HIV screening in the health care setting: status, barriers, and potential solutions

Portable spirometer-based pulmonary function test willingness in China: A nationwide cross-sectional study from the "Happy Breathing Program"

BACKGROUND

Understanding willingness to undergo pulmonary function tests (PFTs) and the factors associated with poor uptake of PFTs is crucial for improving early detection and treatment of chronic obstructive pulmonary disease (COPD). This study aimed to understand willingness to undergo PFTs among high-risk populations and identify any barriers that may contribute to low uptake of PFTs.

METHODS

We collected data from participants in the "Happy Breathing Program" in China. Participants who did not follow physicians' recommendations to undergo PFTs were invited to complete a survey regarding their willingness to undergo PFTs and their reasons for not undergoing PFTs. We estimated the proportion of participants who were willing to undergo PFTs and examined the various reasons for participants to not undergo PFTs. We conducted univariable and multivariable logistic regressions to analyze the impact of individual-level factors on willingness to undergo PFTs.

RESULTS

A total of 8475 participants who had completed the survey on willingness to undergo PFTs were included in this study. Out of these participants, 7660 (90.4%) were willing to undergo PFTs. Among those who were willing to undergo PFTs but actually did not, the main reasons for not doing so were geographical inaccessibility (n = 3304, 43.1%) and a lack of trust in primary healthcare institutions (n = 2809, 36.7%). Among the 815 participants who were unwilling to undergo PFTs, over half (n = 447, 54.8%) believed that they did not have health problems and would only consider PFTs when they felt unwell. In the multivariable regression, individuals who were ≤54 years old, residing in rural townships, with a secondary educational level, with medical reimbursement, still working, with occupational exposure to dust, and aware of the abbreviation "COPD" were more willing to undergo PFTs.

CONCLUSIONS

Willingness to undergo PFTs was high among high-risk populations. Policymakers may consider implementing strategies such as providing financial incentives, promoting education, and establishing community-based programs to enhance the utilization of PFTs.

Investigating the Pregnancy and Post-Partum Health Experiences of Women Living with HIV

INTRODUCTION

Pregnancy and the postpartum period is a difficult time for women living with HIV (WLWH) and postpartum engagement with HIV care is often reduced, with implications for health and well-being. We aimed to explore the postpartum health experiences of WLWH in relation to engagement in HIV care.

METHODS

The NESTOR (iNvESTigating the pregnancy and pOst-paRtum health experience of women living with HIV) study was a UK based qualitative semi-structured interview study. 61 eligible women were identified. We used a purposive sampling technique to recruit women with differing levels of engagement in HIV care. Interviews were conducted via telephone or video call. Interviews were audio recorded and fully transcribed. We used a thematic approach for data analysis, and two researchers independently coded the data and established the key themes.

RESULTS

11 of 61 (18%) eligible women participated in the interviews, and the three main themes were 'infant feeding decisions', 'managing the risk of mother to child transmission', and 'managing the knowledge of their HIV status'. These themes offer detailed insights into the significant psychological and emotional challenges these women had experienced, and the practical support from healthcare professionals in both HIV and maternity services that had enabled them to navigate those challenges.

DISCUSSION

There have been life-changing developments in the treatment and care for people living with HIV. However, even in the U = U (undetectable = untransmittable) era, traditional concerns about breastfeeding, risk of transmission to the infant and stigma continue to shape the postpartum experience of WLWH. As these impact on their emotional and psychological wellbeing, support in these areas needs to be prioritised.

Cotesting for Human Immunodeficiency Virus and Sexually Transmitted Infections in the Emergency Department

BACKGROUND

The Centers for Disease Control and Prevention (CDC) and US Preventive Services Task Force (USPSTF) guidelines recommend screening for human immunodeficiency virus (HIV) in patients aged 15 to 65 years, as well as those at increased risk. Patients screened in the emergency department (ED) for gonorrhea (GC) and/or chlamydia represent an increased-risk population. Our aim was to assess compliance with CDC and USPSTF guidelines for HIV testing in a national sample of EDs.

METHODS

We examined data from the 2010 to 2018 Nationwide Emergency Department Sample, which can be used to create national estimates of ED care to query tests for GC, chlamydia, HIV, and syphilis testing. Weighted proportions and 95% confidence intervals (CIs) were reported, and Rao-Scott χ 2 tests were used.

RESULTS

We identified 13,443,831 (weighted n = 3,094,214) high-risk encounters in which GC/chlamydia testing was performed. HIV screening was performed in 3.9% (95% CI, 3.4-4.3) of such visits, and syphilis testing was performed in 2.9% (95% CI, 2.7-3.2). Only 1.5% of patients with increased risk encounters received both HIV and syphilis cotesting.

CONCLUSIONS

Despite CDC and USPSTF recommendations for HIV and syphilis screening in patients undergoing STI evaluation, only a small proportion of patients are being tested. Further studies exploring the barriers to HIV screening in patients undergoing STI assessment in the ED may help inform future projects aimed at increasing guidance compliance.

Changing HCW attitudes: a case study of normalizing HIV service delivery in emergency departments

Background

Delays in the implementation of evidence-based practices are significant and ubiquitous, compromising health outcomes. Resistance to change is a key factor in hindering adoption and integration of new evidence-based interventions. This study seeks to understand the impact of exposure to HIV testing within a research context on provider attitudes towards HIV counselling and testing (HCT) in emergency departments (ED).

Methods

This is a pre-and-post study design measuring the effect of a new ED-based HCT intervention, conducted by lay counsellors, on provider attitudes in Eastern Cape, South Africa. A validated, anonymized, 7-item survey was self-completed by routine care providers (physicians, nurses, and case managers). Questions were scored on a 5-point Likert scale with 5 consistently reflecting a positive attitude. Mean scores were calculated for each question and compared using a two-sample t-test to assess change in sample means for attitudes among providers surveyed before and after the intervention.

