Linkage-to-care Methods and Rates in U.S. Emergency Department-based HIV Testing Programs: A Systematic Literature Review Brief Report

Public Health Interventions in the Emergency Department: A Framework for Evaluation

Emergency departments (ED) in the United States serve a dual role in public health: a portal of entry to the health system and a safety net for the community at large. Public health officials often target the ED for public health interventions due to the perception that it is uniquely able to reach underserved populations. However, under time and resource constraints, emergency physicians and public health officials must make calculated decisions in choosing which interventions in their local context could provide maximal impact to achieve public health benefit. We identify how decisions regarding public health interventions are affected by considerations of cost, time, and available personnel, and further consider the role of local community needs, health department goals, and political environment. We describe a sample of ED-based public health interventions and demonstrate how to use a proposed framework to assess interventions. We posit a series of questions and variables to consider: local disease prevalence; ability of the ED to perform the intervention; relative efficacy of the ED vs community partnerships as the primary intervention location; and expected outcomes. In using this framework, clinicians should be empowered to improve the public health in their communities.

HIV in youth prevention in the emergency department initiative: A survey of pediatric emergency medicine providers

BACKGROUND

The incidence of HIV among adolescents remains high, and adolescents are known to participate in sexual behaviors that increase their risk for HIV, such as unprotected sex and sex with multiple partners. HIV pre-exposure prophylaxis (PrEP) has been shown to be effective at preventing HIV when taken daily and is approved by the FDA for use in adolescents. Efforts to screen patients in adult emergency departments and connect them with PrEP services have been validated. We surveyed pediatric emergency medicine (PEM) providers to determine their knowledge of PrEP, prescribing practices, willingness to prescribe, and barriers to a screening protocol in the pediatric emergency department (PED).

METHODS

We administered a survey to a multidisciplinary group of PEM providers to measure knowledge, use, willingness, and implementation barriers to PrEP as well as elements needed for a successful referral system.

RESULTS

A total of 87 responses were included for analysis. While 79.1% of all providers had heard of PrEP, only 14.8% of prescribing providers had ever discussed PrEP with a patient, and none had ever prescribed PrEP. Overall, 76.3% of all providers were knowledgeable about PrEP based on answers to true/false questions, with prescribing providers significantly more likely to be knowledgeable compared to nurses (p = 0.005). Knowledgeable providers had higher willingness scores to refer for PrEP compared to providers who were not knowledgeable. Ninety-two percent of providers felt a PrEP referral process from the PED would be feasible. Creation of an eligibility algorithm and educational materials were the most common efforts providers preferred to make them more likely to refer for PrEP. The most notable barriers perceived by providers included patient noncompliance with therapy (20.9%), acceptance of PrEP discussion among patients and parents (19.8%), and cost of therapy (15.1%).

CONCLUSION

PEM providers are knowledgeable about PrEP but have little experience with discussing or prescribing PrEP. Their willingness to refer for PrEP and anticipated feasibility of a PrEP referral system is encouraging. These results support the need for future educational efforts among PEM providers and creation of referral systems for PrEP services from the PED.

Risk factors for HIV infection at a large urban emergency department: a cross-sectional study

OBJECTIVES

In 2019, the US Preventative Services Task Force released updated guidelines recommending HIV screening in all individuals aged 15-64 years and all pregnant females. In the current study, we aimed to identify risk factors for HIV infection in an emergency department (ED) population.

METHODS

We performed a cross-sectional study that employed a post hoc risk factor analysis of ED patients ≥18 years who were screened for HIV between 27 November 2018 and 26 November 2019, at a single urban, quaternary referral academic hospital. Patients were screened using HIV antigen/antibody testing and diagnoses were confirmed using HIV-1/HIV-2 antibody testing. The outcome of interest was the number of positive HIV tests. Multiple logistic regression models were used to identify risk factors associated with HIV positivity.

RESULTS

14 335 adult patients were screened for HIV (mean age: 43±14 years; 52% female). HIV seroprevalence was 0.7%. Independent risk factors for HIV positivity included male sex (adjusted OR (aOR) 3.1 (95% CI 1.7 to 5.6)), unhoused status (aOR 2.9 (95% CI 1.7 to 4.9)), history of illicit drug use (aOR 1.8 (95% CI 1.04 to 3.13)) and Medicare insurance status (aOR 2.2 (95% CI 1.1 to 4.4)).

CONCLUSIONS

The study ED services a high-risk population with regard to HIV infection. These data support universal screening of ED patients for HIV. Risk factor profiles could improve targeted screening at institutions without universal HIV testing protocols.

