1277. Universal Screening Is Key: Identifying Gaps in Adolescent HIV Infection Diagnosis at Local Pediatric Health System When Compared With Regional Adult Hospital

Abstract Background Undiagnosed sexual partners with HIV infection may contribute to up to 30% of new infections annually. Routine HIV screening of high-risk populations has been shown to be effective and is recommended by the CDC. Despite this recommendation, many adolescents are not screened. The negative impact on the adolescent population from inadequate screening has not been fully quantified. Methods Through a retrospective chart review, the course prior to diagnosis of HIV-infected adolescents diagnosed at Children’s Medical Center Dallas (CMC) and Parkland Hospital (PH, the proximate adult county hospital with a universal HIV screening program) was reviewed. Subjects were included if they had a confirmed, positive HIV test between 13 and 21 years of age, and excluded if they had a previous HIV diagnosis. Inpatient, outpatient, and ED encounters at CMC and PH following the subjects’ 13th birthday and before their HIV diagnosis were quantified. Missed opportunity encounters (MOE) were defined as above encounters where there was no HIV screen performed that took place after the date 3 months following their most recent HIV screen. Data were collated by facility and compared. Results 204 subjects met inclusion criteria: 140 (69%) male, 155 (76%) black, and 87 (43%) followed by CMC. There were 412 total encounters (2.02 per subject) out of which 284 (1.39 per subject) qualified as MOE. Seventy-two subjects had at least one MOE. At the CMC ED, there were 6.7 MOE for every new HIV adolescent diagnosis, compared with PH ED where there were 0.9 (P < 0.01) (Figure 1). Adolescents identified through the PH ED were older (PH, 18.8 years vs. CMC, 16.1 years, P < 0.01) (Figure 2), and had a trend toward a lower CD4 count (PH, 337 cells/m3 vs. CMC, 449 cells/m3, ns). Three adolescents were identified with AIDS (CD4 <200) through HIV screening at PH, vs. 1 at the CMC ED. Conclusion Missed opportunity encounters for HIV screening of adolescents are greater in number in pediatric emergency departments without universal screening programs, when compared with similar adult settings with such a program. Implementing a universal HIV screening protocol at pediatric EDs in HIV endemic areas may help to identify HIV-positive adolescents at younger ages and improve long-term outcomes. Disclosures All authors: No reported disclosures.

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1542. Provider Uptake of Extragenital Screening for Gonorrhea and Chlamydia in Active Duty Air Force Members with Incident HIV Diagnosis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1722 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S770-S771

Author(s):

Christian C Lamb ◽

Joseph Yabes ◽

Shilpa Hakre ◽

Jason Okulicz

Keyword(s):

Primary Care ◽

Hiv Infection ◽

Air Force ◽

Clinical Laboratory ◽

Medical Center ◽

Previous History ◽

Primary Care Providers ◽

Care Providers ◽

National Guidelines ◽

Hiv Diagnosis

Abstract Background The prevalence of Neisseria gonorrhea (GC) and Chlamydia trachomatis (CT) is much higher at extragenital anatomic sites among men who have sex with men (MSM) with HIV infection. National guidelines recommend that all MSM with HIV infection undergo screening for extragenital sexually transmitted infections (EG-STIs), however uptake is low in many primary care settings. We evaluated EG-STI screening by primary care providers (PCPs) for US Air Force (USAF) members with incident HIV infection. Methods All USAF members newly diagnosed with HIV infection who received initial HIV specialty care with Infectious Disease (ID) providers at Brooke Army Medical Center from 2016-2018 (n=98) were included. A retrospective chart review was conducted to evaluate STI screening performed by PCPs within 1 week of HIV diagnosis compared to screening at entry into ID care. Demographic, clinical, laboratory and behavioral risk data were collected. STI screening included GC/CT EG-STIs, urethral GC/CT, syphilis, and hepatitis B and C. Results Patients were predominantly male (97.9%) with a median age of 26 (IQR 23, 32) years at HIV diagnosis (Table 1). A previous history of STIs was reported in 53 (54.1%) patients and the majority of males self-identified as MSM (66.3%) or bisexual (22.5%). The median time from HIV diagnosis to ID evaluation was 26 days (IQR 9, 33). PCPs performed any STI screening in 61 (62.2%) patients (Table 2). EG-STI screening was conducted in 3 (3.1%) patients overall and in (3.4%) MSM/bisexuals. A total of 31 (31.6%) patients had missed STIs; the majority due to EG-STIs of the rectum (71%) and pharynx (21.9%). All EG-STIs would have been missed by urethral GC/CT screening alone. Table 1 Table 2 Conclusion EG-STI screening uptake was low among PCPs evaluating USAF members with incident HIV infection. Underutilization of EG-STI screening can result in missed infections and forward transmission of GC/CT. Barriers to low uptake need to be explored. Continued education and training of PCPs may be necessary to improve uptake of EG-STI screening. Disclosures All Authors: No reported disclosures

