Abstract
Since 2006, numerous testing initiatives have been launched across the United States to increase the number of individuals who know their HIV status. These initiatives are often venue based and reported in a variety of settings. However, the effectiveness of these initiatives has not been evaluated to determine if patients were identified earlier in the course of disease or would not have been otherwise tested. In 2010, a publicly funded teaching hospital implemented an electronic medical record prompt to improve the rate of routine HIV screening and diagnosis, focusing on primary care office visits. Both sex and CD4 count were found to be significantly related to being newly diagnosed after the intervention. Routine testing in primary care is an effective strategy to diagnose patients earlier in disease progression, particularly men who might otherwise not be tested and thus would remain undiagnosed until developing symptoms from advanced disease.
Introduction
Nearly 1.1 million Americans are living with HIV and 50 000 Americans are projected to become infected annually. 1,2 Among those infected, about 18% are unaware of their positive status. 1 Improvements in HIV testing and treatment options have decreased death and morbidity related to HIV; however, to take advantage of the improvements in HIV diagnosis and care, HIV-infected individuals must be aware of their HIV-positive status. In 2006, the US Centers for Disease Control and Prevention recommended routine HIV screening of adults, adolescents, and pregnant females aged 13 to 64 in healthcare settings in the United States. 3 Since that time, the White House has supported routine HIV testing as part of its National HIV AIDS Strategy, and the US Preventive Services Task Force recommended HIV testing for persons 15 to 65 years of age—a grade A recommendation ensuring that it is covered by health insurance. 4,5
Prior to this recommendation, risk-based screening was standard and only individuals meeting risk criteria for HIV were targeted for testing. 6 As a result of risk-based screening, individuals not considered at risk by self-report of risk status were not encouraged to seek testing and therefore missed the opportunity for potential diagnosis. 7,8 Conceptually, by implementing routine screening, individuals diagnosed have the opportunity to receive treatment earlier in the course of disease, and by receiving treatment these individuals will live longer and healthier lives and will be less likely to transmit the virus. 9 -12
Since 2006, numerous testing initiatives have been launched across the United States to increase the number of individuals who know their HIV status. These initiatives are often venue based and have been reported in a variety of settings including inpatient and outpatient clinics, community events, and correctional facilities. Additionally, these initiatives have been considered difficult to implement and in many cases deemed unsuccessful due to physician knowledge, attitude, and behavior-related barriers. 13
Evaluation of most testing initiatives has been limited to the number of tests performed and the rate of positive tests, often without accounting for duplicate testing or prior diagnoses. 14 -16 In addition, despite the overall increase in individuals reporting ever being tested for HIV, the rate of new diagnoses as well as late diagnoses (AIDS within 12 months of HIV diagnoses) remained unchanged as of 2011. 17
In 2010, MetroHealth, a publically funded teaching hospital, implemented an electronic medical record (EMR) prompt to improve the rate of routine HIV screening and diagnosis, focusing on primary care office visits. This local testing initiative successfully increased HIV testing among patients seeking primary care, who had not otherwise been tested at the institution. However, the effectiveness of this testing initiative has not been evaluated to determine if patients who were identified earlier in the course of disease or would have otherwise not have been tested.