HIV Pre-Exposure Prophylaxis in the Emergency Department: A Systematic Review

STUDY OBJECTIVE

Many emergency departments (EDs) have identified the importance of HIV prevention and have implemented steps to screen and offer preexposure prophylaxis (PrEP). The objective of this study was to systematically review existing literature that identifies PrEP eligibility in the ED and summarize outcomes along the PrEP cascade of care (awareness, interest, linkage to treatment, initiation, and retention) for patients in ED.

METHODS

Four databases captured all PrEP-related studies in EDs from January 1, 2013 to January 27, 2022. Data were extracted on study characteristics and outcomes, and study quality was assessed using a modified quality assessment tool by the Effective Public Health Practice Project.

RESULTS

Of the 218 articles, 16 were subjected to full-text review, and 7 met inclusion criteria. Although most studies identified patients who were PrEP eligible using criteria adapted from the 2017 Centers for Disease Control and Prevention PrEP guidelines, the number and time frame for each criterion varied. Six studies reported outcomes on the PrEP cascade of care, showing a relatively high prevalence of awareness and interest but a very low prevalence of linkage and uptake. No studies documented retention in PrEP treatment.

CONCLUSION

Although up to a third of patients in ED assessed in the current study were PrEP eligible, less than half of PrEP-eligible participants had prior knowledge of PrEP, and very few who expressed interest in the ED were ultimately linked to PrEP treatment or initiated PrEP. Future research is necessary to identify strategies to increase PrEP education, interest, and linkage to care from the ED.

Missed opportunities for diagnosis of HIV in the emergency department using non-risk-based testing strategy

Objectives

The objective of this study was to identify the number of missed opportunities (MO) for human immunodeficiency virus (HIV) diagnoses within our emergency departments (EDs) and assess any significant associated patient characteristics. Following current Centers for Disease Control guidelines, an opt-out HIV screening program was implemented in 2 of 7 EDs within a large Southern healthcare system. This study sought to differentiate the risk of MO in opt-out compared to clinician-initiated, risk-based ED screening protocols.

Methods

A retrospective analysis was conducted from August 2019 to March 2022 of adult patients (≥18 years old) screened for HIV, comparing the ED screening method and characterization of all MOs. MO was defined as any ED visit, before HIV seropositivity, that included sexually transmitted infection screening and/or treatment with no HIV screening. Two EDs implemented generalized opt-out screening for all adult patients (>18 years old); whereas, the remaining 5 sites relied on clinician-initiated screening. Patient characteristics associated with an MO were evaluated by χ2, t tests, and multivariable logistic regression.

Results

In total, 19,423 patients were screened for HIV, 142 of who tested positive. Of the 142 HIV-positive individuals, 12 (8.5%) had 1 MO and 3 of 12 (25%) had 2. The proportion of patients with a MO was significantly higher at clinician-initiated EDs as compared opt-out EDs (41.7% vs 13.9%, P = 0.01). After adjusting for demographics, individuals seen at clinician-initiated EDs were more likely to have a MO compared opt-out EDs (adjusted odds ratio, 4.64; 95% confidence interval, 1.18-18.27; P = 0.02).

Conclusion

This novel study highlights the success and overall high positivity (0.7%) of an ED-based opt-out screening program. Taken together, the implementation of generalized opt-out screening within a large Southern healthcare system can rapidly increase overall screening, uncover a surprisingly high positivity rate, and decrease MOs for HIV diagnosis.

Comparison of Targeted and Routine Adolescent HIV Screening in a Pediatric Emergency Department

OBJECTIVES

The aims of the study were (1) to compare targeted and routine HIV screening in a pediatric emergency department (PED) and (2) to compare provider documented HIV risk assessment with adolescent perception of HIV risk assessment conducted during the PED visit.

METHODS

This prospective study ran concurrent to a PED routine HIV screening pilot. Adolescents could be tested for HIV by the PED provider per usual care (targeted testing); if not tested, they were approached for the routine screening pilot. A subset of adolescents completed a questionnaire on HIV risk. χ 2 analysis compared adolescents with targeted testing and routine screening. HIV-tested patients were asked if HIV risk was assessed; κ analysis compared this with documentation in the provider note.

