Reassessing HIV Detection Strategies: An Analysis of Opportunistic Screening vs. Indicator-Condition-Driven Diagnosis in Valencia, Spain.

Our study assessed the characteristics of people living with HIV (PLWH) detected via opportunistic screening in Valencia (Spain) to determine diagnoses potentially missed under a more restrictive, indicator-condition diagnostic strategy. We conducted a retrospective analysis of electronic health records of 97 PLWH diagnosed between April 2019 and August 2022. The main outcomes reported were patient CD4+ T cell count, known HIV risk factors at diagnosis, and missed opportunities for diagnosis, defined as the failure of a previously untested patient to undergo HIV testing despite attending previous visits to healthcare facilities prior to diagnosis. Successful linkage to care was achieved for 95.9% of diagnosed patients. Half of the PLWH were diagnosed late, while 47.8% did not meet the criteria for indicator-condition-driven HIV diagnosis at the time of their diagnosis. Additionally, 52.2% did not receive HIV testing despite an average of 5.1 ± 6.0 healthcare visits in the 12 months prior to diagnosis. Spaniards had more missed opportunities for diagnosis than foreigners (64% vs. 40%, p = 0.02). Depending solely on an indicator-condition-driven HIV diagnosis approach could result in 47.8% of cases being missed. Including "migrants" as a testing criterion could lower missed diagnoses to 25.3% but might create inequities in prevention access. In conclusion, our findings provide valuable insights to enhance HIV testing, early diagnosis, and linkage to care. While it is crucial to uphold the indicator-condition-driven HIV diagnosis as baseline practice, improving screening strategies will decrease late diagnoses and missed opportunities, thereby effectively contributing to end the epidemic.

Cribado oportunista del virus de la hepatitis C en un servicio de urgencias en Almería, España / Opportunistic screening for hepatitis C virus infection in an emergency department in Almeria, Spain

Objetivo. Se estima que la prevalencia de infección activa por el virus de la hepatitis C (VHC) en España es de un 0,2%, pero un gran número de personas desconocen su estado de infección. Por ello, se requiere aumentar las estrategias de diagnóstico precoz dirigidas a población vulnerable y con escaso vínculo con el sistema sanitario. El objetivo es evaluar el impacto de un programa de cribado oportunista del VHC en los pacientes atendidos en el servicio de urgencias (SU) de un hospital universitario. Método. Se realizó un cribado oportunista entre agosto de 2021 y abril de 2023 a los pacientes de 18 a 69 años atendidos en el SU que no se habían realizado la prueba del VHC el año anterior, y que requerían un análisis de sangre dentro de la práctica clínica habitual por cualquier motivo. Resultados. Durante el periodo de estudio se atendieron 110.267 pacientes en el SU, fueron candidatos a realizar el cribado 22.712 (20,6%), y finalmente se realizó una serología frente al VHC a 11.368 pacientes (50,1%). Se identificaron 43 casos (0,4% de los test efectuados) de infección activa por VHC (viremia), de los cuales, 24 (56%) desconocían previamente su estado. La media de edad del total de pacientes virémicos fue de 57 (DE: 6 años), 34 (79,1%) eran hombres y 5 (11,6%) tenían nacionalidades distintas a la española. No se identificaron factores de riesgo relacionados con la infección por VHC en 22 (51,2%) de los pacientes, y 41 (95,3%) habían tenido oportunidades de diagnóstico en visitas previas al sistema de salud. De los 18 pacientes analizados mediante elastografía transitoria, 7 (38,8%) presentaban cirrosis en el momento del diagnóstico. Se logró vincular a la atención médica posterior a 33 (77%) de los pacientes con infección activa. Conclusiones. Las tasas de infección activa por VHC detectadas en el programa de cribado fueron más altas que la prevalencia estimada en la población general... (AU)

