Approximately 16% of the estimated 1.1 million persons living with human immunodeficiency
virus (HIV) in the United States are unaware of their infection and thus unable to
benefit from effective treatment that improves health and reduces transmission risk
(1,2). Since 2006, CDC has recommended that health-care providers screen for HIV all
patients aged 13–64 years unless prevalence of undiagnosed HIV infection in their
patients has been documented to be <0.1% (3). This report describes novel HIV screening
programs at the Urban Health Plan (UHP), Inc. in New York City and the Interim Louisiana
Hospital (ILH) in New Orleans. Data were provided by the two programs. UHP screened
a monthly average of 986 patients for HIV during January 2011–September 2013. Of the
32,534 patients screened, 148 (0.45%) tested HIV-positive, of whom 147 (99%) received
their test result and 43 (29%) were newly diagnosed. None of the 148 patients with
HIV infection were previously receiving medical care, and 120 (81%) were linked to
HIV medical care. The ILH emergency department (ED) and the urgent-care center (UCC)
screened a monthly average of 1,323 patients from mid-March to December 2013. Of the
12,568 patients screened, 102 (0.81%) tested HIV-positive, of whom 100 (98%) received
their test result, 77 (75%) were newly diagnosed, and five (5%) had acute HIV infection.
Linkage to HIV medical care was successful for 67 (74%) of 91 patients not already
in care. Routine HIV screening identified patients with new and previously diagnosed
HIV infection and facilitated their linkage to medical care. The two HIV screening
programs highlighted in this report can serve as models that could be adapted by other
health-care settings.
UHP, a federally qualified health center network of eight practice sites and eight
school-based health centers, serves approximately 60,000 unique patients each year.
ILH, a public hospital, serves approximately 76,000 unique patients in its ED and
UCC each year. Both received startup funding from Gilead Sciences’ HIV on the Frontlines
of Communities in the United States (FOCUS)* program to implement routine HIV screening
based on four principles: 1) institutional policy change reflecting an organization-wide
commitment to routine HIV testing and diagnosis; 2) integration of HIV testing into
existing clinical workflows to promote its normalization and sustainability; 3) use
of electronic health records (EHR) to prompt testing, automate laboratory orders,
and track performance; and 4) required staff education on best HIV testing practices
and outcomes.
Before FOCUS, UHP counselors conducted risk-based, point-of-care rapid or laboratory
HIV tests. With the new routine supported by FOCUS at UHP from January 2011 to September
2013, a medical assistant provides HIV information required by New York state, offers
an HIV test to all patients aged 13–64 years with no documented HIV test within 12
months, and documents the offer in the EHR. The EHR prompts the health-care provider
to confirm the patient’s agreement, and the health-care provider orders an HIV laboratory
test. Negative test results are provided at the patient’s next visit or by letter.
The program coordinator contacts patients who test positive and schedules an appointment
to receive their test results and follow-up at the center that provides primary HIV
medical care. The UHP commercial laboratory uses an HIV antibody assay and Western
blot that detects established but not acute HIV infection, the highly infectious stage
before antibodies to HIV develop that contributes disproportionately to HIV transmission
(4).
Before March 2013, when support from FOCUS began, ILH conducted opt-in HIV screening
with point-of-care rapid tests 70 hours a week using staff dedicated only to HIV testing
and counseling. Now the EHR prompts an HIV test offer at triage to all ED and UCC
patients aged ≥13 years who have had no documented HIV test within 6 months. Unless
the patient declines, the HIV test is ordered and processed in the hospital laboratory
24 hours a day, 7 days a week. Test results are delivered during the same visit. Patients
who test positive receive CD4+ T-lymphocyte cell count and HIV viral load tests, meet
with a navigator, and are linked to local HIV care facilities. The ILH laboratory
uses an HIV antigen/antibody combination assay and, if necessary, a nucleic acid test
to detect acute or established HIV infection.
Each program provided data on the testing outcomes before and after the new screening
programs, which were collected from EHRs (last updated in March 2014). At UHP, new
diagnosis and linkage to care† were based on patient report and chart review. ILH
defined a new HIV diagnosis as one not previously reported to the HIV surveillance
system; linkage to care was based on chart review.
At UHP, the percentage of patients tested for HIV increased from 8% during calendar
year 2010 to 56% during January 2011–September 2013. The monthly average number of
patients screened increased from 188 during 2007–2010 to 986 during the routine screening
period. Of the 3,358 patients screened in 2010, 19 (0.57%) tested HIV-positive, of
whom three (16%) were newly diagnosed. Of the 32,534 patients screened during January
2011–September 2013, 148 (0.45%) tested HIV-positive, of whom 147 (99%) received their
test result and 43 (29%) were newly diagnosed. The prevalence of newly diagnosed HIV
infection was higher among males (0.25%) than females (0.08%), non-Hispanics (0.23%)
than Hispanics (0.12%), and persons aged ≥31 years (0.18%–0.19%) than persons aged
≤30 years (0.08%) (Table 1). None of the 148 patients diagnosed with HIV were previously
receiving medical care, and 120 (81%) were subsequently linked to HIV medical care.
