Screening for HIV in EDs Improves Access to Care, Study Finds

From 2014 to 2018, in the midst of an HIV outbreak in Hamilton County, Ohio, an emergency department (ED)-based HIV screening program at a safety-net hospital more than doubled its rate of overall annual HIV diagnoses, from 20 to 42, according to findings published in PLoS One.

The publicly funded screening program, at University of Cincinnati Medical Center, also exponentially increased diagnoses among persons who inject drugs (PWID): from 1 to 18, or a 1700% leap.

“EDs, recognized as essential venues for HIV screening, may play a unique role in identifying undiagnosed HIV among PWID, who frequently present for complications of injection drug use,” the authors noted. “Our objective was to describe changes in HIV diagnoses among PWID detected by an ED HIV screening program.”

The retrospective study analyzed data from electronic records, with the primary outcomes of change in number of overall HIV diagnoses and the numbers seen in the ED, both overall and specifically among PWID. In 2017 alone, Hamilton Country was home to the most new HIV diagnoses per 100,000 individuals, at 17.4 to 22.9.

Overall, 142 new HIV diagnoses were seen through this ED, most of which were seen among Black/African American (65.5%), non-Hispanic/Latino (97.9%), and male (76.8%) individuals, with a median age of 31 years. Close to 10% had no risk factors for HIV, while 26% were among PWID who were receiving a new HIV diagnosis. In addition, among the PWID group, most of the patients were White (81.1%), non-Hispanic/Latino (100%), and male (67.6%). They were slightly older, too, at 33 years.

The analysis also found:

• The ED study site screening program was responsible for 17.6% (95% CI, 15.0%-20.4%) of total countywide HIV diagnoses and 22.4% of those among PWID (95% CI, 16.5%-29.7%)
• More than three-fourths (75.7%) of the patients receiving a new HIV diagnosis had at least 1 injection drug use (IDU)-related conditions at diagnosis
• The most common IDU-related condition was homelessness (48.6%), followed by hepatitis C (35.1%), bacterial infection (32.4%; abscess, cellulitis, bacteremia, sepsis, staphylococcus, skin/tissue disorder, other bacterial infection), and accidental overdose (18.9%)
• Most HIV screenings were targeted at those with known risk factors (36.6%) or with symptoms of HIV infection (46.6%)
• HIV diagnoses in the ED in the study rose from 13.2% of the county total to 22.7%

“The finding that a single, large-scale ED screening program identified 1 in 5 cases of HIV among PWID for the entire county calls for an expanded view of the potential role of EDs in the identification of previously undiagnosed HIV, detection of trends including outbreaks, and even outbreak response,” the authors wrote.

In addition, they report that their findings echo public health recommendations on the use of EDs to link individuals to health care, as well as previous findings in the existing literature that ED-based screenings help to reduce disease transmission. Surveillance is another benefit, they report, having been done for Ebola and COVID-19– and flu-like illness in the past.

Especially for that last point, “Our retrospective analysis revealed that the increase in the number of PWID with newly diagnosed HIV in this ED paralleled county-wide increases,” the authors noted. “This suggests that EDs could potentially be a special focus for public health surveillance entities to identify trends earlier by evaluating ED data in real time.”

They do caution, however, on generalizing their results, due to unavailable data that could have clarified “the degree to which the findings of this report are specific to HIV or PWID.” Another possible limitation is the underestimation or misclassification of HIV diagnoses among PWID due to missing risk-assessment interviews.

Reference

Faryar KA, Ancona RM, Reau Z, et al. HIV detection by an emergency department HIV screening program during a regional outbreak among people who inject drugs. PLoS One. Published online May 18, 2021. doi:10.1371/journal.pone.0251756