Background and objective. The prevalence of active hepatitis C virus (HCV) infection in Spain is estimated to be 0.2%, but a large number of persons are unaware of their infection status. Additional approaches to early diagnosis of HCV infection in vulnerable populations with scarce contact with the national health care system are therefore needed. Our aim was to evaluate the impact of an opportunistic screening program to detect HCV-infected patients attended in our university hospital emergency department (ED). Methods. Opportunistic screening was implemented from August 2021 to April 2023 in ED patients aged 18 to 69 years. The test was ordered if HCV screening had not been done in the last year and blood extraction for testing was indicated for any reason as part of routine ED care. Results. A total of 110 267 patients were seen; 22 712 of them (20.6%) were eligible for screening. Serology for HCV was done for 11 368 of the eligible patients (50.1%). Forty-three cases (in 0.4% of tested samples) of active HCV infection (viremia) were found. In 24 of these cases (56%) the patients had not been aware that they were infected. Their mean (SD) age was 57 (6) years, 34 (79.1%) were men, and 5 (11.6%) were citizens of countries other than Spain. No risk factors related to HCV infection could be found for 22 of the patients (51.2%), and 41 (95.3%) could have been diagnosed during previous contact with the health care system. Of the 18 patients evaluated by transient elastography (FibroScan), 7 (38.8%) had signs of cirrhosis at the time of diagnosis. Thirty-three of the patients with active infections (77%) were subsequently able to access care. Conclusions. The rate of active HCV infection in the screening program was higher than the prevalence estimated for the general population. Opportunistic screening for HCV during ED visits is useful for increasing the number of diagnoses and should be considered as a tool for eradicating this disease. (AU)

Opportunistic screening for hepatitis C virus infection in an emergency department in Almeria, Spain. / Cribado oportunista del virus de la hepatitis C en un servicio de urgencias en Almería, España.

OBJECTIVES: The prevalence of active hepatitis C virus (HCV) infection in Spain is estimated to be 0.2%, but a large number of persons are unaware of their infection status. Additional approaches to early diagnosis of HCV infection in vulnerable populations with scarce contact with the national health care system are therefore needed. Our aim was to evaluate the impact of an opportunistic screening program to detect HCV-infected patients attended in our university hospital emergency department (ED). MATERIAL AND METHODS: Opportunistic screening was implemented from August 2021 to April 2023 in ED patients aged 18 to 69 years. The test was ordered if HCV screening had not been done in the last year and blood extraction for testing was indicated for any reason as part of routine ED care. RESULTS: A total of 110 267 patients were seen; 22 712 of them (20.6%) were eligible for screening. Serology for HCV was done for 11 368 of the eligible patients (50.1%). Forty-three cases (in 0.4% of tested samples) of active HCV infection (viremia) were found. In 24 of these cases (56%) the patients had not been aware that they were infected. Their mean (SD) age was 57 (6) years, 34 (79.1%) were men, and 5 (11.6%) were citizens of countries other than Spain. No risk factors related to HCV infection could be found for 22 of the patients (51.2%), and 41 (95.3%) could have been diagnosed during previous contact with the health care system. Of the 18 patients evaluated by transient elastography (FibroScan), 7 (38.8%) had signs of cirrhosis at the time of diagnosis. Thirty-three of the patients with active infections (77%) were subsequently able to access care. CONCLUSION: The rate of active HCV infection in the screening program was higher than the prevalence estimated for the general population. Opportunistic screening for HCV during ED visits is useful for increasing the number of diagnoses and should be considered as a tool for eradicating this disease.

OBJETIVO: Se estima que la prevalencia de infección activa por el virus de la hepatitis C (VHC) en España es de un 0,2%, pero un gran número de personas desconocen su estado de infección. Por ello, se requiere aumentar las estrategias de diagnóstico precoz dirigidas a población vulnerable y con escaso vínculo con el sistema sanitario. El objetivo es evaluar el impacto de un programa de cribado oportunista del VHC en los pacientes atendidos en el servicio de urgencias (SU) de un hospital universitario. METODO: Se realizó un cribado oportunista entre agosto de 2021 y abril de 2023 a los pacientes de 18 a 69 años atendidos en el SU que no se habían realizado la prueba del VHC el año anterior, y que requerían un análisis de sangre dentro de la práctica clínica habitual por cualquier motivo. RESULTADOS: Durante el periodo de estudio se atendieron 110.267 pacientes en el SU, fueron candidatos a realizar el cribado 22.712 (20,6%), y finalmente se realizó una serología frente al VHC a 11.368 pacientes (50,1%). Se identificaron 43 casos (0,4% de los test efectuados) de infección activa por VHC (viremia), de los cuales, 24 (56%) desconocían previamente su estado. La media de edad del total de pacientes virémicos fue de 57 (DE: 6 años), 34 (79,1%) eran hombres y 5 (11,6%) tenían nacionalidades distintas a la española. No se identificaron factores de riesgo relacionados con la infección por VHC en 22 (51,2%) de los pacientes, y 41 (95,3%) habían tenido oportunidades de diagnóstico en visitas previas al sistema de salud. De los 18 pacientes analizados mediante elastografía transitoria, 7 (38,8%) presentaban cirrosis en el momento del diagnóstico. Se logró vincular a la atención médica posterior a 33 (77%) de los pacientes con infección activa. CONCLUSIONES: Las tasas de infección activa por VHC detectadas en el programa de cribado fueron más altas que la prevalencia estimada en la población general. El cribado oportunista de VHC en los SU puede ser de utilidad para aumentar el diagnóstico y debe ser considerado como una herramienta para la eliminación de la hepatitis C.