Results

A total of 132 surveys were completed across three EDs. Majority of respondents were female (70.5%), 20–29 years old (37.9%), of African race (81.1%), nurses (39.4%), and practicing medicine for 0–4 years (37.9%). Pre-intervention, providers displayed a positive attitude towards ‘the benefit of offering ED-based HCT to patients’ (4.33), ‘the ED offering HCT’ (3.53), ‘all ED patients receiving HCT’ (3.42), ‘concern about patient reaction to HCT’ (3.26), and ‘comfort with disclosing HCT results’ (3.21); and a mildly negative attitude towards ‘only high-risk ED patients receiving HCT’ (2.68), and ‘the burden of offering HCT in a clinical environment’ (2.80). Post-intervention, provider attitudes improved significantly towards ‘all ED patients receiving HCT’ (3.86, p < 0.05), ‘only high-risk ED patients receiving HCT’ (2.30, p < 0.05), ‘the burden of offering HCT in a clinical environment’ (3.21, p < 0.05), and ‘comfort with disclosing HCT results’ (3.81, p < 0.05).

Conclusions

Controlled exposure to new practices with a structured implementation period can shift attitudes beginning a process of practice normalization. In our study, we observed improvements in provider attitudes regarding the benefits of HCT and the burden of offering HCT to all patients in the ED. Research activities may have a role in mitigating resistance to change and supporting intervention adoption.

Aging Love: A Sexual Health Model for Older Adults

Older adults can remain sexually active despite reproductive and sexual changes. Increases in sexual activity are associated with divorce, separation, widowhood, freedom of expression, and freedom from responsibilities. Possibly from misperceptions and/or lack of knowledge and education, some older adults practice poor sexual health behaviours. Health-care practitioners, along with educational and political institutions, hold misperceptions and lack knowledge, education, and training in older adults' sexual health. This article explores older adults' sexual health and the role of nurses, guided by the Health Belief Model and aesthetic knowing, and presents Aging Love: A Photo Series, created to reflect nursing care of older adults' sexual health.

A Collaborative Intervention Between Emergency Medicine and Infectious Diseases to Increase Syphilis and HIV Screening in the Emergency Department

BACKGROUND

Sexually transmitted infections (STIs) are a common reason for evaluation in the emergency department (ED). Given the overlapping risk factors for STIs, patients screened for gonorrhea and chlamydia should be tested for syphilis and HIV. Syphilis and HIV testing rates in the ED have been reported to be low. The study objective was to examine whether collaboration between emergency medicine (EM) and infectious disease (ID) providers improved syphilis and HIV testing in the ED.

METHODS

A multidisciplinary team of EM and ID providers was formed to identify and address barriers to syphilis and HIV testing in the ED. Syphilis, HIV, chlamydia, and gonorrhea testing and infection rates were calculated and compared during 2 time periods: preintervention (January 1, 2012-December 30, 2017) and postintervention (November 1, 2018-November 30, 2019). We also extracted clinical and laboratory data from patients with positive syphilis and HIV results during the study period.

RESULTS

The most commonly cited barrier to syphilis and HIV testing was concern about follow-up of positive results. Compared with the preintervention period, syphilis and HIV testing rates increased significantly in the postintervention period (incidence rate ratios, 30.70 [P < 0.0001] and 28.99 [P < 0.0001] for syphilis and HIV, respectively). The postintervention period was also associated with a significant increase in the identification of patients with positive syphilis and HIV results (incidence rate ratios, 7.02 [P < 0.0001] and 2.34 [P = 0.03], respectively).

CONCLUSIONS

Collaboration between EM and ID providers resulted in a significant increase in syphilis and HIV testing and diagnosis in the ED.

HIV Testing Strategies for Health Departments to End the Epidemic in the U.S

An important goal of the Ending the HIV Epidemic in the U.S. initiative is the timely diagnosis of all people with HIV as early as possible after infection. To end the HIV epidemic, health departments were encouraged to propose new and innovative HIV testing strategies and improve the reach of existing programs. These activities were divided into 3 core strategies: expansion of routine screening in healthcare settings, locally tailored HIV testing initiatives in nonhealthcare settings, and specific efforts to increase the frequency of testing for individuals with increased potential for acquiring HIV. Because HIV testing is such a crucial part of the core activities of the Centers for Disease Control and Prevention's HIV prevention programs, there are many examples of evidence-based programs and best practices for HIV testing in both clinical and nonclinical settings. This article reviews the evidence base for these strategies and some of the activities proposed under the Diagnose pillar to achieve the goal of diagnosing all HIV infections as early as possible. All other Ending the HIV Epidemic in the U.S. activities start with an awareness of HIV status, which is actually the indicator for which most health departments are closest to the proposed targets. There are both proven and emerging approaches to increasing HIV screening and increasing the frequency of HIV screening available. The Ending the HIV Epidemic in the U.S. initiative provides the motivation, the resources, and a coordinated plan to bring them to scale.

Substance use and HIV stage at entry into care among people with HIV

BACKGROUND

Information regarding the impact of substance use on the timing of entry into HIV care is lacking. Better understanding of this relationship can help guide approaches and policies to improve HIV testing and linkage.

METHODS

We examined the effect of specific substances on stage of HIV disease at entry into care in over 5000 persons with HIV (PWH) newly enrolling in care. Substance use was obtained from the AUDIT-C and ASSIST instruments. We examined the association between early entry into care and substance use (high-risk alcohol, methamphetamine, cocaine/crack, illicit opioids, marijuana) using logistic and relative risk regression models adjusting for demographic factors, mental health symptoms and diagnoses, and clinical site.

