Missed Opportunities for HIV Diagnosis

It has been previously shown that patients may present for multiple health issues in the years preceding their initial HIV diagnosis. This retrospective cohort study analyzed the data of patients with a new HIV diagnosis, at Ochsner Health System between January 1, 2011, and December 31, 2012. The primary end point was missed opportunities, the number of healthcare visits these patients made in the 2 years prior to being diagnosed with HIV. The 125 patients in the study cohort had 649 healthcare visits during which an HIV test was not performed. These missed opportunities are the key to capturing the undiagnosed and unaware HIV-positive individual. Primary care is an ideal setting to conduct HIV testing for those who have access to regular health care. However, nontraditional providers should also be encouraged to conduct HIV testing regardless of their ability to provide treatment because evidence shows that knowledge of the diagnosis may change behavior.

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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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Promoting HIV indicator condition-guided testing in hospital settings (PROTEST 2.0): study protocol for a multicentre interventional study

BMC Infectious Diseases ◽

10.1186/s12879-021-06183-8 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Saskia J. Bogers ◽

Maarten F. Schim van der Loeff ◽

Udi Davidovich ◽

Anders Boyd ◽

Marc van der Valk ◽

...

Keyword(s):

The Netherlands ◽

Hiv Testing ◽

Quantitative Methods ◽

Hospital Setting ◽

Audit And Feedback ◽

Interventional Study ◽

Hiv Diagnosis ◽

Post Intervention ◽

Hiv Test ◽

Undiagnosed Hiv

Abstract Background Late presentation remains a key barrier towards controlling the HIV epidemic. Indicator conditions (ICs) are those that are AIDS-defining, associated with a prevalence of undiagnosed HIV > 0.1%, or whose clinical management would be impeded if an HIV infection were undiagnosed. IC-guided HIV testing is an effective strategy in identifying undiagnosed HIV, but opportunities for earlier HIV diagnosis through IC-guided testing are being missed. We present a protocol for an interventional study to improve awareness of IC-guided testing and increase HIV testing in patients presenting with ICs in a hospital setting. Methods We designed a multicentre interventional study to be implemented at five hospitals in the region of Amsterdam, the Netherlands. Seven ICs were selected for which HIV test ratios (proportion of patients with an IC tested for HIV) will be measured: tuberculosis, cervical/vulvar cancer or high-grade cervical/vulvar dysplasia, malignant lymphoma, hepatitis B and C, and peripheral neuropathy. Prior to the intervention, a baseline assessment of HIV test ratios across ICs will be performed in eligible patients (IC diagnosed January 2015 through May 2020, ≥18 years, not known HIV positive) and an assessment of barriers and facilitators for HIV testing amongst relevant specialties will be conducted using qualitative (interviews) and quantitative methods (questionnaires). The intervention phase will consist of an educational intervention, including presentation of baseline results as competitive graphical audit and feedback combined with discussion on implementation and opportunities for improvement. The effect of the intervention will be assessed by comparing HIV test ratios of the pre-intervention and post-intervention periods. The primary endpoint is the HIV test ratio within ±3 months of IC diagnosis. Secondary endpoints are the HIV test ratio within ±6 months of diagnosis, ratio ever tested for HIV, HIV positivity percentage, proportion of late presenters and proportion with known HIV status prior to initiating treatment for their IC. Discussion This protocol presents a strategy aimed at increasing awareness of the benefits of IC-guided testing and increasing HIV testing in patients presenting with ICs in hospital settings to identify undiagnosed HIV in Amsterdam, the Netherlands. Trial registration Dutch trial registry: NL7521. Registered 14 February 2019.

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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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Late diagnosis of HIV: A lookback on cases in North Cumbria

International Journal of STD & AIDS ◽

10.1177/0956462419848867 ◽

2019 ◽

Vol 30 (11) ◽

pp. 1124-1126

Author(s):

B Khalifeh ◽

M Phillips ◽

E Barton

Keyword(s):

Catchment Area ◽

Late Diagnosis ◽

Hiv Diagnosis ◽

Missed Opportunities ◽

Unexplained Weight Loss ◽

Hiv Test ◽

High Prevalence ◽

Low Prevalence ◽

Single Figure ◽

Rural Catchment

Late diagnosis of HIV remains a threat to personal and public health – both increasing the morbidity and mortality of the person and also increasing the chance of unknowingly transmitting HIV. Many HIV testing initiatives, including those of the British HIV Association (BHIVA), focus on levels of high prevalence (greater than 2:1000). However, late diagnosis can be an issue in areas of low prevalence – areas which can be less densely populated and in some cases classified as rural. In our rural catchment area, late diagnosis is an issue with 67% diagnosed late in 2015 (which is skewed by the single figure diagnoses). This lookback examined the number of missed opportunities for HIV diagnosis over a seven-year period and found that where diagnoses were made late in the context of a person having previously presented for care, unexplained weight loss, blood dyscrasias and lymphadenopathy were the most common presentations that could have triggered a HIV test.

