HIV and Hepatitis C Virus Screening in the Emergency Department and Linkage to Care During COVID-19: Challenges and Solutions

Emergency department claims among Medicare beneficiaries with HIV, STDs, viral hepatitis or tuberculosis before and during the COVID-19 pandemic

BACKGROUND

Changes in emergency department (ED) usage among US Medicare beneficiaries (MB) with fee-for-service claims for HIV, viral hepatitis, sexually transmitted diseases (STDs) or tuberculosis (TB) (HHST) services have not been assessed since the COVID-19 pandemic.

METHODS

During 2006-20, we assessed the annual number of MB with each HHST per 1000 persons with ED claims for all conditions, and changes in demographic and geographic distribution of ED claimants for each HHST condition.

RESULTS

Of all persons who attended an ED for any condition, 10.5 million (27.5%) were MB with ≥1 ED claim in 2006; that number (percentage) increased to 11.0 million (26.7%) in 2019 and decreased to 9.2 million (22.7%) in 2020; < 5 MB per 1000 ED population had HHST ED claims in 2020. The percentage increase in ED claims was higher for MB with STDs than for those with other HHST conditions, including a 10% decrease for MB with TB in 2020.

CONCLUSIONS

Trends in ED usage for HHST conditions were associated with changes in demographic and geographic distribution among MB during 2006-20. Updated ED reimbursement policies and primary care practices among MB might improve prevention, diagnosis and treatment of HHST conditions in the future.

The impact of COVID-19 on the HIV continuum of care: challenges, innovations, and opportunities

INTRODUCTION

In February 2019, the United States (US) launched the Ending the HIV Epidemic (EHE) initiative with emphasis on improving the various steps of the Human Immunodeficiency Virus (HIV) prevention and care continuum. However, in March 2020, the Coronavirus Disease 2019 (COVID-19) pandemic was declared, curtailing efforts to end the epidemic in the US.

AREAS COVERED

To describe the impact of the pandemic on EHE in the US, the authors performed a comprehensive literature review focusing on outcomes at each step of the HIV care continuum. Simultaneously, they identified examples of pandemic-era innovations that may help EHE.

EXPERT OPINION

Numerous studies demonstrated pandemic-related disruptions across the care continuum as well as the impact on preexisting barriers to care among People with HIV (PWH) at higher risk for poor outcomes. As the pandemic progressed, innovative approaches to delivering healthcare and providing essential services emerged, including widespread use of telemedicine, expansion of home-based care, self-collected sexually transmitted infection (STI) and HIV testing, and co-located testing for COVID-19 and HIV/STIs. While the COVID-19 pandemic initially hindered achieving EHE in the US, the ability to be agile, flexible, and creative led to innovation in HIV care delivery that may ultimately assist in meeting EHE goals as we transition into the post-pandemic era.

4th Generation HIV screening in the emergency department: net profit or loss for hospitals?

ABSTRACTThe objective of this study was to determine hospital costs and revenue of universal opt-out HIV ED screening. An electronic medical record (EMR)-directed, automated ED screening program was instituted at an academic medical center in San Diego, California. A base model calculated net income in US dollars for the hospital by comparing annual testing costs with reimbursements using payor mixes and cost variables. To account for differences in payor mixes, testing costs, and reimbursement rates across hospitals in the US, we performed a probabilistic sensitivity analysis. The base model included a total of 12,513 annual 4th generation HIV tests with the following payor mix: 18% Medicare, 9% MediCal, 28% commercial and 8% self-payers, with the remainder being capitated contracts. The base model resulted in a net profit for the hospital. In the probabilistic sensitivity analysis, universal 4th generation HIV screening resulted in a net profit for the hospital in 81.9% of simulations. Universal 4th generation opt-out HIV screening in EDs resulted in a net profit to an academic hospital. Sensitivity analysis indicated that ED HIV screening results in a net-profit for the majority of simulations, with higher proportions of self-payers being the major predictor of a net loss.