RESULTS

Over 4 months, 107 adolescents received targeted testing and 344 received routine screening. One 14-year-old patient tested positive by routine screening; this adolescent had 2 PED visits without targeted testing within 60 days. Compared with routine screening, adolescents with targeted testing were more likely female (82% vs 57%, P < 0.001), 16 years or older (71% vs 44%, P < 0.001), or had genitourinary/gynecologic concerns (48% vs 6%, P < 0.001). Adolescents with HIV risk factors were missed by targeted testing but received routine screening. Adolescents with documented HIV risk assessment were more likely to receive targeted testing. There was moderate agreement (κ = 0.61) between provider documentation and adolescent perception of HIV risk assessment.

CONCLUSIONS

There are gaps in PED HIV risk assessment and testing, which may miss opportunities to diagnose adolescent HIV. Routine HIV screening addresses these gaps and expands adolescent HIV testing in the PED.

Universal HIV screening in the emergency department: an interrupted time series analysis

We performed a calendar-matched, 12-month, before (November 27, 2017 to November 26, 2018) and after (November 27, 2018 to November 26, 2019) study, to assess the utility of an emergency department-based HIV screening program. There were 710 and 14 335 patients screened for HIV during the pre and post-best practice alert (BPA) periods, respectively, representing more than a 20-fold increase in HIV screening following BPA implementation. Total HIV positive tests increased 5-fold following BPA implementation.

HIV Testing Uptake According to Opt-In, Opt-Out or Risk-Based Testing Approaches: a Systematic Review and Meta-Analysis

Purpose of Review

Improving HIV testing uptake is essential to ending the HIV pandemic. HIV testing approaches can be opt-in, opt-out or risk-based. This systematic review examines and compares the uptake of HIV testing in opt-in, opt-out and risk-based testing approaches.

Recent Findings

There remain missed opportunities for HIV testing in a variety of settings using different approaches: opt-in (a person actively accepts to be tested for HIV), opt-out (a person is informed that HIV testing is routine/standard of care, and they actively decline if they do not wish to be tested for HIV) or risk-based (using risk-based screening tools to focus testing on certain individuals or sub-populations at greater risk of HIV). It is not clear how the approach could impact HIV test uptake when adjusted for other factors (e.g. rapid testing, country-income level, test setting and population tested).

Summary

We searched four databases for studies reporting on HIV test uptake. In total, 18,238 records were screened, and 150 studies were included in the review. Most studies described an opt-in approach (87 estimates), followed by opt-out (76) and risk-based (19). Opt-out testing was associated with 64.3% test uptake (I² = 99.9%), opt-in testing with 59.8% (I² = 99.9%) and risk-based testing with 54.4% (I² = 99.9%). When adjusted for settings that offered rapid testing, country income level, setting and population tested, opt-out testing had a significantly higher uptake (+ 12% (95% confidence intervals: 3–21), p = 0.007) than opt-in testing. We also found that emergency department patients and hospital outpatients had significantly lower HIV test uptake than other populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11904-022-00614-0.

Risk Factors for Syphilis at a Large Urban Emergency Department

BACKGROUND

The prevalence of syphilis is increasing in the United States. The emergency department (ED) is an important setting to screen and treat underserved populations. To tailor testing protocols to the local population, we aimed to identify risk factors for syphilis positivity in ED patients.

METHODS

We performed a retrospective analysis of ED patients who were screened for syphilis between November 2018 and August 2020. Patients were screened for Treponema pallidum antibody using a multiplex flow immunoassay, and positive results were confirmed by rapid plasma reagin or T. pallidum particle agglutination. Risk factors for new syphilis diagnoses were identified using multiple logistic regression.

RESULTS

We screened 1974 patients for syphilis (mean age, 37 ± 16 years; 56% female). We identified 201 patients with new infections without previous treatment. Independent risk factors for a new diagnosis of syphilis included housing status (undomiciled, 23% [60 of 256]; domiciled, 9% [133 of 1559]; adjusted odds ratio [aOR], 1.9 [95% confidence interval {CI}, 1.2-3.0]), history of HIV (positive, 44% [28 of 63]; negative, 9% [173 of 1893]; aOR, 5.8 [95% CI, 3.0-11.2]), tobacco use (positive, 15% [117 of 797]; negative, 4% [29 of 665]; aOR, 2.4 [95% CI, 1.5-3.9]), and illicit drug use (positive, 14% [112 of 812]; negative, 8% [52 of 678]; aOR, 2.2 [95% CI, 1.0-2.5]).

CONCLUSIONS

Undomiciled housing status, history of HIV, history of tobacco use, and history of illicit drug use were independently associated with a new diagnosis of syphilis in the ED. Broadening targeted syphilis screening algorithms beyond sexually transmitted disease-related complaints could help identify new syphilis cases for treatment.