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1120. Impact of Training Residents to Improve HIV Screening in a Teaching Hospital in Mexico City

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1306 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S590-S590

Author(s):

Lorena Guerrero-Torres ◽

Isaac Núñez-Saavedra ◽

Yanink Caro-Vega ◽

Brenda Crabtree-Ramírez

Keyword(s):

Emergency Department ◽

Time Series ◽

Hiv Testing ◽

Teaching Hospital ◽

Educational Intervention ◽

Temporal Trends ◽

Hiv Screening ◽

Hiv Diagnosis ◽

Post Intervention ◽

Hiv Test

Abstract Background Among 230,000 people living with HIV in Mexico, 24% are unaware of their diagnosis, and half of newly diagnosed individuals are diagnosed with advanced disease. Early diagnosis is the goal to mitigate HIV epidemic. Missed opportunities may reflect a lack of clinicians’ consideration of HIV screening as part of routine medical care. We assessed whether an educational intervention on residents was effective to 1) improve the knowledge on HIV screening; 2) increase the rate of HIV tests requested in the hospitalization floor (HF) and the emergency department (ED); and 3) increase HIV diagnosis in HF and ED. Methods Internal Medicine and Surgery residents at a teaching hospital were invited to participate. The intervention occurred in August 2018 and consisted in 2 sessions on HIV screening with an expert. A questionnaire was applied before (BQ) and after (AQ) the intervention, which included HIV screening indications and clinical cases. The Institutional Review Board approved this study. Written informed consent was obtained from all participants. BQ and AQ scores were compared with a paired t-test. To evaluate the effect on HIV test rate in the HF and ED, an interrupted time series analysis was performed. Daily rates of tests were obtained from September 2016 to August 2019 and plotted along time. Restricted cubic splines (RCS) were used to model temporal trends. HIV diagnosis in HF and ED pre- and post-intervention were compared with a Fisher’s exact test. A p< 0.05 was considered significant. Results Among 104 residents, 57 participated and completed both questionnaires. BQ score was 79/100 (SD±12) and AQ was 85/100 (SD±8), p< .004. Time series of HIV testing had apparent temporal trends (Fig 1). HIV test rate in the HF increased (7.3 vs 11.1 per 100 episodes) and decreased in the ED (2.6 vs 2.3 per 100 episodes). HIV diagnosis increased in the HF, from 0/1079 (0%) pre-intervention to 5/894 (0.6%) post-intervention (p< .018) (Table 1). Fig 1. HIV test rates. Gray area represents post-intervention period. Table 1. Description of episodes, HIV tests and rates pre- and post-intervention in the Emergency Department and Hospitalization Floor. Conclusion A feasible educational intervention improved residents’ knowledge on HIV screening, achieved maintenance of a constant rate of HIV testing in the HF and increased the number of HIV diagnosis in the HF. However, these results were not observed in the ED, where administrative barriers and work overload could hinder HIV screening. Disclosures All Authors: No reported disclosures

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Techniques' Comparison and Report of the North Carolina Experience

PEDIATRICS ◽

10.1542/peds.83.5.843 ◽

1989 ◽

Vol 83 (5) ◽

pp. 843-848

Author(s):

Thomas R. Kinney ◽

Martha Sawtschenko ◽

Mary Whorton ◽

Jean Shearin ◽

Christy Stine ◽

...

