Stepping up from opt-out: Achieving 100% uptake antenatal human immunodeficiency virus testing

All pregnant women in the United Kingdom are offered and encouraged to take up screening for human immunodeficiency virus (HIV), hepatitis B and syphilis, with excellent uptake rates and engagement in care resulting in very few infants being infected with HIV in the United Kingdom. However, in that small number of women who decline testing, there remains an opportunity to offer further support to test and engage them and their baby in care, even if this happens in labour or immediately after birth. In addition, these women may be at increased risk of HIV. Our hospital is in an extremely high prevalence area for HIV, and most untested individuals are of childbearing age. We embarked on a quality improvement project to engage all women delivering at our unit in HIV testing or to test their babies via cord blood at birth. We sought to do this in a constructive and inclusive way, led by the HIV specialist midwife with the support of the HIV antenatal and the hospital senior management teams. Following an initial evaluation, the approach was modified and an innovative approach together with a trusted advocate was used to engage a particularly hard-to-reach group. We have achieved 100% uptake of HIV testing and made two HIV diagnoses that would not otherwise have been made; both in women who reported themselves not to be at risk and both engaged in care and delivered HIV-negative infants.

Calibrating a chief complaint list for low resource settings: a methodologic case study

Background The chief or presenting complaint is the reason for seeking health care, often in the patient’s own words. In limited resource settings, a diagnosis-based approach to quantifying burden of disease is not possible, partly due to limited availability of an established lexicon or coding system. Our group worked with colleagues from the African Federation of Emergency Medicine building on the existing literature to create a pilot symptom list representing an attempt to standardize undifferentiated chief complaints in emergency and acute care settings. An ideal list for any setting is one that strikes a balance between ease of use and length, while covering the vast majority of diseases with enough detail to permit epidemiologic surveillance and make informed decisions about resource needs. Methods This study was incorporated as a part of a larger prospective observational study on human immunodeficiency virus testing in Emergency Departments in South Africa. The pilot symptom list was used for chief complaint coding in three Emergency Departments. Data was collected on 3357 patients using paper case report forms. Chief complaint terms were reviewed by two study team members to determine the frequency of concordance between the coded chief complaint term and the selected symptom(s) from the pilot symptom list. Results Overall, 3537 patients’ chief complaints were reviewed, of which 640 were identified as ‘potential mismatches.’ When considering the 191 confirmed mismatches (29.8%), the Delphi process identified 6 (3.1%) false mismatches and 185 (96.9%) true mismatches. Significant chief-complaint clustering was identified with 9 sets of complaints frequently selected together for the same patient. “Pain” was used 2076 times for 58.7% of all patients. A combination of user feedback and expert-panel modified Delphi analysis of mismatched complaints and clustered complaints resulted in several substantial changes to the pilot symptom list. Conclusions This study presented a systematic methodology for calibrating a chief complaint list for the local context. Our revised list removed/reworded symptoms that frequently clustered together or were misinterpreted by health professionals. Recommendations for additions, modifications, and/or deletions from the pilot chief complaint list we believe will improve the functionality of the list in low resource environments.

Validating a Chief Compliant List for Low Resource Settings: A Methodologic Case Study

Background:The chief or presenting complaint is the reason for seeking health care, often in the patient’s own words. In limited resource settings, a diagnosis-based approach to quantifying burden of disease is not possible, partly due to limited availability of an established lexicon or coding system. Collaboration with World Health Organization colleagues resulted in the creation of a pilot symptom list representing an attempt to standardize undifferentiated chief complaints in emergency and acute care settings. A validated universal chief complaint list would profoundly benefit clinicians, researchers, and policymakers world-wide by allowing the communication and development of system-level priorities based around the signs and symptoms most often experienced by the patients being served.Methods: This study was incorporated as a part of a larger prospective observational study on human immunodeficiency virus testing in Emergency Departments in South Africa. The pilot symptom list was used for chief complaint coding in three Emergency Departments. Data was collected on 3,357 patients using paper case report forms. Chief complaint terms were reviewed by two study team members to determine the frequency of concordance between the coded chief complaint term and the selected symptom(s) from the pilot symptom list.Results:Overall, 3,537 patients’ chief complaints were reviewed, of which 640 were identified as ‘potential mis-matches’. When considering the 191 confirmed mis-matches (29.8%), the Delphi process identified 6 (3.1%) false mismatches and 185 (96.9%) true mismatches. Significant chief-complaint clustering was identified with 9 sets of complaints frequently selected together for the same patient. “Pain” was used 2,076 times for 58.7% of all patients. Testing for validity and functionality of the initial draft dataset via user feedback and expert-panel modified Delphi analysis resulted in several substantial changes to the pilot symptom list.Conclusions:This study found that the pilot symptom list with aforementioned modifications could be applied to a low resource emergency system. Recommendations for additions, modifications, and/or deletions from the draft chief complaint list will improve validity and functionality of the list in low resource environments. Selecting a patient’s chief complaint from a validated list offers a vital tool to help triage patients, streamline emergency care delivery, and improve patient outcomes.

Human Immunodeficiency Virus Testing, Diagnosis, Linkage to Care, and Prevention Services Among Persons Who Inject Drugs, United States, 2012–2017

Background Human immunodeficiency virus (HIV) testing and early diagnosis is associated with effective disease management and reduction in HIV transmission among persons who inject drugs (PWID). We examined trends in HIV testing outcomes among PWID during 2012–2017. Methods Centers for Disease Control and Prevention (CDC)-funded HIV testing data submitted by 61 health departments and 150 directly-funded community-based organizations during 2012–2017 were analyzed. We calculated estimated annual percentage changes (EAPC) to assess trends for HIV testing and testing outcomes. Results A total of 19 739 857 CDC-funded HIV tests were conducted during 2012–2017. Of these, 529 349 (2.7%) were among PWID. The percentage of newly diagnosed HIV increased from .7% in 2012 to .8% in 2017 (EAPC, 4.15%). The percentage interviewed for partner services increased from 46.7% in 2012 to 66.3% in 2017 (EAPC, 1.81%). No significant change was identified in trends for linkage to HIV medical care ≤90 days after diagnosis (EAPC, 0.52%) or referral to HIV prevention services (EAPC, 0.98%). Conclusions Human immunodeficiency virus testing data revealed an increasing trend in newly diagnosed HIV among PWID but not linkage to HIV medical care or referral to prevention services. Expanding efforts to increase HIV testing and enhance linkage to services can lead to reductions in HIV transmission and improved health outcomes.