Investigators discovered a more than twofold increase in cases of acute HIV during the COVID-19 pandemic as part of an ED-based screening program at UChicago Medicine (UCM). The cause of the increase remains unknown, but it underscores the importance of screening despite the fact the pandemic has strained all resources.
- Identifying HIV-positive patients during the acute phase is important because that is when patients are highly contagious.
- COVID-19 and HIV symptoms overlap. It is nearly impossible to distinguish between the two without testing. In fact, some patients present to the UCM ED concerned about COVID-19 when, in fact, they are HIV-positive.
- It is critical to make HIV screening easy for emergency clinicians. Delegate the notification and linkage-to-care aspects to other groups.
- The ED at UCM added a phlebotomy station to the rapid assessment area for patients with viral symptoms so they could undergo COVID-19 and HIV testing concurrently.
The U.S. government’s push to end the HIV epidemic ran into the COVID-19 pandemic. Lockdowns, travel restrictions, and fear are preventing many from accessing routine care that could prevent HIV or identify infections at an early, highly infectious stage. Many screening programs also are hurting as healthcare staff and other resources have been reallocated toward COVID-19-related care.
There is an opportunity in the ED to initiate or expand HIV screening programs to identify illness and link patients to appropriate care. UChicago Medicine (UCM) has identified a steep increase in cases of acute HIV since the COVID-19 pandemic began. Program administrators have put the pieces in place to ensure these patients receive needed care without interfering with patient flow or giving already-overworked emergency clinicians new headaches.
Symptoms of HIV, COVID-19 Overlap
The federally funded Expanded HIV Testing and Linkage to Care (X-TLC) program provides services throughout the south side of Chicago, but HIV screening and diagnoses have declined at most sites since the COVID-19 pandemic began, explains Kimberly Stanford, MD, MPH, assistant professor in emergency medicine at the University of Chicago. Working with colleagues in infectious disease, Stanford found a way to continue HIV screening at prepandemic rates in her ED at UCM without placing undue burdens on emergency clinicians. The program required some adjustments, but it is hard to overstate the effort’s value. During the COVID-19 pandemic, program administrators have seen a more than twofold increase in the number of diagnoses of acute HIV in patients presenting to the ED vs. acute HIV infection diagnoses in the four previous years.
“Acute HIV is the phase that happens for most people ... usually within a few weeks of becoming infected,” Stanford observes. “They go through what can be a very mild viral illness, the symptoms go away, and then many people will remain asymptomatic — sometimes for years from their HIV [diagnosis].”
However, this acute phase is important from a public health standpoint because this is a time when a patient’s viral load is extraordinarily high, making the disease highly contagious.
“There is a lot of transmission during this phase, even more so because most patients don’t know they have HIV yet because it is so soon after they were infected,” Stanford says. “It is also a very important time to get patients on antiretroviral therapy [ART]. If you get them on [ART] early on, you can reduce the severity of their illness, improve long-term outcomes, and prevent transmission from them to other members of the community.”
Clinicians must understand the symptoms of HIV and COVID-19 can overlap. In fact, what brings many undiagnosed patients to the ED is concern they might have contracted COVID-19 when, in fact, they have contracted HIV.
“They are both acute viral illnesses, so you get fever, you can have body aches, you can have nausea, vomiting, diarrhea, fatigue, and headache,” Stanford explains, adding HIV symptoms also can mimic other viral illnesses like the flu or a cold.
Without testing, it is nearly impossible to tell which viral illness is the culprit by just looking at a patient and hearing about his or her symptoms. Further, Stanford notes concerns about COVID-19 may be driving more patients to the ED.
“In the past, if somebody thought they had the flu, a cold, or they just weren’t feeling well, they would be more likely to just ride it out at home,” she says. “Now, there is fear and anxiety about COVID-19.”
Ease the Burden
How can EDs resume or initiate HIV screening approaches that do not adversely affect patient flow or operational efficiency? Of critical importance, according to Stanford, is making the screening process as easy as possible for emergency clinicians. “That includes physicians, advanced practice providers, and nurses,” she says. “Try to make it so they have the least amount of work possible.”
For instance, at UCM, there is much educational information about HIV screening posted in the ED. This shortens the amount of time providers have to spend educating patients. Further, there is a prompt in the EMR that automatically pops up when a patient should be offered the screening.
“Providers don’t have to figure out who is eligible. They can just click the button and order [HIV] screening,” Stanford says. “We have integrated it into our routine so it has become standard.”
Any patient younger than age 65 years who has not been diagnosed with HIV or tested for the illness in the previous year is eligible for HIV screening at UCM. When the EMR prompt appears at triage or later, either the patient or the provider can decline the screening. Stanford acknowledges some providers, for whatever reason, will ignore the prompt, but the ED at UCM screens about 36% of eligible patients.