Keyword(s):

North Carolina ◽

Filter Paper ◽

Screening Program ◽

Medical Center ◽

Sample Collection ◽

Capillary Tubes ◽

Blood Samples ◽

Screening Programs ◽

The North ◽

Duke University

Controversy still exists as to the best laboratory method to use to screen newborns for sickle cell disease and other hemoglobinopathies. The proposed methods include hemoglobin electrophoresis, column chromatography, isoelectric focusing, and high performance liquid chromatography. There is also debate concerning the preferred method of sample collection. The proposed methods of sample collection include cord blood or blood obtained from the infant collected in a tube with anticoagulant or on filter paper. We compared hemoglobin electrophoresis patterns from infant blood samples collected in heparinized capillary tubes and on filter paper. This comparison was performed because hemoglobin electrophoresis of dried blood samples collected on filter paper has been advocated as a practical, reliable, and inexpensive method for mass screening programs, although the limitations of this technique have not been explored fully. We also summarize data from the North Carolina Newborn Hemoglobinopathy Screening Program, which relates to the advantages and limitations of hemoglobin electrophoresis from filter paper blood specimens. MATERIALS AND METHODS Specimens Four sets of specimens were used for this study: (1) specimens collected at Duke University Medical Center to compare hemoglobin electrophoresis patterns of hemolysates from filter paper and heparinized capillary tubes, (2) specimens collected by the North Carolina program for hemoglobinopathy screening, (3) specimens routinely collected at Duke University in heparinized capillary tubes for newborn hemoglobinopathy screening, and (4) samples for retesting to examine the error rate of the state program and to confirm screening results compatible with a hemoglobinopathy. Samples for Direct Comparison Between Filter Paper and Heparinized Specimens

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845. Impact of the COVID-19 Pandemic on Routine HIV Screening in an Emergency Department

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab466.1040 ◽

2021 ◽

Vol 8 (Supplement_1) ◽

pp. S513-S513

Author(s):

Elizabeth A Aguilera ◽

Gilhen Rodriguez ◽

Gabriela P Del Bianco ◽

Gloria Heresi ◽

James Murphy ◽

...

Keyword(s):

Emergency Department ◽

Screening Program ◽

Medical Center ◽

Hiv Infections ◽

Hiv Screening ◽

Opt Out ◽

Number Of Patients ◽

Confirmatory Tests ◽

Routine Hiv Screening ◽

The Impact

Abstract Background The Emergency Department (ED) at Memorial Hermann Hospital (MHH) - Texas Medical Center (TMC), Houston, Texas has a long established screening program targeted at detection of HIV infections. The impact of the COVID-19 pandemic on this screening program is unknown. Methods The Routine HIV screening program includes opt-out testing of all adults 18 years and older with Glasgow score > 9. HIV 4th generation Ag/Ab screening, with reflex to Gennius confirmatory tests are used. Pre-pandemic (March 2019 to February 2020) to Pandemic period (March 2020 to February 2021) intervals were compared. Results 72,929 patients visited MHH_ED during the pre-pandemic period and 57,128 in the pandemic period, a 22% decline. The number of patients tested for HIV pre-pandemic was 9433 and 6718 pandemic, a 29% decline. When the pandemic year was parsed into first and last 6 months interval and compared to similar intervals in the year pre pandemic, 39% followed by 16% declines in HIV testing were found. In total, 354 patients were HIV positives, 209, (59%) in the pre-pandemic and 145 (41%) in the pandemic period.The reduction in new HIV infections found was directly proportional to the decline in patients visiting the MHH-ED where the percent of patients HIV positive was constant across intervals (2.21% vs 2.26%). Demographic and outcome characteristics were constant across the compared intervals. Conclusion The COVID -19 pandemic reduced detection of new HIV infections by screening in direct proportion to the reduction in MHH-ED patient visits. The impact of COVID-19 pandemic decreased with duration of the pandemic. Disclosures All Authors: No reported disclosures

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1255. Comparison in AIDS-Related Mortality Between African Americans and Whites with Human Immunodeficiency Virus During the HAART Era

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1118 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S451-S451

Author(s):

Jennifer Cihlar ◽

Carl Fichtenbaum

Keyword(s):