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Post-test comparison of HIV test knowledge and changes in sexual risk behaviour between clients accessing HIV testing online versus in-clinic

Sexually Transmitted Infections ◽

10.1136/sextrans-2018-053652 ◽

2019 ◽

Vol 95 (2) ◽

pp. 102-107 ◽

Cited By ~ 3

Author(s):

Travis Salway ◽

Kimberly Thomson ◽

Darlene Taylor ◽

Devon Haag ◽

Elizabeth Elliot ◽

...

Keyword(s):

Sexual Health ◽

Condom Use ◽

Hiv Testing ◽

Sexual Risk ◽

Risk Behaviour ◽

Health Clinic ◽

Sexual Risk Behaviour ◽

Missed Opportunities ◽

Hiv Test ◽

Post Test

ObjectiveInternet-based HIV testing offers the potential to address privacy-related barriers to testing and increase frequency of testing but may result in missed opportunities related to sexual health education and prevention that typically occur in face-to-face encounters. In this study, we assessed the HIV test knowledge and sexual risk behaviour of clients testing for HIV through GetCheckedOnline, an internet-based sexually transmitted and bloodborne infection testing platform inclusive of HIV testing, in comparison to clients testing through a large sexual health clinic.MethodsWe concurrently recruited GetCheckedOnline clients and clinic clients from Vancouver, Canada, over the course of a 10-month period during 2015–2016. Participants completed baseline and 3-month questionnaires, anonymous and online. A six-item score was used to estimate knowledge of HIV test concepts typically conveyed during an HIV pretest encounter in a clinic. We used multiple regression to estimate associations between testing modality (online vs clinic based) and two outcomes—HIV test knowledge and change in condom use pre/post-test—with adjustment for relevant background factors.ResultsAmong 352 participants, online testers demonstrated higher HIV post-test knowledge than clinic-based testers (mean score 4.65/6 vs 4.09/6; p<0.05); this difference was reduced in adjusted analysis (p>0.05). Men who have sex with men, clients with a university degree, those who have lived in Canada >10 years and English speakers had higher HIV post-test knowledge (p<0.05). Eighteen per cent of online testers and 10% of clinic-based testers increased condom use during the 3 months post-test (p>0.05).ConclusionsIn this comparative study between online and clinic-based testers, we found no evidence of decreased HIV test knowledge or decreased condom use following HIV testing through GetCheckedOnline. Our findings suggest that with careful design and attention to educational content, online testing services may not lead to missed opportunities for HIV education and counselling.

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Missed Opportunities for Human Immunodeficiency Virus (HIV) Testing During Injection Drug Use–Related Healthcare Encounters Among a Cohort of Persons Who Inject Drugs With HIV Diagnosed During an Outbreak—Cincinnati/Northern Kentucky, 2017–2018

Clinical Infectious Diseases ◽

10.1093/cid/ciaa507 ◽

2020 ◽

Author(s):

Nathan W Furukawa ◽

Erin F Blau ◽

Zach Reau ◽

David Carlson ◽

Zachary D Raney ◽

...

Keyword(s):