RESULTS

We found that current methamphetamine use, past and current cocaine and marijuana use was associated with earlier entry into care compared with individuals who reported no use of these substances.

CONCLUSION

Early entry into care among those with substance use suggests that HIV testing may be differentially offered to people with known HIV risk factors, and that individuals with substances use disorders may be more likely to be tested and linked to care due to increased interactions with the healthcare system.

Use of machine learning techniques to identify HIV predictors for screening in sub-Saharan Africa

Aim

HIV prevention measures in sub-Saharan Africa are still short of attaining the UNAIDS 90–90-90 fast track targets set in 2014. Identifying predictors for HIV status may facilitate targeted screening interventions that improve health care. We aimed at identifying HIV predictors as well as predicting persons at high risk of the infection.

Method

We applied machine learning approaches for building models using population-based HIV Impact Assessment (PHIA) data for 41,939 male and 45,105 female respondents with 30 and 40 variables respectively from four countries in sub-Saharan countries. We trained and validated the algorithms on 80% of the data and tested on the remaining 20% where we rotated around the left-out country. An algorithm with the best mean f1 score was retained and trained on the most predictive variables. We used the model to identify people living with HIV and individuals with a higher likelihood of contracting the disease.

Results

Application of XGBoost algorithm appeared to significantly improve identification of HIV positivity over the other five algorithms by f1 scoring mean of 90% and 92% for males and females respectively. Amongst the eight most predictor features in both sexes were: age, relationship with family head, the highest level of education, highest grade at that school level, work for payment, avoiding pregnancy, age at the first experience of sex, and wealth quintile. Model performance using these variables increased significantly compared to having all the variables included. We identified five males and 19 females individuals that would require testing to find one HIV positive individual. We also predicted that 4·14% of males and 10.81% of females are at high risk of infection.

Conclusion

Our findings provide a potential use of the XGBoost algorithm with socio-behavioural-driven data at substantially identifying HIV predictors and predicting individuals at high risk of infection for targeted screening.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01346-2.

Potential Contributions of Clinical and Community Testing in Identifying Persons with Undiagnosed HIV Infection in the United States

BACKGROUND

An estimated 166,155 individuals in the United States have undiagnosed HIV infection. We modeled the numbers of HIV-infected individuals who could be diagnosed in clinical and community settings by broadly implementing HIV screening guidelines.

SETTING

United States.

METHODS

We modeled testing for general population (once lifetime) and high-risk populations (annual): men who have sex with men, people who inject drugs, and high-risk heterosexuals. We used published data on HIV infections, HIV testing, engagement in clinical care, and risk status disclosure.

RESULTS

In clinical settings, about 76 million never-tested low-risk and 2.6 million high-risk individuals would be tested, yielding 36,000 and 55,000 HIV diagnoses, respectively. In community settings, 30 million low-risk and 4.4 million high-risk individuals would be tested, yielding 75,000 HIV diagnoses.

CONCLUSION

HIV testing in clinical and community settings diagnoses similar numbers of individuals. Lifetime and risk-based testing are both needed to substantially reduce undiagnosed HIV.

Using a report card to increase HIV screening in a large primary care group practice

Background

Despite increased efforts to promote HIV screening, a large proportion of the US population have never been tested for HIV.

Objective

To determine whether provider education and personalised HIV screening report cards can increase HIV screening rates within a large integrated healthcare system.

Design

This quality improvement study provided a cohort of primary care physicians (PCPs) a brief educational intervention and personalised HIV screening report cards with quarterly performance data.

Participants

Participants included a volunteer cohort of 20 PCPs in the department of adult and family medicine.

Main measures

Per cent of empaneled patients screened for HIV by cohort PCPs compared with PCPs at the Kaiser Permanente Oakland Medical Center (KPOAK) and the non-Oakland Medical Centers in Northern California region (Kaiser Permanente Northern California (KPNC)).

Key results

Of the 20 participating PCPs, 13 were female and 7 were male. Thirteen were internal medicine and seven family medicine physicians. The average age was 40 years and average practice experience was 9 years after residency. During the 12-month intervention, the estimated increase in HIV screening in the cohort PCP group was 2.6% as compared with 1.9% for KPOAK and 1.8% for KPNC.

Conclusions

These findings suggest that performance-related report cards are associated with modestly increased rates of HIV screening by PCPs.

Critical Ethics: How to Balance Patient Autonomy With Fairness When Patients Refuse Coronavirus Disease 2019 Testing

OBJECTIVES

A cornerstone of our healthcare system's response to the coronavirus disease 2019 pandemic is widespread testing to facilitate both isolation and early treatment. When patients refuse to undergo coronavirus disease testing, they compromise not only just their own health but also the health of those around them. The primary objective of our review is to identify the most ethical way a given healthcare system may respond to a patient's refusal to undergo coronavirus disease 2019 testing.

DATA SOURCES

We apply a systematic approach to a true clinical case scenario to evaluate the ethical merits of four plausible responses to a patient's refusal to undergo coronavirus disease testing. Although our clinical case is anecdotal, it is representative of our experience at our University Tertiary Care Center.

DATA EXTRACTION

Each plausible response in the case is rigorously analyzed by examining relevant stakeholders, facts, norms, and ethical weight both with respect to individuals' rights and to the interests of public health. We use the "So Far No Objections" method as the ethical approach of choice because it has been widely used in the Ethics Modules of the Surgical Council on Resident Education Curriculum of the American College of Surgeons.

DATA SYNTHESIS

Two ethically viable options may be tailored to individual circumstances depending on the severity of the patient's condition. Although unstable patients must be assumed to be coronavirus disease positive and treated accordingly even in the absence of a test, stable patients who refuse testing may rightfully be asked to seek care elsewhere.