African Americans ◽

Hiv Infection ◽

Medical Center ◽

Statistical Significance ◽

National Database ◽

Attributable Mortality ◽

Hiv Diagnosis ◽

Cd4 Counts ◽

Standard Data ◽

White Patients

Abstract Background Higher death rates have been reported in African American (AA) compared with non-Hispanic whites with HIV infection. However, there are no published studies of attributable mortality by racial and ethnic groups. We evaluated differences in attributable mortality between AA and whites. Methods We conducted a retrospective review of all persons with HIV infection who received care at the University of Cincinnati Medical Center whose deaths were between 1996 and 2017. We abstracted chart data using a standard data tool and identified all deaths reported to the social security national database. Probable cause of death was assigned using the EuroSida CoDe methodology. Primary endpoint was to compare AIDS vs. non-AIDS-related deaths between AA and whites. Results Initial analysis of 588 deaths are reported through 2007 (44% AA and 53% white). The median age at the time of HIV diagnosis was 37 years for AA patients and 36 years for white patients, while median age at the time of death was 43 years for AA and 42 years for whites (P = ns). 16.9% of AA were women, 2.6% were transgender; 10.3% of whites were women and 1% were transgender (P < 0.02). Risk factors for HIV acquisition included: MSM, 61.3% of whites vs. 46.0% AA; heterosexual contact, 11.7% of whites vs. 13.4% for AA; and injection drug use 16.9% white vs. 18.3% AA (P < 0.0001). African Americans had both lower median CD4 counts at the time of diagnosis and within 3–6 months prior to death (167 and 68 cells/mm3, respectively) as compared with whites (214 and 103 cells/mm3, respectively) (P < 0.0001 for both). There was no statistical significance of having AIDS at entry into the practice between AA and whites (P = 0.79). AIDS-related deaths accounted for a larger percentage of overall deaths within white patients (51%) compared with AA patients (40%) (P = 0.03). Conclusion Our data show that while a greater percent of AIDS-related deaths were found in whites vs. AA in the early HAART era, AA patients typically have lower CD4 counts at the time of diagnosis and within 3–6 months prior to death. Future analyses will examine specific attributable mortality, HIV viremia and changes in causes of death over later HAART era. Understanding factors associated with mortality may inform care models to prevent or delay future deaths. Disclosures All authors: No reported disclosures.

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HIV Screening of Surgeons and Dentists: A Cost-Effectiveness Analysis

Infection Control and Hospital Epidemiology ◽

10.1086/646826 ◽

1994 ◽

Vol 15 (10) ◽

pp. 635-645 ◽

Cited By ~ 4

Author(s):

Randall L. Sell ◽

Albert J. Jovell ◽

Joanna E. Siegel

Keyword(s):

Cost Effectiveness ◽

Hiv Transmission ◽

Program Effectiveness ◽

Screening Program ◽

Cost Effective ◽

Hiv Positive ◽

Hiv Screening ◽

Case Scenario ◽

Screening Programs ◽

Voluntary Program

AbstractObjective:To assess the cost-effectiveness of human immunodeficiency virus (HIV) screening strategies of surgeons and dentists.Design:We constructed a model to project costs and HIV transmissions prevented over 15 years for four screening scenarios: 1) one-time voluntary screening, 2) one-time mandatory screening, 3) annual voluntary screening, and 4) annual mandatory screening. One-time screening occurs only in the first year of the program; annual screening occurs once each year. Under mandatory screening, all practitioners are tested and risks of practitioner-to-patient transmission are eliminated for all practitioners testing positive. Voluntary screening assumes 90% of HIV-positive and 50% of HIV-negative practitioners are tested, and risks of transmission in the clinical setting are eliminated for 90% of HIV-positive surgeons and dentists. All costs and benefits are discounted at 5% per annum over 15 years.Results:Using “best-case” scenario assumptions, we find for surgeons that a one-time voluntary screening program would be most cost-effective, at $899,336 for every HIV transmission prevented. For dentists, the one-time voluntary program also is the most cost-effective, at $139,571 per transmission prevented. Annual mandatory programs were least cost-effective for both surgeons and dentists, at $63.3 million and $2.2 million per transmission prevented, respectively.Conclusions:HIV screening of surgeons and dentists ranks among the more expensive medical lifesaving programs, even using liberal assumptions about program effectiveness. Frequency of screening and whether testing is mandatory or voluntary dramatically affect cost per transmission prevented; these features should be considered carefully in designing specific HIV screening programs.