Cribado oportunista del virus de la hepatitis C en un servicio de urgencias en Almería, España / Opportunistic screening for hepatitis C virus infection in an emergency department in Almeria, Spain

Objetivo. Se estima que la prevalencia de infección activa por el virus de la hepatitis C (VHC) en España es de un 0,2%, pero un gran número de personas desconocen su estado de infección. Por ello, se requiere aumentar las estrategias de diagnóstico precoz dirigidas a población vulnerable y con escaso vínculo con el sistema sanitario. El objetivo es evaluar el impacto de un programa de cribado oportunista del VHC en los pacientes atendidos en el servicio de urgencias (SU) de un hospital universitario. Método. Se realizó un cribado oportunista entre agosto de 2021 y abril de 2023 a los pacientes de 18 a 69 años atendidos en el SU que no se habían realizado la prueba del VHC el año anterior, y que requerían un análisis de sangre dentro de la práctica clínica habitual por cualquier motivo. Resultados. Durante el periodo de estudio se atendieron 110.267 pacientes en el SU, fueron candidatos a realizar el cribado 22.712 (20,6%), y finalmente se realizó una serología frente al VHC a 11.368 pacientes (50,1%). Se identificaron 43 casos (0,4% de los test efectuados) de infección activa por VHC (viremia), de los cuales, 24 (56%) desconocían previamente su estado. La media de edad del total de pacientes virémicos fue de 57 (DE: 6 años), 34 (79,1%) eran hombres y 5 (11,6%) tenían nacionalidades distintas a la española. No se identificaron factores de riesgo relacionados con la infección por VHC en 22 (51,2%) de los pacientes, y 41 (95,3%) habían tenido oportunidades de diagnóstico en visitas previas al sistema de salud. De los 18 pacientes analizados mediante elastografía transitoria, 7 (38,8%) presentaban cirrosis en el momento del diagnóstico. Se logró vincular a la atención médica posterior a 33 (77%) de los pacientes con infección activa. Conclusiones. Las tasas de infección activa por VHC detectadas en el programa de cribado fueron más altas que la prevalencia estimada en la población general... (AU)

Background and objective. The prevalence of active hepatitis C virus (HCV) infection in Spain is estimated to be 0.2%, but a large number of persons are unaware of their infection status. Additional approaches to early diagnosis of HCV infection in vulnerable populations with scarce contact with the national health care system are therefore needed. Our aim was to evaluate the impact of an opportunistic screening program to detect HCV-infected patients attended in our university hospital emergency department (ED). Methods. Opportunistic screening was implemented from August 2021 to April 2023 in ED patients aged 18 to 69 years. The test was ordered if HCV screening had not been done in the last year and blood extraction for testing was indicated for any reason as part of routine ED care. Results. A total of 110 267 patients were seen; 22 712 of them (20.6%) were eligible for screening. Serology for HCV was done for 11 368 of the eligible patients (50.1%). Forty-three cases (in 0.4% of tested samples) of active HCV infection (viremia) were found. In 24 of these cases (56%) the patients had not been aware that they were infected. Their mean (SD) age was 57 (6) years, 34 (79.1%) were men, and 5 (11.6%) were citizens of countries other than Spain. No risk factors related to HCV infection could be found for 22 of the patients (51.2%), and 41 (95.3%) could have been diagnosed during previous contact with the health care system. Of the 18 patients evaluated by transient elastography (FibroScan), 7 (38.8%) had signs of cirrhosis at the time of diagnosis. Thirty-three of the patients with active infections (77%) were subsequently able to access care. Conclusions. The rate of active HCV infection in the screening program was higher than the prevalence estimated for the general population. Opportunistic screening for HCV during ED visits is useful for increasing the number of diagnoses and should be considered as a tool for eradicating this disease. (AU)

Emergency department contribution to HCV elimination in the Iberian Peninsula.

