Acute HIV Discovered During Routine HIV Screening With HIV Antigen-Antibody Combination Tests in 9 US Emergency Departments.

STUDY OBJECTIVE: Newer combination HIV antigen-antibody tests allow detection of HIV sooner after infection than previous antibody-only immunoassays because, in addition to HIV-1 and -2 antibodies, they detect the HIV-1 p24 antigen, which appears before antibodies develop. We determine the yield of screening with HIV antigen-antibody tests and clinical presentations for new diagnoses of acute and established HIV infection across US emergency departments (EDs). METHODS: This was a retrospective study of 9 EDs in 6 cities with HIV screening programs that integrated laboratory-based antigen-antibody tests between November 1, 2012, and December 31, 2015. Unique patients with newly diagnosed HIV infection were identified and classified as having either acute HIV infection or established HIV infection. Acute HIV infection was defined as a repeatedly reactive antigen-antibody test result, a negative HIV-1/HIV-2 antibody differentiation assay, or Western blot result, but detectable HIV ribonucleic acid (RNA); established HIV infection was defined as a repeatedly reactive antigen-antibody test result and a positive HIV-1/HIV-2 antibody differentiation assay or Western blot result. The primary outcomes were the number of new HIV diagnoses and proportion of patients with laboratory-defined acute HIV infection. Secondary outcomes compared reason for visit and the clinical presentation of acute HIV infection. RESULTS: In total, 214,524 patients were screened for HIV and 839 (0.4%) received a new diagnosis, of which 122 (14.5%) were acute HIV infection and 717 (85.5%) were established HIV infection. Compared with patients with established HIV infection, those with acute HIV infection were younger, had higher RNA and CD4 counts, and were more likely to have viral syndrome (41.8% versus 6.5%) or fever (14.3% versus 3.4%) as their reason for visit. Most patients with acute HIV infection displayed symptoms attributable to acute infection (median symptom count 5 [interquartile range 3 to 6]), with fever often accompanied by greater than or equal to 3 other symptoms (60.7%). CONCLUSION: ED screening using antigen-antibody tests identifies previously undiagnosed HIV infection at proportions that exceed the Centers for Disease Control and Prevention's screening threshold, with the added yield of identifying acute HIV infection in approximately 15% of patients with a new diagnosis. Patients with acute HIV infection often seek ED care for symptoms related to seroconversion.

Outcomes of a Pharmacist-Led Hepatitis C Virus Treatment Program in an Urban Safety-Net Health System, Chicago, 2017-2019.

OBJECTIVE: A recommendation in March 2020 to expand hepatitis C virus (HCV) screening to all adults in the United States will likely increase the need for HCV treatment programs and guidance on how to provide this service for diverse populations. We evaluated a pharmacist-led HCV treatment program within a routine screening program in an urban safety-net health system in Chicago, Illinois. METHODS: We collected data on all patient treatment applications submitted from January 1, 2017, through June 30, 2019, and assessed outcomes of and patient retention in the treatment cascade. RESULTS: During the study period, 203 HCV treatment applications were submitted for 187 patients (>1 application could be submitted per patient): 49% (n = 91) were aged 55-64, 62% (n = 116) were male, 67% (n = 125) were Black, and 15% (n = 28) were Hispanic. Of the 203 HCV treatment applications, 87% (n = 176) of patients were approved for treatment, 91% (n = 161) of whom completed treatment. Of the 161 patients who completed treatment, 81% (n = 131) attended their sustained virologic response (SVR) follow-up visit, 98% (n = 129) of whom reached SVR. The largest drop in the treatment cascade was the 19% decline from receipt of treatment to SVR follow-up visit. CONCLUSION: The pharmacist-led model for HCV treatment was effective in navigating patients through the treatment cascade and achieving SVR. Widespread implementation of pharmacist-led HCV treatment models may help to hasten progress toward 2030 HCV elimination goals.

Routine Screening and Linkage to Care for Hepatitis C Virus in an Urban Safety-Net Health System, 2017-2019.