Increasing HIV early diagnosis by implementing an automated screening strategy in emergency departments

INTRODUCTION

Late HIV diagnosis is associated with increased morbidity, mortality and risk of onward transmission. Increasing HIV early diagnosis is still a priority. In this observational study with historical control, we determined the impact of an opportunistic HIV screening strategy in the reduction of late diagnosis and missed opportunities for earlier diagnosis.

METHODS

The screening programme was implemented in the emergency department (ED) of the Hospital de Cascais between September 2018 and September 2021. Eligible patients were aged 18-64 years, with no known HIV diagnosis or antibody testing performed in the previous year, and who required blood work for any reason. Out of the 252 153 emergency visits to the ED, we identified 43 153 (17.1%) patients eligible for HIV testing. Among the total population eligible for the screening, 38 357 (88.9%) patients were ultimately tested for HIV. Impact of the ED screening was determined by analysing late diagnosis in the ED and missed opportunities at different healthcare settings 3 years before and 3 years after the start of the ED screening.

RESULTS

After 3 years of automated HIV ED testing, we found 69 newly diagnosed HIV cases (54% male, 39% Portuguese nationals, mean age 40.5 years). When comparing the characteristics of HIV diagnoses made in the ED, we observed a significant reduction in the number of people with late HIV diagnosis before and after implementation of the screening programme (78.4% vs. 39.1%, respectively; p = 0.0291). The mean number of missed opportunities for diagnosis also fell (2.6 vs. 1.5 annual encounters with the healthcare system per patient, p = 0.0997).

CONCLUSIONS

People living with HIV in Cascais and their providers miss several opportunities for earlier diagnosis. Opportunistic screening strategies in settings previously deemed to be unconventional, such as EDs, are feasible and effective in mitigating missed opportunities for timely HIV diagnosis.

Intersecting epidemics: the impact of coronavirus disease 2019 on the HIV prevention and care continua in the United States

OBJECTIVE

To summarize the broad impact of the coronavirus disease 2019 (COVID-19) pandemic on HIV prevention and care in the United States with a focus on the status-neutral HIV care continuum.

DESIGN

We conducted an editorial review of peer-reviewed literature on the topics of HIV-risk behaviors, sexually transmitted illness (STI) and HIV prevalence, HIV prevention and treatment trends, and evolving practices during the COVID-19 pandemic.

METHODS

For relevant literature, we reviewed, summarized, and categorized into themes that span the HIV prevention and care continua, including sexual risk behaviors, mental health, and substance use.

RESULTS

We identified important changes within each component of the HIV care continuum across the United States during the COVID-19 pandemic. Shifts in prevention practices, engagement with care, care provision, medication adherence, testing, and prevalence rates were observed during the pandemic.

CONCLUSION

Although heightened disparities for people at risk for, and living with, HIV were seen during the COVID-19 pandemic, many health systems and clinics have achieved and maintained engagement in HIV prevention and care. This review highlights barriers and innovative solutions that can support durable and accessible health systems through future public health crises.

Sustained Impact of the Coronavirus Disease 2019 Pandemic on Hepatitis C Virus Treatment Initiations in the United States

BACKGROUND

Recent reports indicated declines in hepatitis C virus (HCV) testing during the first half of 2020 in the United States due to coronavirus disease 2019 (COVID-19), but the longer-term impact on HCV testing and treatment is unclear.

METHODS

We obtained monthly state-level volumes of HCV antibody, RNA and genotype testing, and HCV treatment initiation, stratified by age and gender, spanning January 2019 until December 2020 from 2 large national laboratories. We performed segmented regression analysis for each state from a mixed-effects Poisson regression model with month as the main fixed predictor and state as a random intercept.

RESULTS

During the pre-COVID-19 period (January 2019-March 2020), monthly HCV antibody and genotype tests decreased slightly whereas RNA tests and treatment initiations remained stable. Between March and April 2020, there were declines in the number of HCV antibody tests (37% reduction, P < .001), RNA tests (37.5% reduction, P < .001), genotype tests (24% reduction, P = .023), and HCV treatment initiations (31%, P < .001). Starting April 2020 through the end of 2020, there were significant increases in month-to-month HCV antibody (P < .001), RNA (P = .035), and genotype tests (P = .047), but only antibody testing rebounded to pre-COVID-19 levels. HCV treatment initiations remained low after April 2020 throughout the remainder of the year.