Late diagnosis of HIV, which is frequently defined as a CD4 count of <200 and/or progression to AIDS in ≤12 months following diagnosis, is associated with poor outcomes due to opportunistic infections, increased medical care costs due to increased hospitalization, and decrease in CD4 recovery. Significant short-term mortality is also associated with late presentation. 18 Conversely, the earlier an individual is diagnosed, the less likely the individual is to transmit HIV because of adoption of safer sexual behavior and/or use of highly active antiretroviral therapy. Additionally, early diagnosis facilitates entry into medical care and promotes preservation of immune function and prolongation of disease-free survival. 19
Background
The MetroHealth System (MHS) is a publicly funded academic teaching hospital in Cleveland, Ohio, and the primary provider of indigent care to the community. In 2010, MHS initiated an EMR prompt for HIV testing at all sites for individuals 13 to 64 years old. A published research report shows that this testing initiative increased the proportion of individuals who were ever tested and focused on those never tested in outpatient primary care. 20 The methods of this intervention are described elsewhere. 21
Materials and Methods
Laboratory reports of positive Western blots were used to identify individuals newly diagnosed with HIV. For this analysis, only tests associated with an office visit from a primary care site for individuals who were 18 years and older at the time of diagnosis were included. A manual chart review then confirmed that patients were not previously diagnosed with HIV. Previously diagnosed cases and those diagnosed in specialty care, obstetrics, and during hospitalization were excluded from the analysis. Demographics (sex and race), clinical characteristics (CD4 count at the time of diagnosis and self-reported HIV risk factor), and indicators of healthcare utilization (number of hospital admissions 12 months prior to diagnosis, self-report of prior HIV testing, and number of emergency department [ED] visits 12 months prior to diagnosis) were collected via manual review of the EMR. Institutional review board (IRB) approval for the conduct of this study was granted by the MHS IRB.
Measures
Demographics (sex, race, and age), clinical characteristics (CD4 count at diagnosis and self-reported HIV risk factor), and indicators of healthcare utilization (hospital visits 12 months prior to diagnosis, previously tested ever, and ED visits 12 months prior to diagnosis) were collected.
Sex
Sex was measured as male, female, or transgendered. Due to low numbers of transgendered individuals diagnosed in primary care during the study period, they were excluded from the analysis.
Race
For the purpose of this study, race was delimited to 2 categories: African American and other.
Age
Age was defined as how old, in years, the individual was at the time of HIV diagnosis.
CD4 count
The first CD4 count (cells/mm3) was recorded as the CD4 count at diagnosis and occurred within 1 year of diagnosis.
Risk factor for HIV
Self-reported HIV risk was collected from the initial office visit or social work visit subsequent to diagnosis and categorized as heterosexual, men who have sex with men or bisexual, injection drug user, or not reported.
Healthcare utilization characteristics
Healthcare utilization for hospital visits and ED visits was determined by the number of encounters that occurred in the 12 months prior to diagnosis. These encounters were categorized as 0 and 1 or more encounters. Prior HIV testing was based on self-report at the initial HIV office visit following diagnosis and was not verified by other sources.
Timing of test for diagnosis
The outcome of interest was the timing of test that indicated HIV infection and was defined as a binary variable. Patients were classified as diagnosed before the HIV testing intervention or after the HIV testing intervention.
Analysis
Descriptive statistics were completed to characterize the sample newly diagnosed. Crude and adjusted logistic regressions were performed to determine if there was a significant difference between patients who were diagnosed before and after implementation of the EMR prompt. All analyses were performed using SAS version 9.3 (SAS Institute).
Results
Sample Characteristics
A total of 89 individuals were newly diagnosed in primary care office visits at MHS between 2008 and 2012. Overall, these individuals were on average 39.85 years old (SD = 11.94), primarily African American (n = 49, 55%), male (n = 66, 74.1%), and not previously hospitalized 12 months prior to being diagnosed (n = 83, 93.2%). Thirty-nine percent (n = 35) were seen in the ED 12 months prior to being diagnosed and 52.8% (n = 47) reported prior HIV testing as shown in Table 1. Individuals who were diagnosed before the intervention (n = 46) had a mean age of 38 years (SD = 12.52) and had a mean CD4 count of 331.2 cells/mm3 (SD = 197.8). On average, individuals who were newly diagnosed after the intervention (n = 43) were older (mean = 41 years, SD = 11.08) and had a higher CD4 count (mean = 399.4, SD = 297.2).
Demographic and Clinical Characteristics of Individuals Diagnosed with HIV in Primary Care Overall, 2008 to 2012.
Abbreviations: ED, emergency department; IDU, injection drug user; MSM, men who have sex with men; SD, standard deviation.