Once the pandemic hit, the UCM ED created a rapid assessment area for patients who were seen with viral illness symptoms.1 At this point, Stanford integrated a station into this area for phlebotomy, too, so that eligible patients who were swabbed for COVID-19 testing could undergo blood draws for HIV screening. “Just having that right there with the supplies reduced barriers because people didn’t have to think about it,” Stanford observes.
There was some initial pushback to the idea of continuing with the HIV screening program during a pandemic. Leaders addressed these concerns with education. “We went to nursing meetings, physician faculty meetings, and resident meetings explaining the importance of this,” Stanford says.
One other obstacle was a slight delay in confirmatory HIV testing because the lab became overwhelmed, but that problem has been largely resolved. Importantly, the approach does not require any additional staff or resources. “The tests are ordered and drawn by nurses and techs who are already taking care of the patients ... our [ED] staff doesn’t follow up on any of the tests,” Stanford says. “We have a team from infectious disease ... that has made a commitment to follow up on all the results.”
Partner with ID Staff
David Pitrak, MD, chief of infectious diseases and a professor of medicine at UCM, says the health system has always promoted routine HIV screening in the ED, but agrees the success of the modified approach depends on ensuring no extra burdens are placed on frontline emergency providers. “They are not responsible for following up on the test results and they are not responsible for doing any patient notification,” he says. “Our section [infectious diseases] reviews all the HIV testing for the entire medical center on a daily basis, seven days a week, and we notify any patients who have a positive HIV test.”
However, Pitrak notes that to effectively execute notification, emergency staff must understand how important it is to obtain good contact information for patients. In the case of UCM, that message has been well-received. “We have not had any difficulty contacting patients by phone after the ED visit,” he explains. “We actually notify more than 98% of patients of their results.”
Infectious disease staffers also have quickly linked HIV-positive patients to care. “For new patients who are diagnosed, [the linkage to care rate] is well above 90%,” Pitrak reports. “For our patients who we diagnose who are previously known to be infected [with HIV] — and we don’t know that until we check with public health — those patients are a little more difficult to link to care. These are the patients who have fallen out of care previously.”
Typically, for HIV-positive patients, a physician or social worker in the infectious disease division will contact them and explain what the test results mean. These staffers also stress there is therapy available immediately (i.e., the next day).
The newly tweaked HIV screening process at UCM has enabled that program to continue unabated. “I think ours is the only program that has shown that if you test people who have the symptoms of COVID-19, you are going to find a small percentage of patients who won’t have COVID-19; they will have acute HIV,” Pitrak says. “Those folks would otherwise be missed.”
Pitrak says it is unclear what is behind the more than twofold increase in acute HIV diagnoses that have been observed at UCM during the pandemic. “We don’t know if it is just that people with acute infection are now coming to the ED because they are more concerned they have COVID-19,” he says. “A lot of patients tell me that they went to the ED because they thought they had COVID.”
Other factors could be playing a role. For instance, Pitrak observes there has been a decline of in-person visits at clinics that perform HIV screening and provide pre-exposure prophylaxis. “I think we are also possibly seeing an increase in new transmissions, and the [increase in] acute cases may just be the tip of the iceberg,” Pitrak cautions.
Regardless of the factors involved, Pitrak and Stanford urge EDs to implement or continue with routine HIV screening. “The lessons are that it is possible to do this even when there is a pandemic going on. Perhaps it is even more important with the pandemic because people are losing their access to regular outpatient care,” Stanford says. “The ED is an even more important source of screening and care than ever.”
By easing burdens on emergency personnel, that could make everyone more likely to participate in HIV screening. “Whatever ways you can automate [the process] — use your EMR to remind people, make it as easy as possible to order, and have follow-up taken care of by somebody else,” Stanford says.
Provide regular updates on screening program results to emergency providers. “Every month, and sometimes more often, we give feedback to all the staff about the HIV infections we have caught and any new things we have learned,” Stanford explains. “I think that has really helped to increase enthusiasm for the program because [emergency clinicians] see they are making a difference.”
Generally, infectious disease specialists will be the most logical partners to work with the ED in developing an effective HIV screening program, according to Pitrak.
“Most hospitals that have an ED have a section of infectious diseases ... and these departments usually have a staff that sees patients with HIV. Even if [an infectious diseases department] doesn’t have a comprehensive HIV care program, the ID physician or another group could certainly do the notification, and then link [patients] to a group that does that type of comprehensive HIV care,” Pitrak advises. “There is no sense in screening if you can’t notify people of their results or link them to care. I think that is better done by a group that deals with HIV all the time.”
- Stanford, KA, Friedman EE, Schmitt J, et al. Routine screening for HIV in an urban emergency department during the COVID-19 pandemic. AIDS Behav 2020;24:2757-2759.