BACKGROUND: Undiagnosed cases of hepatitis C virus (HCV) infection result in significant morbidity and mortality, further transmission, and increased public health costs. Testing in emergency departments (EDs) is an opportunity to expand HCV screening. The goal of this project was to increase the proportion of eligible patients screened for HCV in urban areas. METHODS: An opportunistic automated HCV screening program was implemented in the EDs of 4 public hospitals in Spain and Portugal at different periods between 2018 and 2023. HCV prevalence was prospectively evaluated, and single-step or reflex testing was used for confirmation in the same sample. RESULTS: More than 90% of the population eligible for testing were screened in the participating centers. We found HCV antibody seroprevalence rates ranging from 0.6 to 3.9%, with between 19 and 53% of viremic individuals. CONCLUSIONS: Opportunistic HCV screening in EDs is feasible, does not disrupt ED activities, is highly effective in increasing diagnosis, and contributes to WHO's HCV elimination goals.

Increasing HIV early diagnosis by implementing an automated screening strategy in emergency departments.

INTRODUCTION: Late HIV diagnosis is associated with increased morbidity, mortality and risk of onward transmission. Increasing HIV early diagnosis is still a priority. In this observational study with historical control, we determined the impact of an opportunistic HIV screening strategy in the reduction of late diagnosis and missed opportunities for earlier diagnosis. METHODS: The screening programme was implemented in the emergency department (ED) of the Hospital de Cascais between September 2018 and September 2021. Eligible patients were aged 18-64 years, with no known HIV diagnosis or antibody testing performed in the previous year, and who required blood work for any reason. Out of the 252 153 emergency visits to the ED, we identified 43 153 (17.1%) patients eligible for HIV testing. Among the total population eligible for the screening, 38 357 (88.9%) patients were ultimately tested for HIV. Impact of the ED screening was determined by analysing late diagnosis in the ED and missed opportunities at different healthcare settings 3 years before and 3 years after the start of the ED screening. RESULTS: After 3 years of automated HIV ED testing, we found 69 newly diagnosed HIV cases (54% male, 39% Portuguese nationals, mean age 40.5 years). When comparing the characteristics of HIV diagnoses made in the ED, we observed a significant reduction in the number of people with late HIV diagnosis before and after implementation of the screening programme (78.4% vs. 39.1%, respectively; p = 0.0291). The mean number of missed opportunities for diagnosis also fell (2.6 vs. 1.5 annual encounters with the healthcare system per patient, p = 0.0997). CONCLUSIONS: People living with HIV in Cascais and their providers miss several opportunities for earlier diagnosis. Opportunistic screening strategies in settings previously deemed to be unconventional, such as EDs, are feasible and effective in mitigating missed opportunities for timely HIV diagnosis.

HIV screening and linkage to care in a health department in Valencia, Spain: Lessons learned from a healthcare quality improvement project.

Spain's rate of new human immunodeficiency virus (HIV) diagnoses exceeds that of the European Economic Area average (8.6 vs 5.6:100,000 in 2018). The country has failed to meet the first of United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets for HIV control by 2020, with 87.0% of people living with HIV knowing their status, and late presentation rates of 47.6% and 51.5% country-wide and in the Valencian autonomous community, respectively. Advancing screening and linkage to care (SLTC) practices is necessary to effectively control the epidemic. The Valencia Viral Screening (CRIVALVIR) project adopted the TEST model for opportunistic and systematic HIV SLTC in individuals aged 18 to 80 who required blood work for any purpose, as of February 2019. SLTC was integrated into routine clinical workflow across primary care centers serving a population of 360,000 people in Valencia, Spain. Our project successfully upscaled total HIV testing by 194% to over 32,000 patients tested in 14 months. We found an overall prevalence of 0.13% (0.08-0.21) among those screened per protocol (n = 13,061), with foreign-born citizens presenting a 12.5 times significantly higher likelihood of acquiring HIV (95% confidence interval 4.63-33.96, P < .0001). We improved late presentation by 18.2 percentage points and prevented an estimated 58 to 70 new secondary infections. HIV screening of the general population in primary care is an effective strategy for achieving timely diagnosis and preventing new infections. Opportunistic, systematic, opt-out approaches are essential to control the HIV epidemic.