CONCLUSIONS

Although patient autonomy is a fundamental principle of our society's medical ethic, during a pandemic we must, in the interest of vulnerable and critically ill patients, draw certain limits to obliging the preferences of noncritically ill patients with decisional capacity.

Exploring the Spatial Determinants of Late HIV Diagnosis in Texas

INTRODUCTION

Despite statewide progress and continuous HIV prevention efforts in Texas, HIV diagnosis at a late stage of infection persists. Diagnosis delay differs in magnitude and spatial distribution. We examined the local spatial relationships of late HIV diagnosis with a selection of variables in an area of Texas that includes large metropolises and high HIV morbidity.

METHODS

We compared regression modeling approaches to study the associations between the regional percentage of late HIV diagnosis from 2011 through 2015, regional measures of poverty, lack of health insurance (uninsurance), educational attainment, unemployment, and the average regional distance from residence to an HIV testing site: global ordinary least squares linear regression, spatial error model, geographically weighted regression, and multiscale geographically weighted regression (MGWR). Cartographic representation of the local R², coefficient estimates, and their t values assisted in the interpretation of results.

RESULTS

The MGWR model resulted in a better fit and identified education and uninsurance as globally fixed predictors, whereas the relationships between late HIV diagnosis and poverty, unemployment, and distance varied spatially. The model performed better in rural areas and in suburban areas of the largest cities than in urban areas.

CONCLUSION

The MGWR results provided local estimates of associations. The results highlight the importance of focusing on a local context. Modeling at the local scale is particularly useful for characterizing relationships between explanatory and dependent variables when the relationships vary spatially. In the context of HIV prevention, relationships that are of local relevance can inform local policy and complement routine screening in clinical settings.

Routine screening for hepatitis C viral infection in patients undergoing elective cranial neurosurgery

OBJECTIVE

Undiagnosed hepatitis C virus (HCV) and HIV in patients present risks of transmission of bloodborne infections to surgeons intraoperatively. Presurgical screening has been suggested as a protocol to protect surgical staff from these pathogens. The authors sought to determine the incidence of HCV and HIV infection in elective craniotomy patients and analyze the cost-effectiveness of universal and risk factor-specific screening for protection of the surgical staff.

METHODS

All patients undergoing elective craniotomy between July 2009 and July 2016 at the National Brain Aneurysm Center who did not refuse screening were included in this study. The authors utilized rapid HCV and HIV tests to screen patients prior to elective surgery, and for each patient who tested positive using the rapid HCV or HIV test, qualitative nucleic acid testing was used to confirm active viral load, and risk factor information was collected. Patients scheduled for nonurgent surgery who were found to be HCV positive were referred to a hepatologist for preoperative treatment. The authors compared risk factors between patients who tested positive on rapid tests, patients with active viral loads, and a random sample of patients who tested negative. The authors also tracked the clinical and material costs of HCV and HIV rapid test screening per patient for cost-effectiveness analysis and calculated the cost per positive result of screening all patients and of screening based on all patient risk factors that differed significantly between patients with and those without positive HCV test results.

RESULTS

The study population of patients scheduled for elective craniotomy included 1461 patients, of whom 22 (1.5%) refused the screening. Of the 1439 patients screened, 15 (1.0%) tested positive for HCV using rapid HCV screening; 9 (60%) of these patients had active viral loads. No patient (0%) tested positive for HIV. Seven (77.8%) of the 9 patients with active viral loads underwent treatment with a hepatologist and were referred back for surgery 3-6 months after sustained virologic response to treatment, but the remaining 2 patients (22.2%) required urgent surgery. Of the 9 patients with active viral loads, 1 patient (11%) had a history of both intravenous drug abuse and tattoos. Two of the 9 patients (22%) had tattoos, and 3 (33%) were born within the age-screening bracket (born 1945-1965) recommended by the Centers for Disease Control and Prevention. Rates of smoking differed significantly (p < 0.001) between patients who had active viral loads of HCV and patients who were HCV negative, and rates of smoking (p < 0.001) and IV drug abuse (p < 0.01) differed significantly between patients who were HCV rapid-test positive and those who were HCV negative. Total screening costs (95% CI) per positive result were $3,877.33 ($2,348.05-$11,119.28) for all patients undergoing HCV rapid screening, $226.29 ($93.54-$312.68) for patients with a history of smoking, and $72.00 ($29.15-$619.39) for patients with a history of IV drug abuse.

CONCLUSIONS

The rate of undiagnosed HCV infection in this patient population was commensurate with national levels. While the cost of universal screening was considerable, screening patients based on a history of smoking or IV drug abuse would likely reduce costs per positive result greatly and potentially provide cost-effective identification and treatment of HCV patients and surgical staff protection. HIV screening found no infected patients and was not cost-effective.

Unexpected Diagnosis

A 74-year-old man presented to the ER with an eight-month history of shortness of breath, cough, anorexia, and weight loss. He had emigrated from sub-Saharan African to the USA, where he was diagnosed and treated for coronary artery disease, heart failure, and stroke; was hospitalized several times; and underwent hernia surgery. Despite the complex care that he received in the USA for many years, the diagnosis of AIDS was continually missed for years, and the patient was eventually diagnosed at the age of 74.

Outcome of an HIV education program for primary care providers: Screening and late diagnosis rates

Background

Late HIV diagnosis remains one of the challenges in combating the epidemic. Primary care providers play an important role in screening for HIV infection. Our study aims to evaluate the relationship between knowledge and barriers to HIV testing and screening outcomes. The impact of an education program for primary care providers, towards improving HIV testing and late diagnosis rates, is also assessed.