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Universal Implementation of Newborn Screening in India

International Journal of Neonatal Screening ◽

10.3390/ijns6020024 ◽

2020 ◽

Vol 6 (2) ◽

pp. 24 ◽

Cited By ~ 1

Author(s):

Thomas Mookken

Keyword(s):

Newborn Screening ◽

Congenital Hypothyroidism ◽

Universal Screening ◽

Screening Program ◽

Developed Countries ◽

Screening Programs ◽

Successful Program ◽

Personal Experiences ◽

High Incidence ◽

Glucose 6 Phosphate Dehydrogenase

Newborn screening is a successful program in many developed countries. In India, the benefits of dried blood spot screening have been recognized and that screening is slowly gaining traction. There are significant issues standing in the way of universal implementation of a newborn screening program in India: awareness, cost, advocacy, public policy, and politics. Three regional screening programs, Chandigarh, Goa, and Kerala could serve as models for other programs in India. The data for this commentary were based on personal experiences from managing public newborn screening programs, searches on PubMed and Google, and personal interactions with experts in the field. The overwhelming recommendation is to universally screen for congenital hypothyroidism in India, because it is easy and inexpensive to treat, with excellent outcomes. It would also be beneficial to consider screening universally for glucose-6-phosphate dehydrogenase deficiency due to its high incidence and ease of treatment. Finally, sickle cell disease should be screened in those areas in India where it is prevalent due to the costs associated with universal screening. Achieving universal screening is a challenge, and it is very difficult to predict when every baby born in India will be screened for at least congenital hypothyroidism.

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954. Missed opportunities for HIV Screening in the Emergency Department

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1140 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S508-S509

Author(s):

Amanda Hirsch ◽

Christopher F Carpenter

Keyword(s):

Hiv Testing ◽

Transmission Rate ◽

Retrospective Chart Review ◽

The United States ◽

Hiv Screening ◽

Hiv Diagnosis ◽

Missed Opportunities ◽

Hiv Test ◽

Diagnosis Rate

Abstract Background There are 1.14 million people infected with human immunodeficiency virus (HIV) in the United States, and only about 86% are diagnosed. HIV diagnosis is the first step to care and expanded testing is essential to reduce transmission. Individuals with undiagnosed HIV have a transmission rate 3.5 times higher than those aware of their infection. Individuals seeking testing and treatment for sexually transmitted infections (STIs) represent a higher risk population for HIV infection. Despite revised Centers for Disease Control and Prevention (CDC) recommendations to expand HIV testing in healthcare settings, testing remains low. A significant obstacle to expanded testing, especially in emergency departments (EDs), is concern about ensuring appropriate HIV test tracking and follow-up. Methods We performed a retrospective chart review of patients presenting with symptoms of an STI between January 1, 2015 and July 8, 2019 at eight Beaumont Health EDs in Southeast Michigan. De-identified data was collected from the electronic health record (EHR) for patients aged 10 and older who had testing for one or more STIs including gonorrhea, syphilis, and chlamydia. Patients were evaluated for concurrent HIV testing during the encounter, and patients known to be HIV infected were excluded. Results Of 32,640 encounters during which patients not known to be HIV infected were tested for STIs, only 68 (0.21%) included HIV antibody/antigen screening. Of those tested, only one (1.47%) returned reactive. The remaining 67 screenings returned non-reactive. Applying only 10% of this diagnosis rate to the total number of STI encounters suggests an opportunity to diagnose 47 additional individuals; applying 50% of this rate and the corresponding value is 239 individuals. Conclusion These results highlight the need for expanded HIV screening in EDs. Systematic HIV test tracking and follow-up removes this burden from ED providers and enables expanded HIV testing in these settings. Disclosures All Authors: No reported disclosures

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Pragmatic randomized trial of a distress screening program using an effectiveness-implementation hybrid design.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.27_suppl.5 ◽

2019 ◽

Vol 37 (27_suppl) ◽

pp. 5-5

Author(s):

Erin Elizabeth Hahn ◽

Corrine E. Munoz-Plaza ◽

Dana Pounds ◽

Lindsay Joe Lyons ◽

Janet S. Lee ◽

...