At ILH, the HIV screening program increased the percentage of patients tested from
17% (ED) and 3% (UCC) during calendar year 2012 to 26% (ED) and 17% (UCC) from mid-March
to December 2013. The monthly average number of patients screened increased from 821
during 2010–2012 to 1,323 in the 2013 period. Of the 11,257 patients screened in 2012,
106 (0.94%) tested HIV-positive, of whom 54 (51%) were newly diagnosed. Of the 12,568
patients screened from mid-March to December 2013, 102 (0.81%) tested HIV-positive,
of whom 100 (98%) received their test result, 77 (75%) were newly diagnosed, and five
(5%) had acute HIV infection. The prevalence of newly diagnosed HIV infection was
higher among males (0.89%) than females (0.28%), blacks (0.63%) than whites (0.49%),
Hispanics (1.00%) than non-Hispanics (0.60%), and persons aged 23–30 years (0.92%)
than in age groups <23 (0.68%) and >30 years (0.32%–0.71%) (Table 2). Among the 102
patients testing HIV-positive, 91 (89%) were not previously receiving medical care;
67 (74%) of these 91 patients, including the five patients with acute HIV infection,
were linked to HIV medical care.
Discussion
The findings of both FOCUS programs demonstrate that routine HIV screening using existing
clinical staff increased the numbers of patients tested and diagnosed with HIV infection.
The prevalence of undiagnosed HIV infection at both programs exceeded CDC’s recommended
threshold (≥0.1%) for routine screening (3), and most persons previously diagnosed
with HIV infection at both programs were not receiving medical care. UHP and ILH identified
patients with undiagnosed and previously diagnosed HIV infections and successfully
linked the majority to HIV medical care. Active linkage is an essential element of
a routine screening program to ensure that HIV-infected persons receive HIV care and
services. These integrated routine HIV screening programs can serve as models for
other emergency and primary health-care settings.
Several factors associated with the FOCUS principles, including supportive institutional
policy changes, EHR prompts, staff education, and conventional laboratory testing
for HIV, contributed to these sustainable and scalable routine HIV screening programs.
Similar EHR prompts, provider training, and periodic feedback led to immediate and
sustained increases in HIV testing in Veterans Healthcare Administration facilities
during 2009–2011 (5). New laboratory testing methods can reduce turnaround time for
test results, are more sensitive during early infection, and can detect acute HIV
infections. The transition from point-of-care rapid testing to laboratory testing
reduced staff time (6) and costs (7), increased feasibility to test larger numbers
of patients, and allowed ILH to detect acute HIV infections. Almost all patients who
tested HIV-positive received their test results. UHP received FOCUS support in the
first 2 years but has continued the HIV screening program without external funding.
Replication of the FOCUS model has begun; UHP staff trained five federally qualified
health centers in New York City in 2013 to implement routine HIV screening.
The findings in this report are subject to at least four limitations. First, it was
not possible to assess how much each factor of the new screening strategy individually
contributed to the increase in screening. Second, the findings from this study might
not be generalizable to other clinic settings with different HIV prevalence. Third,
UHP might have underestimated HIV infections because its laboratory testing was unable
to detect acute HIV infection. Finally, linkage to care might be underreported if
it occurred at a different care facility.
Routine HIV screening with an active linkage element reduces the number of persons
unaware of their HIV infection and links patients to medical care. These patients
are then able to benefit from effective treatment to improve health and reduce transmission
risk (2). The two programs highlighted in this report screened more patients for HIV
by using EHR prompts, conventional laboratory testing, and provider training and feedback.
Combined, these techniques identified more patients with HIV infection and linked
them to care by adopting practices that other health-care settings might choose to
replicate.
What is already known on this topic?
In 2006, CDC issued recommendations for routine human immunodeficiency virus (HIV)
screening of adults, adolescents, and pregnant women in health-care settings. However,
many clinical settings have not adopted routine screening. Routine screening promotes
the linkage of HIV-infected persons into medical care. This allows them to benefit
from effective treatment, which improves their health and reduces HIV transmission.
What is added by this report?
Electronic health record prompts, staff education, and shift from point-of-care rapid
testing to laboratory testing were features that made routine HIV screening programs
successful at the Urban Health Plan in New York City and the Interim Louisiana Hospital
in New Orleans. This allowed integration of HIV screening into clinic workflow, scalability
(i.e., the ability to expand the number of patients screened), and sustainability.
In addition to identifying patients newly diagnosed with HIV infection, routine screening
also identified patients previously diagnosed but not in care, and actively linked
these patients to care.
What are the implications for public health practice?
These programs made HIV screening more scalable, and linked patients to HIV care.
The design is being sustained without external support at the Urban Health Plan and
is being replicated in other clinics. These two programs can serve as models that
could be adapted by other health-care settings.