Methods

A self-administered questionnaire that was developed within the framework of the European project OptTEST was used to examine HIV knowledge and barriers to HIV testing scores before and after being involved in an HIV education program. A quasi-experimental design with pre- and post-intervention measures was performed to investigate its impact. We performed multivariable logistic regression analysis to assess the relationship between variables for the HIV testing offer.

Results

A total of 20 primary care centers and 454 primary care staff were included. Baseline OptTEST results showed that more knowledgeable staff offered an HIV test more frequently (OR 1.07; CI 95% 1.01–1.13; p = 0.027) and had lower barrier scores (OR 0.89; CI 95% 0.77–0.95; p = 0.005). Nurses had lower scores in knowledge-related items (OR 0.28; CI 95% 0.17–0.46; p<0.001), but higher scores in barrier-related items than physicians (OR 3.28; CI 95% 2.01–5.46; p<0.001). Specific centers with more knowledgeable staff members had a significant association with a greater level of new HIV diagnosis rates (OR 1.61; CI 95% 1.04–2.49; p = 0.032). After the intervention, we found that 12 out of 14 individual questions showed improved scores. In the 6 months after the training program, we similarly found a higher HIV testing rate (OR 1.19; CI 1.02–1.42; p = 0.036).

Conclusions

This study highlights the association between knowledge and barriers to HIV testing, including HIV testing rates. It shows that it is possible to modify knowledge and reduce perceived barriers through educational programs, subsequently improving HIV screening outcomes.

Healthcare providers' knowledge, readiness, prescribing behaviors, and perceived barriers regarding routine HIV testing and pre-exposure prophylaxis in DeLand, Florida

Objectives

Florida ranks highest in the United States among newly diagnosed HIV infections. This ranking reflects the need for investigation of healthcare providers' knowledge, readiness, prescribing behaviors, and perceived barriers to routine HIV testing and pre-exposure prophylaxis.

Methods

We adapted national questionnaires with questions co-developed with Florida Department of Health to form a 25-item instrument. Questionnaires were distributed to the population of eligible healthcare providers in DeLand, Florida.

Results

Results from an approximate 20% response rate that encompasses 12 providers demonstrate baseline findings to inform future studies. For example, 75% of respondents were aware of FL Administrative Code 64D-3.042 that pregnant women should receive HIV testing during first and third trimesters. However, 50% of respondents rarely or never offer tests to pregnant women according to practice guidelines. About 75% of respondents strongly agree or agree with willingness to prescribe pre-exposure prophylaxis to high-risk patients, yet 8.3% always or very often prescribe pre-exposure prophylaxis.

Conclusions

Results convey the importance of and need for greater collaboration between providers and the Florida Department of Health to enhance providers' knowledge, readiness, and, ultimately, behaviors regarding routine HIV testing and pre-exposure prophylaxis prescription.

Sexual risk factors related to lack of HIV-screening in people attending erotic industry shows

The current aim of the fight against the HIV epidemic is to reduce the proportion of missed opportunities for HIV diagnosis. Erotic industry Shows (ES) were deemed to be appropriate events to organize awareness campaigns and to propose HIV Rapid Diagnostic Test (HIV-RDT) to people who are sexually active and likely to engage in unsafe sex practices. In 2015, a cross-sectional study in 4 ES was conducted to document the sexual risk factors associated with HIV-screening test approach and the proportion of positive HIV-RDT. Prevention booths were set up to offer HIV-screening to individuals ≥18 years volunteers for HIV-RDT and to respond to a validated anonymous self-reported questionnaire. In 4 ES, 943 participants were questioned and tested, mainly men (64%), young (mean age 30 years old), living as a couple (63.7%). A large majority (95.1%) reported sexual intercourse over the last year. The mean number of partners was 4.8. About 2/3 had unprotected sex. 37.5% had never been tested and had their first test during this campaign. The 430 participants who reported no previous HIV-testing during the last 5 years more frequently declared heterosexual intercourse (OR: 2.31), identifying as a male (OR: 1.82), having transactional sex (OR: 1.92), living as a couple (OR: 1.67), having fewer sexual partners (OR: 1.06) and being younger (OR = 1.02). Three people (0.32%) were tested positive for the HIV-RDT; linkage with care was ensured for confirmatory test. This innovative and original intervention showed for the first time the usefulness of HIV-screening and awareness campaigns, in fun and commercial backdrop event. Individuals who had never been HIV-tested and who had no intention of doing so before this campaign were reached and engaged. ES are potential new locations to get HIV information and screening, to tackle sexual health-related issues and reflect on sexual risk behaviors.

Doing battle with "the monster:" how high-risk heterosexuals experience and successfully manage HIV stigma as a barrier to HIV testing

Background

Annual HIV testing is recommended for populations at-risk for HIV in the United States, including heterosexuals geographically connected to urban high-risk areas (HRA) with elevated rates of HIV prevalence and poverty, who are primarily African American/Black or Hispanic. Yet this subpopulation of “individuals residing in HRA” (IR-HRA) evidence low rates of regular HIV testing. HIV stigma is a recognized primary barrier to testing, in part due to its interaction with other stigmatized social identities. Guided by social-cognitive and intersectionality theories, this qualitative descriptive study explored stigma as a barrier to HIV testing and identified ways IR-HRA manage stigma.

Methods

In 2012-2014, we conducted in-depth qualitative interviews with 31 adult IR-HRA (74% male, 84% African American/Black) with unknown or negative HIV status, purposively sampled from a larger study for maximum variation on HIV testing experiences. Interviews were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach that was both theory-driven and inductive.