CONCLUSIONS

HCV testing and treatment dropped by >30% during April 2020 at the start of the COVID-19 pandemic, but although HCV testing increased again later in 2020, HCV treatment rates did not recover. Efforts should be made to link HCV-positive patients to treatment and revitalize HCV treatment engagement by healthcare providers.

Prevalence of Viral Hepatitis in Unselected, Consecutively Enrolled Patients Hospitalised for SARS-CoV-2

Diagnosing people living with chronic viral hepatitis is challenging due to the absence of symptoms as long as liver decompensated cirrhosis come out. The aim of this retrospective study was to evaluate the prevalence of HBV and/or HCV infections in a non-selected population, hospitalised for SARS-CoV-2 infection in a tertiary care hospital in Northern Italy. During the study period 1,429 patients were admitted to hospital for SARS-CoV-2 infection, serologic tests for HBV and/or HCV were available for 382 (27%) patients and 3 were excluded due to their previous known serologic status. Among 379 patients, 235 (62%) were male, median age was 70 years (range 21–103), 360 (95%) were Caucasian. Among them, 372/379 (98%) were screened for HBsAg, 320/379 (84%) for HBcAb. HBsAg was positive in 2/372 (0.5%, 95% CI 0.0006–0.02) patients (only in one HBV-DNA was performed that was negative), while HBcAb was found positive in 55/320 (17%, 95% CI 0.13–0.22). Among 370/379 (98%) patients screened for HCV, 11/370 (3%, 95% CI 0.02–0.05) had positive HCV-Ab. Five out of 11 (45%) were tested for HCV-RNA that resulted positive in two patients (0.5%, 95% CI 0.0006–0.02). Considering this data, even though the screening was performed in only 27% of study population, a tailored screening in people with known risk factors for hepatitis might be preferable to universal screening in low prevalence areas. Also a prompt diagnostic workout should begin in case of clinical or laboratory suspicion of hepatitis and in those starting immunosuppressive treatments.

A Tale of Three Pandemics – SARS-CoV-2, HCV, and HIV in an Urban Emergency Department in Baltimore, Maryland

Background

We sought to determine the prevalence and sociodemographic and clinical correlates of acute and convalescent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections among emergency department (ED) patients in Baltimore.

Methods

Remnant blood samples from 7450 unique patients were collected over 4 months in 2020 for SARS-CoV-2 antibody (Ab), HCV Ab, and HIV-1/2 antigen and Ab. Among them, 5012 patients were tested by polymerase chain reaction for SARS-CoV-2 based on clinical suspicion. Sociodemographics, ED clinical presentations, and outcomes associated with coinfections were assessed.

Results

Overall, 729 (9.8%) patients had SARS-CoV-2 (acute or convalescent), 934 (12.5%) HCV, 372 (5.0%) HIV infection, and 211 patients (2.8%) had evidence of any coinfection (HCV/HIV, 1.5%; SARS-CoV-2/HCV, 0.7%; SARS-CoV-2/HIV, 0.3%; SARS-CoV-2/HCV/HIV, 0.3%). The prevalence of SARS-CoV-2 (acute or convalescent) was significantly higher in those with HCV or HIV vs those without (13.6% vs 9.1%, P < .001). Key sociodemographic disparities (race, ethnicity, and poverty) and specific ED clinical characteristics were significantly correlated with having any coinfections vs no infection or individual monoinfection. Among those with HCV or HIV, aged 18–34 years, Black race, Hispanic ethnicity, and a cardiovascular-related chief complaint had a significantly higher odds of having SARS-CoV-2 (prevalence ratios: 2.02, 2.37, 5.81, and 2.07, respectively).

Conclusions

The burden of SARS-CoV-2, HCV, and HIV co-pandemics and their associations with specific sociodemographic disparities, clinical presentations, and outcomes suggest that urban EDs should consider implementing integrated screening and linkage-to-care programs for these 3 infections.