Emergency Department ◽

Human Immunodeficiency Virus ◽

Drug Use ◽

Hiv Testing ◽

Injection Drug Use ◽

Injection Drug ◽

Hiv Diagnosis ◽

Persons Who Inject Drugs ◽

Missed Opportunities ◽

Immunodeficiency Virus

Abstract Background Persons who inject drugs (PWID) have frequent healthcare encounters related to their injection drug use (IDU) but are often not tested for human immunodeficiency virus (HIV). We sought to quantify missed opportunities for HIV testing during an HIV outbreak among PWID. Methods PWID with HIV diagnosed in 5 Cincinnati/Northern Kentucky counties during January 2017–September 2018 who had ≥1 encounter 12 months prior to HIV diagnosis in 1 of 2 Cincinnati/Northern Kentucky area healthcare systems were included in the analysis. HIV testing and encounter data were abstracted from electronic health records. A missed opportunity for HIV testing was defined as an encounter for an IDU-related condition where an HIV test was not performed and had not been performed in the prior 12 months. Results Among 109 PWID with HIV diagnosed who had ≥1 healthcare encounter, 75 (68.8%) had ≥1 IDU-related encounters in the 12 months before HIV diagnosis. These 75 PWID had 169 IDU-related encounters of which 86 (50.9%) were missed opportunities for HIV testing and occurred among 46 (42.2%) PWID. Most IDU-related encounters occurred in the emergency department (118/169; 69.8%). Using multivariable generalized estimating equations, HIV testing was more likely in inpatient compared with emergency department encounters (adjusted relative risk [RR], 2.72; 95% confidence interval [CI], 1.70–4.33) and at the healthcare system receiving funding for emergency department HIV testing (adjusted RR, 1.76; 95% CI, 1.10–2.82). Conclusions PWID have frequent IDU-related encounters in emergency departments. Enhanced HIV screening of PWID in these settings can facilitate earlier diagnosis and improve outbreak response.

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FC30-01 - Severe mental illness is an HIV indicator disease

European Psychiatry ◽

10.1016/s0924-9338(11)73686-0 ◽

2011 ◽

Vol 26 (S2) ◽

pp. 1983-1983

Author(s):

M. Ferrara ◽

G. Solignani ◽

S. Ferrari ◽

M. Rigatelli ◽

G. Guaraldi

Keyword(s):

Mental Illness ◽

Severe Mental Illness ◽

Hiv Testing ◽

Psychiatric Symptoms ◽

Case Histories ◽

Hiv Diagnosis ◽

Hiv Test ◽

Mental Health Settings ◽

Undiagnosed Hiv ◽

Routine Hiv Testing

IntroductionHIV testing is not yet a routine procedure in most mental health settings although adults with severe mental illness (SMI) are disproportionately affected by HIV/AIDS.ObjectivesWe focused our attention to explore if the appropriate care of patients with SMI may include a routine HIV testing offering and thus contribute to diagnose HIV-infected persons earlier in the course of their infection.MethodsWe present three case histories related to primary HIV diagnosis in patients presenting with different psychiatric disorders, admitted to Modena teaching Hospital in the passed two years.ResultsPsychiatric symptoms delayed HIV diagnosis in all of the three reported cases.ConclusionsThe case histories here presented suggest that HIV testing is appropriate in the care of people with SMI, avoiding delay in HIV diagnosis with an obvious clinical benefit for the patient. Further studies are needed to assess the prevalence of HIV in those patients. These will be able to validate psychiatric diseases within a specific HIV indicator diseases list and help identifying a segment of the population in which HIV test must be routinely offered as a public health strategy, to face the burden of undiagnosed HIV infection.

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A new surveillance system for monitoring HIV infection in Victoria, Australia

Sexual Health ◽

10.1071/sh07011 ◽

2007 ◽

Vol 4 (3) ◽

pp. 195 ◽

Cited By ~ 10

Author(s):

Rebecca Guy ◽

Megan S. C. Lim ◽

Yung-Hsuan J. Wang ◽

Nicholas Medland ◽

Jonathan Anderson ◽

...

Keyword(s):

Hiv Infection ◽

Hiv Testing ◽

Surveillance System ◽

Risk Behaviour ◽

Anal Intercourse ◽

Unprotected Anal Intercourse ◽

Hiv Positive ◽

Sexual Risk Behaviour ◽

Hiv Diagnosis ◽

Hiv Test

Objectives: To establish a new mechanism for monitoring patterns of HIV infection, in the context of a sustained increase in HIV diagnosis among men who have sex with men (MSM) in Victoria. Methods: Between April 2004 and August 2005, a linked voluntary HIV sentinel surveillance system was implemented at five medical clinics with a high case load of MSM. Using a questionnaire, doctors collected HIV testing history, demographic and sexual risk behaviour information from all clients undergoing voluntary HIV testing. Questionnaires were linked with HIV test results. Logistic regression analysis was conducted to determine factors associated with HIV infection. Results: Of 3435 MSM tested for HIV at participating sites, 1.7%, (95% CI = 1.2–2.2) were newly diagnosed with HIV; between 2004 and 2005 the proportion increased from 1.3% (95% CI = 1.2–1.5) to 2.0% (95% CI = 1.8–2.2), P = 0.107. There was no significant change in the number of HIV tests conducted per month or in demographic characteristics, testing history and sexual behaviour characteristics between time periods. In multivariate analysis, reporting unprotected anal intercourse (UAI) with any partner, UAI with a HIV-positive partner/s and being aged 30–39 years or 40 years or greater were significantly associated with HIV infection. Conclusion: This new surveillance mechanism, based on linked testing at participating clinics, indicates that the increase in HIV notifications in 2005 was unrelated to changes in testing and data from a Melbourne sexual behavioural survey suggests the increase was more likely to be attributed to increases in transmission within the past few years. The sentinel system highlighted UAI, especially with HIV positive partner/s are important transmission factors.