OBJECTIVE: Hepatitis C virus (HCV) is a major threat to public health in the United States. We describe and evaluate an HCV screening and linkage-to-care program, including emergency department, inpatient, and outpatient settings, in an urban safety-net health system in Chicago. METHODS: Sinai Health System implemented a universal HCV screening program in September 2016 that offered patient navigation services (ie, linkage to care) to patients with a positive result for HCV on an RNA test. We collected data from February 1, 2017, through January 31, 2019, on patient demographic characteristics, risk factors, and various outcomes (eg, number of patients screened, test results, proportions of new diagnoses, number of patients eligible for patient navigation services, and proportion of patients who attended their first medical appointment). We also examined outcomes by patients' knowledge of infection. RESULTS: Of 21 018 people screened for HCV, 6% (1318/21 018) had positive test results for HCV antibody, 68% (878/1293) of whom had positive HCV RNA test results. Of these 878 patients, 68% were born during 1945-1965, 68% were male, 65% were Black, 19% were Latino, 55% were newly diagnosed, and 64% were eligible for patient navigation services. Risk factors included past or current drug use (53%), unemployment (30%), and ever incarcerated (21%). Of 562 patients eligible for navigation services, 281 (50%) were navigated to imaging services, and 203 (72%) patients who completed imaging attended their first medical appointment. CONCLUSION: Patient navigation played a critical role in linkage success, but securing stable, long-term financial support for patient navigators is a challenge.

Implementing an HIV and sexually transmitted disease screening program in an emergency department.

STUDY OBJECTIVE: We assess the feasibility, effectiveness, and cost of routinely recommended HIV/sexually transmitted disease screening in an urban emergency department (ED). METHODS: From April 2003 to August 2004, patients aged 15 to 54 years were offered rapid HIV testing, and those aged 15 to 25 years were also offered gonorrhea and chlamydia testing (nucleic acid amplification), Monday through Friday, 11 am to 8 pm. Infected patients were referred for treatment and care. Prevalence, treatment rates, and cost were assessed. RESULTS: Among 3,030 patients offered HIV testing, 1,447 (47.8%) accepted, 8 (0.6%) tested positive, and 3 (37.5%) were linked to care. Among 791 patients offered sexually transmitted disease testing, 386 (48.8%) accepted, 320 provided urine (82.9%), 48 (15.0%) tested positive, and 42 (87.5%) were treated for gonorrhea or chlamydia. The program cost was $72,928. Costs per HIV-infected patient identified and linked to care were, respectively, $9,116 and $24,309; cost per sexually transmitted disease-infected patient treated was $1,736. The program cost for HIV/sexually transmitted disease screening was only $14,340 more than if we screened only for HIV. CONCLUSION: Through ED-based HIV/sexually transmitted disease screening, we identified and treated many sexually transmitted disease-infected patients but identified few HIV-infected patients and linked even fewer to care. However, sexually transmitted disease screening can be added to HIV screening at a reasonable cost.

Implementing Routine HIV Screening in Three Chicago Hospitals: Lessons Learned.

OBJECTIVE: This study describes routine HIV screening implementation and outcomes in three hospitals in Chicago, Illinois. METHODS: Retrospective data from three hospitals were examined, and routine testing procedures, testing volume, reactive test results, and linkage-to-care outcomes were documented. RESULTS: From January 2012 through March 2014, 40,788 HIV tests were administered at the three hospitals: 18,603 (46%) in the emergency department (ED), 7,546 (19%) in the inpatient departments, and 14,639 (36%) in outpatient clinics. The screened patients varied from 1% to 22% of the total eligible patient population across hospitals. A total of 297 patients tested positive for HIV for a seropositivity rate of 0.7%; 129 (43%) were newly diagnosed and 168 (57%) were previously diagnosed, with 64% of those previously diagnosed out of care at the time of screening. The inpatient areas had the highest seropositivity rate (0.6%). The percentage of newly diagnosed patients overall who were linked to care was 77%. Of newly diagnosed patients, 51% had ≥ 1 missed opportunity for testing (with a mean of 3.8 visits since 2006), and 30% of patients with missed opportunities were late testers (baseline CD4+ counts <200 cells per cubic millimeter). CONCLUSION: Routine screening is an essential tool for identifying new infections and patients with known infection who are out of care. Hospitals need to provide HIV screening in inpatient and outpatient settings--not just EDs--to decrease missed opportunities. Routine screening success will be driven by how notification and testing are incorporated into the normal medical flow, the level of leadership buy-in, the ability to conduct quality assurance, and local testing laws.

HIV testing in a resource-poor urban emergency department.

In an effort to help fight the HIV epidemic, we offered standard HIV testing to high-risk and symptomatic patients attending an urban emergency department (ED) located in a high-prevalence area. We assessed rates of consent, HIV infection, and linkage into care by demographic and risk characteristics. Consent rates were consistently greater than 50% across the various demographics and risk groups. The HIV prevalence rate was 3% and ranged from 0% to 50% across groups. Of those eligible to enter care 69% attended their first infectious disease clinic appointment. One recommendation to increase the number of people who are aware of their serostatus is to offer HIV testing in underutilized venues, such as an urban ED. The results of this project offer suggestions for future pursuits.