Study Shows Missed Opportunities for HIV Diagnosis

New University of Cincinnati (UC) research on HIV testing at local emergency departments shows that hospitals miss opportunities to diagnose patients who do not know they are infected with HIV, even when a regular testing program is in place.

The study is part of a special supplement to the July issue of Annals of Emergency Medicine, sponsored by the Centers for Disease Control and Prevention (CDC). The supplement includes a series of studies on HIV testing in the nations emergency departments, finding that while a growing number of emergency departments (EDs) are providing some HIV testing, there are still challenges to widespread expansion of testing as a routine part of emergency care.

UC assistant professor of emergency medicine Michael Lyons, MD, was one of four guest editors for the publication. "HIV testing in is one of the most critical parts of the fight against HIV," says Lyons, lead author on the study. "Previous studies have shown that patients with undiagnosed HIV often visit healthcare settings, particularly emergency departments, before eventually receiving a diagnosis, but how to capitalize on these opportunities for earlier diagnosis remains unclear. We also do not fully understand how the frequency of missed opportunities differs between different emergency departments."

The study reviewed records for a set of 276 newly diagnosed HIV patients to determine whether the diagnosis might have been made in an earlier ED visit that didnt include an HIV test. Researchers found missed opportunities occurred in 157 visits to an academic emergency department, 24 visits in an urban community hospital and six visits to a suburban community hospital.

"The number of missed opportunities differed between facilities, but all centers had at least some encounters with persons with undiagnosed HIV," says Christopher Lindsell, PhD, co-author and vice chair for research in emergency medicine at UC.

"Many, but not all, encounters included at least one indication for HIV testing. This suggests that only universal screening will identify all undiagnosed patientsbut when thats not feasible, physicians can improve overall detection by testing patients who they recognize as having increased risk of infection. All EDs should be capable of HIV testing in these instances."

A related study by Lindsell, also in the CDC supplement, described a method for hospitals to estimate the number of patients with undiagnosed HIV that visit their ED. "We know that not all EDs see the same number of undiagnosed patients. With this tool, an ED can estimate their need for screening before investing significant resources to increase testing," says Lindsell.

Several other UC studies, led by emergency medicine and infectious diseases researchers, are also included in the supplement, all designed to better understand how to expand HIV testing and prevention in emergency department settings.

"With this research, the academic emergency medicine community is helping to interpret and implement the CDCs recommendations for routine screening in health care settings," says Lyons. "Altogether there has been a lot of progress; there are still many challenges to expanding HIV testing. Were trying to provide a road map to show where and how limited testing resources are best allocated and trying to motivate screening uptake by emergency physicians."

One UC study, led by former emergency medicine resident Nathan Hudepohl, MD, measured the number of patient visits and HIV tests in the UC Health University Hospital ED from 2003 through 2008. They found that although the HIV testing program provided testing during fewer than 2 percent of ED visits each year, the number of ED patients who had been tested by the program eventually grew to 6.9 percent.

"In just five years of testing, we increased the proportion of ED patients known to have been tested in the program 18 percent," says Lyons.

"Although this falls short of the universal testing advocated by the CDC, our results show that incremental efforts can gradually accumulate impact over time. Even if an ED cannot test as frequently as is recommended, the ED can still work towards screening the population by providing whatever amount of testing is possible."

Another UC study included in the supplement, led by current UC medical student Andrea Sitlinger, looked at patient attitudes toward HIV-prevention counseling in the ED. Though the CDC recommends delinking prevention counseling from HIV screeningso that hospitals unable to offer counseling can still test patientsthe general effectiveness of prevention counseling in EDs is unknown. The study found that patients found counseling generally useful, though a significant minority did not derive benefit from it and did not remember aspects of the counseling.

The UC research featured in the supplement was supported by the Emergency Medicine Foundation and the National Institute of Allergy and Infectious Diseases. The UC Health University Hospital Center for Emergency Care HIV testing program is supported by the Ohio Department of Health and the Cincinnati Health Network. No authors report conflicts of interest.

Co-authors include Andrew Ruffner, Beth Wayne, Kimberly Hart and Alexander Trott, MD, in the UC Department of Emergency Medicine; Carl Fichtenbaum, MD, in the UC Department of Internal Medicine; and Patrick Sullivan, PhD, of Emory University.