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Indicator condition-guided HIV testing with an electronic prompt in primary healthcare: a before and after evaluation of an intervention

Sexually Transmitted Infections ◽

10.1136/sextrans-2018-053792 ◽

2019 ◽

Vol 95 (4) ◽

pp. 238-243 ◽

Cited By ~ 1

Author(s):

Laia Cayuelas Redondo ◽

Marina Ruíz ◽

Belchin Kostov ◽

Ethel Sequeira ◽

Pablo Noguera ◽

...

Keyword(s):

Hiv Testing ◽

Primary Healthcare ◽

Hiv Infections ◽

Hiv Test ◽

Younger Patient ◽

Before And After ◽

New Diagnosis ◽

The Impact ◽

Test Request ◽

Made In

ObjectiveIndicator condition (IC)-guided HIV testing is a strategy for the diagnosis of patients with HIV. The aim of this study was to assess the impact on the proportion of HIV tests requested after the introduction of an electronic prompt instructing primary healthcare (PHC) physicians to request an HIV test when diagnosing predefined IC.MethodsA prospective interventional study was conducted in 2015 in three PHC centres in Barcelona to assess the number of HIV test requests made during the implementation of an electronic prompt. Patients aged 18–65 years without HIV infection and with a new diagnosis of predefined IC were included. The results were compared with preprompt (2013) and postprompt data (2016).ResultsDuring the prompt period, 832 patients presented an IC (median age 41.6 years [IQR 30–54], 48.2% female). HIV tests were requested in 296 individuals (35, 6%) and blood tests made in 238. Four HIV infections were diagnosed (positivity rate 1.7%, 95% CI 0.5% to 4.4%). The number of HIV tests requested based on IC increased from 12.6% in 2013 to 35.6% in 2015 (p<0.001) and fell to 17.9% after removal of the prompt in 2016 (p<0.001). Younger patient age (OR 0.97, 95% CI 0.96 to 0.98), birth outside Spain (OR 1.53, 95% CI 1.06 to 2.21) and younger physician age (OR 0.97, 95% CI 0.96 to 0.99) were independent predictive factors for an HIV test request during the prompt period. The electronic prompt (OR 3.36, 95% CI 2.70 to 4.18) was the factor most closely associated with HIV test requests. It was estimated that 10 (95% CI 3.0 to 26.2) additional new cases would have been diagnosed if an HIV test had been performed in all patients presenting an IC.ConclusionsA significant increase in HIV test requests was observed during the implementation of the electronic prompt. The results suggest that this strategy could be useful in increasing IC-guided HIV testing in PHC centres.

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HIV – lessons from a late diagnosis

Acute Medicine Journal ◽

10.52964/amja.0613 ◽

2016 ◽

Vol 15 (2) ◽

pp. 84-87

Author(s):

Xin Hui S. Chan ◽

◽

Barbara L. Onen ◽

Mansoor M. Raza ◽

Dushyant Mital ◽

...

Keyword(s):

Hiv Testing ◽

Hiv Diagnosis ◽

Septic Complications ◽

Routine Testing ◽

Late Hiv Diagnosis ◽

Hiv Test ◽

High Prevalence ◽

Wide Experience ◽

Routine Hiv Testing ◽

The Uk

Late HIV diagnosis is the most important predictor of HIV-related morbidity and mortality in the UK and often results from missed testing opportunities during earlier contact with health services. The HPA now recommends routine HIV testing be commissioned as a priority for all general medical admissions in high prevalence areas, such as Milton Keynes. We present the case of a patient admitted to our Medical Admissions Unit (MAU) managed initially for presumed septic complications of metastatic disease who was later found to have terminal HIV disease. In keeping with UK-wide experience which we review, a local audit following this case found MAU HIV test coverage increased after routine testing but not after staff education alone, and resulted in implementation of routine HIV testing in our MAU.

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