Hospitals, EDs miss many HIV-infected individuals

Study calls for routine HIV testing

Hospitals and their emergency departments (EDs) miss repeated opportunities to identify people who are infected with HIV but do not know their status, according to new research by Michael Mugavero, MD, associate professor in the University of Alabama at Birmingham (UAB) School of Medicine.1

Among patients newly-diagnosed during an inpatient hospitalization, more than half had prior missed opportunities for HIV screening in a hospital or ED, he found. The study found sociodemographic disparities in hospital diagnosis of HIV. Patients who are black, have an opportunistic infection and low CD4 cell count were more likely to be diagnosed in the hospital.

"We evaluated patients who were newly-initiating HIV care at the UAB 1917 HIV clinic from September 2006, when the CDC's guidelines on universal HIV screening were first released," says Michael Mugavero, MD, associate professor in the University of Alabama at Birmingham (UAB) School of Medicine.

"We found that 28% of the 300 new clinic patients since that time were diagnosed with HIV in an emergency room or during an inpatient hospitalization, including 30 individuals at our institution," he adds.

Among the 30 patients diagnosed at the university hospital, more than half had been in the hospital's ED or inpatient setting within the previous two years. This suggests there were missed opportunities for HIV testing, Mugavero says.

"Clearly they had access to the system," he says.

The demographic characteristics of patients who received their HIV diagnosis during an ED or inpatient hospital stay suggest these patients with missed early diagnosis opportunities are more likely to be African American or another minority, have socioeconomic disparities, have Medicare, Medicaid or no insurance, and who had not had a previous HIV test.

"We found that patients in the ED and hospital tended to be older at the time of diagnosis," Mugavero says.

Additional costs average $76,500

Finding HIV patients late has economic implications, which researchers briefly addressed.

For instance, the study found that the missed opportunities for HIV diagnosis resulted in patients being hospitalized due to HIV disease and opportunistic infections, costing an average of $76,500 per patient hospitalization, Mugavero says.

"Part of our interpretation was that half of the patients diagnosed as inpatients had accessed the ED or been in our hospital at UAB," he adds. "If we had diagnosed them at that time and gotten them into appropriate therapy, might some of these hospitalizations been avoided?"

It's possible that if hospitals put resources into supporting routine HIV testing that it would pay for itself, he says. "Our numbers are small and you need to be cautious, but part of our message is: How do you pay for it?"

If hospitals end up absorbing the cost of routine HIV screening then the question is whether this will avert costs of hospitalizations of undiagnosed HIV/AIDS patients, he adds.

"This study did not use a sophisticated economic analysis," Mugavero says. "I think that we need more sophisticated economic analyses in terms of thinking about averting costs of hospitalization by implementing routine testing in the emergency department."

Hospitals like the UAB hospital often offer HIV testing on a case-by-case basis, following no particular set policies or protocols, he notes.

Implementation of HIV screening in an ED setting is challenging and ideally would require an internal champion. Challenges include obtaining staff buy-in, launching and then sustaining the program, and maintaining staff enthusiasm for the practice.

The UAB hospital has received a Centers for Disease Control and Prevention (CDC) grant to fund routine HIV testing in the emergency department. It's an opt-out program, using a rapid HIV test, and researchers have identified a physician champion who has discussed it with nurses and other ED physicians, lab and hospital administrators and won their cooperation, Mugavero says.

"We have to communicate why this is important and why we care," he adds. "And we have to get people who are diagnosed as HIV positive into outpatient medical treatment at the HIV clinic a few blocks away shortly thereafter."

If the newly-diagnosed HIV-positive patients do not seek treatment then there is no public health benefit to their being screened.

So what might appear to be a simple task of implementing routine HIV testing becomes complex and challenging to sustain.

"It requires significant personnel to do it around the clock," Mugavero says. "Ultimately, our long-term goal is to work with the hospital's administration to work together to ensure long-term sustainability of a routine HIV testing program."

Reference

  1. Modi S, Willig J, Tamhane A, et al. Missed opportunities and costs associated with inpatient HIV diagnosis.Poster:1060. Presented at the 48th Annual Meeting of the Infectious Disease Society, held Oct. 21-24, 2010, in Vancouver, British Columbia, Canada.