Keyword(s):

Randomized Trial ◽

Screening Program ◽

Medical Center ◽

Qualitative Interviews ◽

Audit And Feedback ◽

Implementation Barriers ◽

Distress Screening ◽

Screening Programs ◽

Adaptive Workflow ◽

New Diagnosis

5 Background: Implementation of guideline-recommended distress screening in oncology remains challenging. Evidence suggests that multicomponent care pathways to identify distress severity with algorithm-based referral and management are effective, yet testing of pragmatic implementation in community settings remains limited. We conducted a pragmatic randomized trial of a distress screening program in a large healthcare system to evaluate effectiveness and simultaneously examined implementation outcomes. Methods: We designed a highly pragmatic study per the Pragmatic-Explanatory Continuum Indicator Summary-2 with adaptive workflow design. Randomization was at the medical center level (N=6); eligible patients had a new diagnosis of breast cancer (no exclusions). Eligible patients were offered the distress screening program as part of usual care: PHQ-9 screening, algorithm-based scoring and referral, referral tracking, and audit and feedback of performance data. Control sites had access to the PHQ-9 and scoring algorithm. We compared number screened, distress severity, and referral. We conducted qualitative interviews with stakeholders on implementation barriers and facilitators. Results: We enrolled 1,436 eligible patients; 692 control, 744 intervention. Groups were similar in demographic and tumor characteristics (Table); 80% of patients completed screening at intervention sites vs <1% at control sites. Of those screened at intervention sites, 10% scored in the medium/high range indicating need for referral; 94% received an appropriate referral. We conducted 20 interviews; the program was found to be highly feasible and acceptable. Conclusions: Our pragmatic, adaptive approach resulted in the large majority of patients screened and appropriately referred with a high degree of acceptability and feasibility. Our results can promote more widespread, sustained adoption of effective distress screening programs. Clinical trial information: NCT02941614. [Table: see text]

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Delayed diagnosis of HIV infection in Victoria 1994 to 2006

Sexual Health ◽

10.1071/sh08028 ◽

2009 ◽

Vol 6 (2) ◽

pp. 117 ◽

Cited By ~ 14

Author(s):

Chris Lemoh ◽

Rebecca Guy ◽

Keflemariam Yohannes ◽

Jenny Lewis ◽

Alan Street ◽

...

Keyword(s):

Drug Use ◽

Hiv Infection ◽

Delayed Diagnosis ◽

Injecting Drug Use ◽

Sexual History ◽

Hiv Diagnosis ◽

Male Homosexual ◽

Hiv Test ◽

High Prevalence ◽

Epidemiological Characteristics

Background: The identification of factors associated with delayed diagnosis of HIV infection in Victoria, Australia was the aim of the present study. Methods: Demographic and epidemiological characteristics of cases notified to the Victorian HIV surveillance database between 1 January 1994 and 31 December 2006 were analysed. Delayed diagnosis was defined as: CD4 count below 200 cells mm−3 at HIV diagnosis or diagnosis of AIDS earlier than 3 months after HIV diagnosis. Results: Diagnosis of HIV was delayed in 627 (22.6%) of 2779 cases. Of these, 528 (84.2%) had either a high-risk exposure or were born in a high-prevalence country. The most common exposure was male homosexual contact in 64.3% of cases. Independent risk factors for delayed diagnosis were: older age at diagnosis (30–39 years odds ratio [OR] 2.15, ≥ 50 years OR 7.50, P < 0.001), exposure via routes other than male homosexual sex or injecting drug use (heterosexual sex OR 2.51, P < 0.001, unknown/other route OR 4.24, P < 0.001); birth in Southern/Eastern Europe (OR 2.54), South-east Asia (OR 2.70) or the Horn of Africa/North Africa (OR 3.71, P < 0.001), and male gender (OR 0.47 for females, P < 0.001). Conclusion: Delay in the diagnosis of HIV infection is common in Victoria, but potentially avoidable in the majority of cases. Most people with delayed diagnosis had a history of male homosexual contact, injecting drug use, birth in a high-prevalence country or sexual contact with such individuals. An accurate sexual history, together with knowledge of their country of birth, should identify most individuals who should be offered an HIV test.

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