Barriers to Engagement in Opioid Use Disorder Treatment After Buprenorphine Induction

OBJECTIVES

Expanded access to buprenorphine induction, including via emergency departments, increases the likelihood of treatment engagement for patients with opioid use disorder (OUD). However, longer-term retention among these patients remains a challenge. In this study, we aimed to identify barriers to engaging and retaining patients with OUD in care and additional services that might improve retention.

METHODS

We surveyed counselors at an urban safety net addictions treatment clinic.

RESULTS

Twenty-five of 27 (93%) eligible counselors responded. Counselors described patients who were homeless, had no prior treatment history, or lacked health insurance as hardest to retain in treatment. Housing assistance, residential treatment placement, regular access to a phone, and mental health services were thought to be most beneficial for improving retention. Respondents most often reported that screening for services should happen at intake, and almost all respondents agreed that "retention of patients receiving treatment for OUD would improve with a dedicated case manager and/or more coordinated case management services."

CONCLUSIONS

Engagement in OUD treatment would be improved with interventions to mitigate the significant social and psychiatric comorbidities of addiction. Community- and emergency department-initiated buprenorphine is a promising intervention whose full promise cannot be realized without interventions to improve treatment retention.

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.

COVID-19 and beyond: Lessons learned from emergency department HIV screening for population-based screening in healthcare settings

Emergency departments (EDs) have played a major role in the science and practice of HIV population screening. After decades of experience, EDs have demonstrated the capacity to provide testing and linkage to care to large volumes of patients, particularly those who do not otherwise engage the healthcare system. Efforts to expand ED HIV screening in the United States have been accelerated by a collaborative national network of emergency physicians and other stakeholders called EMTIDE (Emergency Medicine Transmissible Infectious Diseases and Epidemics). As the COVID-19 pandemic evolves, EDs nationwide are being tasked with diagnosing and managing COVID-19 in a myriad of capacities, adopting varied approaches based in part on know-how, local disease trends, and the supply chain. The objective of this article is to broadly summarize the lessons learned from decades of ED HIV screening and provide guidance for many analogous issues and challenges in population screening for COVID-19. Over time, and with the accumulated experience from other epidemics, ED screening should develop into an overarching discipline in which the disease in question may vary, but the efficiency of response is increased by prior knowledge and understanding.

How to best conduct universal HIV screening in emergency departments is far from settled

HIV screening in the emergency department (ED), including universal screening irrespective of risk assessments, has shown strong promise in past studies, identifying many new cases of HIV infection among those who lack access to traditional HIV testing services. Yet, over the years a consistent set of challenges and limitations have presented themselves in settings throughout the United States. We review considerations for evaluating and improving the success of ED-based HIV screening programs in the United States.

Prevalence and Temporal Characteristics of Housing Needs in an Urban Emergency Department

Introduction

Our objective was to determine the proportion of patients in our emergency department (ED) who are unhoused or marginally housed and when they typically present to the ED.

Methods

We surveyed patients in an urban, safety-net ED from June–August 2018, using a sampling strategy that met them at all times of day, every day of the week. Patients used two social needs screening tools with additional questions on housing during sampling shifts representing two full weeks. Housing status was determined using items validated for housing stability, including PRAPARE, the Accountable Health Communities Survey, and items from the United States Department of Health and Human Services. Propensity scores estimated differences among respondents and non-respondents.

Results

Of those surveyed, 35% (95% confidence interval [CI], 31–38) identified as homeless and 28% (95% CI, 25–31) as unstably housed. Respondents and non-respondents were similar by propensity score. The average cumulative number of homeless and unstably housed patients arriving per daily 8-hour window peaks at 7 AM, with 46% (95% CI, 29–64) of the daily aggregate of those reporting homelessness and 44% (95% CI, 24–64) with unstable housing presenting over the next eight hours.

Conclusion

The ED represents a low-barrier contact point for reaching individuals experiencing housing challenges, who may interact rarely with other institutions. The current prevalence of homelessness and housing instability among urban ED patients may be substantially higher than reported in historical and national-level statistics. Housing services offered within normal business hours would reach a meaningful number of those who are unhoused or marginally housed

Unique Needs for the Implementation of Emergency Department Human Immunodeficiency Virus Screening in Adolescents

BACKGROUND

The Centers for Disease Control and Prevention (CDC) recommend universal human immunodeficiency virus (HIV) screening starting at 13 years, which has been implemented in many general U.S. emergency departments (EDs) but infrequently in pediatric EDs. We aimed to 1) implement a pilot of routine adolescent HIV screening in a pediatric ED and 2) determine the unique barriers to CDC-recommended screening in this region of high HIV prevalence.