Results

Stigma was a primary barrier to HIV testing among IR-HRA. In the context of an under-resourced community, HIV stigma was experienced as emerging from, and being perpetuated by, health care organizations and educational institutions, as well as community members. Participants noted it was “better not to know” one’s HIV status, to avoid experiencing HIV-related stigma, which could interact with other stigmatized social identities and threaten vital social relationships, life chances, and resources. Yet most had tested for HIV previously. Factors facilitating testing included health education to boost knowledge of effective treatments for HIV; understanding HIV does not necessitate ending social relationships; and tapping into altruism.

Conclusions

In the context of economic and social inequality, HIV stigma operates on multiple, intersecting layers. IR-HRA struggle with an aversion to HIV testing, because adopting another stigmatized status is dangerous. They also find ways to manage stigma to engage in testing, even if not at recommended levels. Findings highlight strategies to reduce HIV stigma at the levels of communities, institutions, and individuals to improve rates of annual HIV testing necessary to eliminate HIV transmission and reduce HIV-related racial and ethnic health disparities among IR-HRA.

How well are U.S. primary care providers assessing whether their male patients have male sex partners?

Identifying patients at-risk for HIV infection, such as men who have sex with men (MSM), is an important step in providing HIV testing and prevention interventions. It is unknown how primary care providers (PCPs) assess MSM status and related HIV-risk factors. We analyzed data from a panel-derived web-based survey for healthcare providers conducted in 2014 to describe how PCPs in the U.S. determined their patients' MSM status. We calculated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to describe PCP characteristics associated with systematically determining MSM status (i.e., PCP used "a patient-completed questionnaire" or "routine verbal review of sex history"). Among the 1008 PCPs, 56% determined MSM status by routine verbal review of sexual history; 41% by patient disclosure; 39% by questions driven by symptoms/history; 23% by using a patient-completed questionnaire, and 9% didn't determine MSM status. PCPs who systematically determined MSM status (n=665; 66%) were more likely to be female (aPR=1.16, CI=1.06-1.26), to be affiliated with a teaching hospital (aPR=1.15, CI=1.06-1.25), to routinely screen all patients aged 13-64 for HIV (aPR=1.29, CI=1.18-1.41), and to estimate that 6% or more of their male patients are MSM (aPR=1.14, CI=1.01-1.30). The majority of PCPs assessed MSM status and HIV risk factors through routine verbal reviews of sexual history. Implementing a systematic approach to identify MSM status and assess risk may allow PCPs to identify more patients needing frequent HIV testing and other preventive services, while mitigating socio-cultural barriers to obtaining such information.

A mixed methods study of HIV-related services in buprenorphine treatment

BACKGROUND

Opioid use disorder (OUD) is a major risk factor in the acquisition and transmission of HIV. Clinical practice guidelines call for the integration of HIV services in OUD treatment. This mixed methods study describes the integration of HIV services in buprenorphine treatment and examines whether HIV services vary by prescribers' medical specialty and across practice settings.

METHODS

Data were obtained via qualitative interviews with buprenorphine experts (n = 21) and mailed surveys from US buprenorphine prescribers (n = 1174). Survey measures asked about screening for HIV risk behaviors at intake, offering HIV education, recommending all new patients receive HIV testing, and availability of on-site HIV testing. Prescribers' medical specialty, practice settings, caseload demographics, and physician demographics were measured. Multivariate models of HIV services were estimated, while accounting for the nesting of physicians within states.

RESULTS

Qualitative interviews revealed that physicians often use injection behaviors as the primary indicator for whether a patient should be tested for HIV. Interviews revealed that HIV-related services were often viewed as beyond the scope of practice among general psychiatrists. Surveys indicated that prescribers screened for an average of 3.2 of 5 HIV risk behaviors (SD = 1.6) at intake. About 62.0% of prescribers delivered HIV education to patients and 53.2% recommended HIV testing to all new patients, but only 32.3% offered on-site HIV testing. Addiction specialists and psychiatrists screened for significantly more HIV risk behaviors than physicians in other specialties. Addiction specialists and psychiatrists were significantly less likely than other physicians to offer on-site testing. Physicians in individual medical practice were significantly less likely to recommend HIV testing and to offer onsite testing than physicians in other settings.

CONCLUSIONS

Buprenorphine treatment providers have not uniformly integrated HIV-related screening, education, and testing services for patients. Differences by medical specialty and practice setting suggest an opportunity for targeting efforts to increase implementation.

Missed opportunities for earlier diagnosis of HIV in patients who presented with advanced HIV disease: a retrospective cohort study

OBJECTIVE

To quantify and characterise missed opportunities for earlier HIV diagnosis in patients diagnosed with advanced HIV.

DESIGN

A retrospective observational cohort study.

SETTING

A central tertiary medical centre in Israel.

MEASURES

The proportion of patients with advanced HIV, the proportion of missed opportunities to diagnose them earlier, and the rate of clinical indicator diseases (CIDs) in those patients.

RESULTS

Between 2010 and 2015, 356 patients were diagnosed with HIV, 118 (33.4%) were diagnosed late, 57 (16%) with advanced HIV disease. Old age (OR=1.45 (95% CI 1.16 to 1.74)) and being heterosexual (OR=2.65 (95% CI 1.21 to 5.78)) were significant risk factors for being diagnosed late. All patients with advanced disease had at least one CID that did not lead to an HIV test in the 5 years prior to AIDS diagnosis. The median time between CID and AIDS diagnosis was 24 months (IQR 10-30). 60% of CIDs were missed by a general practitioner and 40% by a specialist.

CONCLUSIONS

Missed opportunities to early diagnosis of HIV occur in primary and secondary care. Lack of national guidelines, lack of knowledge regarding CIDs and communication barriers with patients may contribute to a late diagnosis of HIV.

Barriers and Facilitators to HIV Testing Among Women

AIM

The purpose of this secondary analysis was to analyze for barriers and facilitators to HIV testing in women attending community health clinics.

