strategies, human immunodeficiency virus (HIV) remains a major public health epidemic. The Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report article, “Vital Signs: HIV Diagnosis, Care, and Treatment Among Persons Living with HIV – United States, 2011,” highlights current areas of concern regarding HIV diagnosis and care. The CDC estimates that 1.2 million people in the U.S. are living with HIV. Of them, 86% have received a diagnosis (14% remain undiagnosed and unaware), but only 40% are engaged in care and a mere 30% are virally suppressed. Emergency departments (EDs) can play a major role in combatting the HIV epidemic through regular screening and facilitating linkage to chronic HIV care. Universal opt-out screening as recommended by the CDC in 2006 has been shown to be effective but expensive, and has not been widely implemented in EDs nationwide. Cost-effective models and a renewed commitment from ED providers are needed to enhance ED-based HIV containment strategies.

Evaluation of the Centers for Disease Control and Prevention Recommendations for Hepatitis C Virus Testing in an Urban Emergency Department

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recommends 1-time hepatitis C virus (HCV) testing in the 1945-1965 birth cohort, in addition to targeted risk-based testing. Emergency departments (EDs) are key venues for HCV testing because of the population served and success in HIV screening. We determined the burden of undocumented HCV infection in our ED, providing guidance for implementation of ED-based HCV testing.

METHODS

An 8-week seroprevalence study was conducted in an urban ED in 2013. All patients with excess blood collected for clinical purposes were included. Demographic and clinical information including documented HCV infection was obtained from electronic medical records. HCV antibody testing was performed on excess samples.

RESULTS

Of 4713 patients, 652 (13.8%) were HCV antibody positive. Of these, 204 (31.3%) had undocumented HCV infection. Among patients with undocumented infections, 99 (48.5%) would have been diagnosed based on birth cohort testing, and an additional 54 (26.5%) would be identified by risk-based testing. If our ED adhered to the CDC guidelines, 51 (25.0%) patients with undocumented HCV would not have been tested. Given an estimated 7727 unique ED patients with HCV infection in a 1-year period, birth cohort plus risk-based testing would identify 1815 undocumented infections, and universal testing would identify additional 526 HCV-infected persons.

CONCLUSIONS

Birth cohort-based testing would augment identification of undocumented HCV infections in this ED 2-fold, relative to risk-based testing only. However, our data demonstrate that one-quarter of infections would remain undiagnosed if current CDC birth cohort recommendations were employed, suggesting that in high-risk urban ED settings a practice of universal 1-time testing might be more effective.

Improvements in the continuum of HIV care in an inner-city emergency department

OBJECTIVE

The Johns Hopkins Hospital Emergency Department has served as a window on the HIV epidemic for 25 years, and as a pioneer in emergency department-based screening/linkage-to-care (LTC) programs. We document changes in the burden of HIV and HIV care metrics to the evolving HIV epidemic in inner-city Baltimore.

DESIGN/METHODS

We analyzed seven serosurveys conducted on 18 ,144 adult Johns Hopkins Hospital Emergency Department patients between 1987 and 2013 as well as our HIV-screening/LTC program (2007, 2013) for trends in HIV prevalence, cross-sectional annual incidence estimates, undiagnosed HIV, LTC, antiretrovirals treatment, and viral suppression.

RESULTS

HIV prevalence in 1987 was 5.2%, peaked at more than 11% from 1992 to 2003 and declined to 5.6% in 2013. Seroprevalence was highest for black men (initial 8.0%, peak 20.0%, last 9.9%) and lowest for white women. Among HIV-positive individuals, proportion of undiagnosed infection was 77% in 1987, 28% in 1992, and 12% by 2013 (P < 0.001). Cross-sectional annual HIV incidence estimates declined from 2.28% in 2001 to 0.16% in 2013. Thirty-day LTC improved from 32% (2007) to 72% (2013). In 2013, 80% of HIV-positive individuals had antiretrovirals ARVs detected in sera, markedly increased from 2007 (27%) (P < 0.001). Proportion of HIV-positive individuals with viral suppression (<400 copies/ml) increased from 23% (2001) to 59% (2013) (P < 0.001).

CONCLUSION

Emergency department-based HIV testing has evolved from describing the local epidemic to a strategic interventional role, serving as a model for early HIV detection and LTC. Our contribution to community-based HIV-screening and LTC program parallels declines in undiagnosed HIV infection and incidence, and increases in antiretroviral use with associated viral suppression in the community.