METHODS

This was a prospective 4-month implementation of a routine HIV screening pilot in a convenience sample of adolescents 13 to 18 years at a single pediatric ED, based on study personnel availability. Serum-based fourth-generation HIV testing was run through a central laboratory. Parents were allowed to remain in the room for HIV counseling and testing. Data were collected regarding patient characteristics and HIV testing quality metrics. Comparisons were made using chi-square and Fisher's exact tests. Regression analysis was performed to assess for an association between parent presence at the time of enrollment and adolescent decision to participate in HIV screening.

RESULTS

Over 4 months, 344 of 806 adolescents approached consented to HIV screening (57% female, mean ± SD = 15.1 ± 1.6 years). Adolescents with HIV screening were more likely to be older than those who declined (p = 0.025). Other blood tests were collected with the HIV sample for 21% of adolescents; mean time to result was 105 minutes (interquartile range = 69 to 123) and 79% were discharged before the result was available. Having a parent present for enrollment was not associated with adolescent participation (adjusted odds ratio = 1.07, 95% CI = 0.67 to 1.70). Barriers to testing included: fear of needlestick, time to results, cost, and staff availability. One of 344 tests was positive in a young adolescent with Stage 1 HIV.

CONCLUSIONS

Routine HIV screening in adolescents was able to be implemented in this pediatric ED and led to the identification of early infection in a young adolescent who would have otherwise been undetected at this stage of disease. Addressing the unique barriers to adolescent HIV screening is critical in high-prevalence regions and may lead to earlier diagnosis and treatment in this vulnerable population.

Asymptomatic Adolescent HIV: Identifying a Role for Universal HIV Screening in the Pediatric Emergency Department

Adolescents account for most undiagnosed HIV infections in the United States. Although the Centers for Disease Control and Prevention (CDC) recommends universal HIV screening for all patients ≥13 years, <10% of adolescents have been tested for HIV. To identify earlier opportunities for adolescent HIV prevention and diagnosis in a region of high HIV prevalence, we sought to describe pediatric emergency department (PED) visits made by a retrospective cohort of adolescents who were later diagnosed with HIV as young adults (<25 years) through an adult emergency department (ED) universal HIV screening program. CD4+ count was used to estimate the time of HIV infection before diagnosis and all PED visits in the 10 years before diagnosis were analyzed. Universal HIV screening in the adult ED diagnosed 193 young adults (median 22 years; 90% men; 29% stage 3); 70% had CD4+ at diagnosis that was used to estimate time of infection (mean 3.8 years). Thirty-eight HIV-infected young adults had a total of 109 PED visits in the 10 years before HIV diagnosis. Sexual history was documented in 12% of PED visits and a sexually transmitted infection test was sent in 6%. Ten HIV-infected young adults had 26 PED visits during the time in which they were likely already infected with HIV, each a potential missed opportunity for earlier diagnosis. HIV-infected and at-risk adolescents are underrecognized in PED visits. Implementation of CDC-recommended universal screening may lead to earlier diagnoses and improve outcomes; the PED may also be critical in identifying adolescents eligible for preexposure prophylaxis.

Universal HIV and Birth Cohort HCV Screening in San Diego Emergency Departments

Universal HIV and HCV screening in emergency departments (ED) can reach populations who are less likely to get tested otherwise. The objective of this analysis was to evaluate universal opt-out HIV and HCV screening in two EDs in San Diego. HIV screening for persons aged 13-64 years (excluding persons known to be HIV+ or reporting HIV testing within last 12 months) was implemented using a 4th generation HIV antigen/antibody assay; HCV screening was offered to persons born between 1945 and 1965. Over a period of 16 months, 12,575 individuals were tested for HIV, resulting in 33 (0.26%) new HIV diagnoses, of whom 30 (90%) were successfully linked to care. Universal screening also identified 74 out-of-care for >12-months HIV+ individuals of whom 50 (68%) were successfully relinked to care. Over a one-month period, HCV antibody tests were conducted in 905 individuals with a seropositivity rate of 9.9% (90/905); 61 seropositives who were newly identified or never treated for HCV had HCV RNA testing, of which 31 (51%) resulted positive (3.4% of all participants, including 18 newly identified RNA positives representing 2% of all participants), and 13/31 individuals (42%) were linked to care. The rate of newly diagnosed HCV infections exceeded the rate of newly diagnosed HIV infections by >7-fold, underlining the importance of HCV screening in EDs.