INTRODUCTION

The Centers for Disease Control and Prevention (CDC), reported that all women account for 20% or 1 in 5 of new HIV cases (CDC, 2012). Of those new cases in heterosexual women, 5,300 were Black, 1,300 were White, and 1,200 were Hispanic/Latina. The CDC estimated that in 2012 there were 9,268 individuals living with a diagnosis of HIV or AIDS, of which 19% were women.

RESULTS

The existing de-identified data consisted of thirty individual interviews conducted using a semi-structured interview guide was collected as the initial phase of the parent study, "HIV Testing and Women's Attitudes on HIV Vaccine Trials". This secondary analysis addressed the identification of key obstacles to HIV testing and only those related portions of the transcripts were analyzed. The major themes identified were familiarity with testing, stigma, fear, perceived risks, and access to care.

CONCLUSION

The themes implicated the need to further assess women for barriers and facilitators to testing, tailor community based interventions that have the ability to decrease fear and stigma, increase trust in testing methods and offer counseling to positive results.

Effects of Brief Messaging About Undiagnosed Infections Detected through HIV Testing Among Black and Latino Men Who Have Sex With Men in the United States

We examined intent to get tested for HIV infection and use condoms among n = 604 uninfected black and Latino men who have sex with men after receiving brief information messaging that 1 in 10 minority men who have sex with men had HIV infection and did not know it. Information awareness, newness, believability, HIV testing cost willingness, and associated demographic variables were also assessed.

Assessment and improvement of HIV screening rates in a Midwest primary care practice using an electronic clinical decision support system: a quality improvement study

Background

Universal human immunodeficiency virus (HIV) screening remains low in many clinical practices despite published guidelines recommending screening for all patients between ages 13–65. Electronic clinical decision support tools have improved screening rates for many chronic diseases. We designed a quality improvement project to improve the rate of universal HIV screening of adult patients in a Midwest primary care practice using a clinical decision support tool.

Methods

We conducted this quality improvement project in Rochester, Minnesota from January 1, 2014 to December 31, 2014. Baseline primary care practice HIV screening data were acquired from January 1, 2014 to April 30, 2014. We surveyed providers and educated them about current CDC recommended screening guidelines. We then added an HIV screening alert to an existing electronic clinical decision support tool and post-intervention HIV screening rates were obtained from May 1, 2014 to December 31, 2014. The primary quality outcome being assessed was change in universal HIV screening rates.

Results

Twelve thousand five hundred ninety-six unique patients were eligible for HIV screening in 2014; 327 were screened for HIV. 6,070 and 6,526 patients were seen before and after the intervention, respectively. 1.80 % of eligible patients and 3.34 % of eligible patients were screened prior to and after the intervention, respectively (difference of −1.54 % [−2.1 %, −0.99 %], p < 0.0001); OR 1.89 (1.50, 2.38). Prior to the intervention, African Americans were more likely to have been screened for HIV (OR 3.86 (2.22, 6.71; p < 0.001) than Whites, but this effect decreased significantly after the intervention (OR 1.90 (1.12, 3.21; p = 0.03).

Conclusions

These data showed that an electronic alert almost doubled the rates of universal HIV screening by primary care providers in a Midwestern practice and reduced racial disparities, but there is still substantial room for improvement in universal screening practices. Opportunities for universal HIV screening remain abundant, as many providers either do not understand the importance of screening average risk patients or do not remember to discuss it. Alerts to remind providers of current guidelines and help identify screening opportunities can be helpful.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0320-5) contains supplementary material, which is available to authorized users.

Costs of Expanded Rapid HIV Testing in Four Emergency Departments

OBJECTIVE

The HIV Prevention Trials Network (HPTN) 065 trial sought to expand HIV screening of emergency department (ED) patients in Bronx, New York, and Washington, D.C. This study assessed the testing costs associated with different expansion processes and compared them with costs of a hypothetical optimized process.

METHODS

Micro-costing studies were conducted in two participating EDs in each city that switched from point-of-care (POC) to rapid-result laboratory testing. In three EDs, laboratory HIV testing was only conducted for patients having blood drawn for clinical reasons; in the other ED, all HIV testing was conducted with laboratory testing. Costs were estimated through direct observation and interviews to document process flows, time estimates, and labor and materials costs. A hypothetical optimized process flow used minimum time estimates for each process step. National wage and fringe rates and local reagent costs were used to determine the average cost (excluding overhead) per completed nonreactive and reactive test in 2013 U.S. dollars.

RESULTS

Laboratory HIV testing costs in the EDs ranged from $17.00 to $23.83 per completed nonreactive test, and POC testing costs ranged from $17.64 to $37.60; cost per completed reactive test ranged from $89.29 to $123.17. Costs of hypothetical optimized HIV testing with automated process steps were approximately 45% lower for nonreactive tests and 20% lower for reactive tests. The cost per ED visit to conduct expanded HIV testing in each hospital ranged from $1.21 to $3.96.

CONCLUSION

An optimized process could achieve additional cost savings but would require an investment in electronic system interfaces to further automate testing processes.

Why Physicians Don't Ask: Interpersonal and Intrapersonal Barriers to HIV Testing-Making a Case for a Patient-Initiated Campaign

In 2006, the US Centers for Disease Control and Prevention recommended HIV testing for all adolescents and adults aged 13 to 64 in health care settings with a HIV prevalence of at least 0.1%. However, 55% of US adults have never been tested and therefore do not know their HIV status. To understand suboptimal HIV testing rates, this study sought to illuminate interpersonal and intrapersonal physician barriers to HIV testing. One hundred and eighty physicians from health centers in Houston completed a survey based on Cabana's Knowledge, Attitudes and Behaviors model. One-third of the physicians faced at least 1 interpersonal barrier to HIV testing, such as a difference in age or language. Many (41%) physicians faced at least 1 intrapersonal barrier, such as believing their patients would be feeling uncomfortable discussing HIV. Notably, 71% of physicians would prefer their patients ask for the test. A patient-engaging campaign may be an innovative solution to increasing HIV testing and reducing the number of undiagnosed persons.