Logistic Regression Results
Unadjusted logistic regression analyses were conducted and no demographic or clinical characteristics were shown to be significantly related to being newly diagnosed after the intervention (Table 2, third column). Among the key findings, in the adjusted logistic regression analysis, sex and CD4 count were significantly related to being newly diagnosed after the intervention (Table 2, fourth column). Males were 5.35 times (95% CI: 1.25-27.58) more likely than females to be newly diagnosed after the intervention. For every 50 cells/mm3 increase in CD4 count, diagnosis after the intervention increased by 14% (adjusted odds ratio [aOR]: 1.14, 95% CI: 1.03-1.30).
Descriptive Statistics by Time of Diagnosis and Crude, aORs, and 95% CIs for Timing of HIV Diagnosis in Primary Care, 2008 to 2012.
Abbreviations: 95% CIs, 95% confidence intervals; aOR, adjusted odds ratio; ED, emergency department; IDU, injection drug user; MSM, men who have sex with men.
aValues represent mean and standard deviation.
bOdds ratio represents a 50-unit increase.
cSignificant at .05.
Discussion
Diagnosing HIV in primary care effectively identified patients who were healthier based on CD4 count and were less likely to have been tested for other reasons (hospitalization, illness). Additionally, men, a subgroup of the population known to be infrequent users of primary care, were more likely to have been tested after the intervention. As noted previously by Avery et al, men had very low rates of ever being tested before the intervention despite comprising the three-quarters of the cases locally and nationally. 20 Men access health care and seek preventive services less frequently than women, yet engage in risk behaviors more frequently. 22,23 It remains important to capitalize on every primary care health encounter to ensure men are tested and if found to be HIV positive, they may begin care earlier in the course of the disease. 23
In addition to demographics and initial CD4 count, we reviewed markers of healthcare utilization. Interestingly, we saw opposite trends with hospitalization and ED visits. We suspect this may be related to local practices of frequent HIV testing among hospitalized patients and with a paucity of testing occurring in the ED. Diagnosing individuals with higher CD4 counts, who infrequently use health care, may mean that these individuals are not experiencing health issues related to HIV and are therefore not seeking care. Because individuals are not experiencing signs or symptoms of infection when diagnosed, diagnosis is potentially occurring earlier in disease progression. With earlier diagnosis, prognosis and treatment may be more effective. 24,25
There was not a meaningful difference in age between newly diagnosed individuals before and after the testing intervention despite the national rise in cases among young adults. The implementation of the Patient Protection and Affordable Care Act and more young healthy individuals encouraged to seek preventive care may change who attends primary-care clinics. However, additional strategies may be needed to better reach and test this group.
Although hospitalizations 12 months prior to diagnosis and diagnoses among heterosexuals were not significantly associated with being diagnosed after the intervention, the implications of these results are important to note. After the intervention, individuals were 5.99 times (95% CI: 0.67-134.26) more likely to not have been hospitalized in the 12 months prior to diagnosis, suggesting that individuals being diagnosed may be healthier. We observed that diagnoses among individuals reporting only heterosexual sex, which is a group of individuals who do not traditionally consider themselves at risk for contracting HIV, were 2.50 times (95% CI: 0.61-12.20) more likely to occur after the intervention compared to all other risk groups. The current study was limited because of its small sample size and the use of chart review for determining prior testing history and risk factor for HIV.
Routine testing in primary care is an effective strategy to diagnose patients earlier in disease progression, particularly men who might otherwise not be tested and thus would remain undiagnosed until developing symptoms from advanced disease. As more people have health insurance, primary care practices are expected to be challenged with capacity. Meaningful use of the EMR is essential as providers are expected to see more patients in less time. Our initiative focused on testing patients who had never been tested and used the EMR for clinical decision support to determine who needed to be tested. We observed higher CD4 counts in patients diagnosed following the intervention and this initiative is the first to demonstrate that routine screening for HIV will identify patients at an earlier clinical stage.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.