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.

Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study

Background

While antiretroviral therapy (ART) availability for HIV patients has increased dramatically in Uganda, patient linkage to and retention in care remains a challenge. We assessed patterns of engagement in care in 20 Ugandan health facilities with low retention based on national reporting.

Methods

We assessed patient linkage to care (defined as registering for pre-ART or ART care at the facility within 1 month of HIV diagnosis) and 6-month retention in care (having a visit 3-6 months after ART initiation) and associations with patient−/facility-level factors using multivariate logistic regression.

Results

Among 928 newly HIV-diagnosed patients, only 53.0% linked to care within 1 month. Of these, 83.7% linked within 1 week. Among 678 newly initiated ART patients, 14.5% never returned for a follow-up visit at the facility. Retention was 71.7% according to our primary definition but much lower if stricter definitions were used. Most patients were already falling behind appointment schedules at their first ART follow-up (median: 28 days post-initiation vs. recommended 14 days). 27.3% of newly-initiated patients had follow-up appointments scheduled 45+ days apart rather than monthly per national guidelines. Linkage and retention were not strongly correlated with each other within facilities (r_s = 0.06; p = 0.82). Females, adolescents, and patients in rural settings tended to have lower linkage and retention in multivariable-adjusted models.

Conclusions

Linkage support may be most critical immediately after testing positive, as patients are less likely to link over time. More information is needed on reasons for appointment schedules by clinicians and implications on retention.

Trial registration

This study was registered in the Pan African Clinical Trial Registry database (#PACTR201611001756166).

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3042-8) contains supplementary material, which is available to authorized users.

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.

An evaluation of the SD Bioline HIV/syphilis duo test

Many health agencies now recommend routine HIV and syphilis testing for pregnant women and most-at-risk populations such as men who have sex with men. With the increased availability of highly sensitive, low cost rapid point-of-care tests, the ability to meet those recommendations has increased, granting wider access to quick and accurate diagnoses. Using blood specimens collected from a Baltimore City Health Department (BCHD) sexually transmitted infection clinic, we evaluated the SD Bioline HIV/Syphilis Duo, a rapid test that simultaneously detects antibodies to HIV and syphilis and has the potential to further benefit clinics and patients by reducing costs, testing complexity, and patient wait times. SD DUO HIV sensitivity and specificity, when compared to BCHD results, were 91.7 and 99.5%, respectively. SD DUO syphilis sensitivity and specificity, when compared to rapid plasma reagin, were 85.7 and 96.8%, respectively, and 69.7 and 99.7%, respectively, when compared to Treponema pallidum particle agglutination (TPPA). SD DUO syphilis sensitivity and specificity, when compared to a traditional screening algorithm, improved to 92.3 and 100%, respectively, and improved to 72.9 and 99.7%, respectively, when compared to a reverse screening algorithm. The HIV component of the SD DUO performed moderately well. However, results for the SD DUO syphilis component, when compared to TPPA, support the need for further testing and assessment.

Healthcare contacts among patients lost to follow-up in HIV care: review of a large regional cohort utilizing electronic health records

In the United States 40% of HIV patients are lost to follow-up (LTFU) following linkage to HIV care and an estimated 30-61% of new HIV transmissions are attributed to this group. To characterize those LTFU and healthcare contacts they make, we retrospectively analyzed a large regional HIV cohort in Calgary, Canada, utilizing a province-wide electronic health record. Adults engaged in HIV care between January 2010 and August 2014 who had >12 months without HIV clinic contact were identified as LTFU. Of 1928 individuals engaged in care, 176 became LTFU with 64% having no healthcare contacts, 20% receiving HIV care elsewhere, and 16% making non-HIV healthcare contacts. Those LTFU making non-HIV healthcare contacts did so a median of six times (interquartile range 2-8), 76% attending emergency departments (ED). Compared to those retained in care, LTFU patients were younger (median age 43 versus 47 years), had lower CD4⁺ cell counts (median 420 versus 500 × 10⁶/l) and more commonly resided outside of the centralized HIV clinic's city (odds ratio 4.58) (all p < 0.01). Our finding that a majority of those LTFU did not make healthcare contacts suggests that community and HIV clinic-based relinkage programs are needed. For those LTFU who make healthcare contacts enhanced ED-based relinkage programs could engage a majority.