Correlates of HIV testing among rural African American cocaine users

Andersen's Revised Behavioral Model of Health Services Use (RBM) was used as a framework in this correlational cross-sectional study to examine factors associated with HIV testing among a sample of 251 rural African American cocaine users. All participants reported using cocaine and being sexually active within the past 30 days. Independent variables were categorized according to the RBM as predisposing, enabling, need, or health behavior factors. Number of times tested for HIV (never, one time, two to four times, five or more times) was the outcome of interest. In ordered logistic regression analyses, HIV testing was strongly associated with being female, of younger age (predisposing factors); having been tested for sexually transmitted diseases or hepatitis, ever having been incarcerated in jail or prison (enabling factors); and having had one sex partner the past 30 days (health behavior factor). Other sexual risk behaviors, drug use, health status, and perception of risk were not associated with HIV testing. Our findings confirm the importance of routine testing in all healthcare settings rather than risk-based testing.

Mitigating HIV health disparities: the promise of mobile health for a patient-initiated solution

The HIV epidemic is an ongoing public health problem fueled, in part, by undertesting for HIV. When HIV-infected people learn their status, many of them decrease risky behaviors and begin therapy to decrease viral load, both of which prevent ongoing spread of HIV in the community. Some physicians face barriers to testing their patients for HIV and would rather their patients ask them for the HIV test. A campaign prompting patients to ask their physicians about HIV testing could increase testing. A mobile health (mHealth) campaign would be a low-cost, accessible solution to activate patients to take greater control of their health, especially populations at risk for HIV. This campaign could achieve Healthy People 2020 objectives: improve patient-physician communication, improve HIV testing, and increase use of mHealth.

A Novel Approach to Realizing Routine HIV Screening and Enhancing Linkage to Care in the United States: Protocol of the FOCUS Program and Early Results

BACKGROUND

The United States health care system remains far from implementing the Centers for Disease Control and Prevention's recommendation of routine human immunodeficiency virus (HIV) screening as part of health care for adults. Although consensus for the importance of screening has grown, innovations in implementing routine screening are still lacking. HIV on the Frontlines of Communities in the United States (FOCUS) was launched in 2010 to provide an environment for testing innovative approaches to routine HIV screening and linkage to care.

OBJECTIVE

The strategy of the FOCUS program was to develop models that maximize the use of information systems, fully integrate HIV screening into clinical practice, transform basic perceptions about routine HIV screening, and capitalize on emerging technologies in health care settings and laboratories.

METHODS

In 10 of the most highly impacted cities, the FOCUS program supports 153 partnerships to increase routine HIV screening in clinical and community settings.

RESULTS

From program launch in 2010 through October 2013, the partnerships have resulted in a total of 799,573 HIV tests and 0.68% (5425/799,573) tested positive.

CONCLUSIONS

The FOCUS program is a unique model that will identify best practices for HIV screening and linkage to care.

HIV testing trends: Southeastern Pennsylvania, 2002-2010

There are limited data on HIV testing trends after 2006 when the Centers for Disease Control and Prevention (CDC) introduced opt-out HIV testing with the aims of identifying HIV-infected persons early and linking them to care. We used data from the Southeastern Pennsylvania Household Health Survey between 2002 and 2010 to evaluate HIV testing over time. 50,698 adult (≥18 years) survey respondents were included. HIV testing increased after the CDC recommendations: 42.1% of survey respondents received testing at least once in 2002 versus 51.4% in 2010, p<0.001. Testing trends increased among all demographic groups, but existing differences in testing before 2006 persisted after that year as follows: younger patients, racial/ethnic minorities, patients on Medicaid were all more likely to get tested than their counterparts. Blacks and patients seeking care in community health centers had the fastest rise in HIV testing. The probability of HIV testing in Blacks was 0.56 (95% CI 0.54-0.60) in 2002 and increased to 0.73 (0.70-0.76) by 2010. Patients seeking care in community health centers had a probability of HIV testing of 0.57 (0.47-0.66) in 2002, which increased to 0.69 (0.60-0.77) by 2010. In comparison, patients in private clinics had an HIV testing probability of 0.40 (0.36-0.43) in 2002 compared to 0.47 (0.40-0.54) in 2010. HIV testing is increasing, particularly among ethnic minorities and in community health centers. However, testing remains to be improved in that setting and across all clinic types.

Point-of-Care HIV Testing and Linkage in an Urban Cohort in the Southern US

The Southern states experience the highest rates of HIV and AIDS in the US, and point-of-care (POC) testing outside of primary care may contribute to status awareness in medically underserved populations in this region. To evaluate POC screening and linkage to care at an urban south site, analyses were performed on a dataset of 3,651 individuals from an integrated rapid-result HIV testing and linkage program to describe this test-seeking cohort and determine trends associated with screening, results, and linkage to care. Four percent of the population had positive results. We observed significant differences by test result for age, race and gender, reported risk behaviors, test location, and motivation for screening. The overall linkage rate was 86%, and we found significant differences for clients who were linked to HIV care versus persons whose linkage could not be confirmed with respect to race and gender, location, and motivation. The linkage rate for POC testing that included a comprehensive intake visit and colocated primary care services for in-state residents was 97%. Additional research on integrated POC screening and linkage methodologies that provide intake services at time of testing is essential for increasing status awareness and improving linkage to HIV care in the US.