Date Published: July 4, 2017
Author(s): Joseph DeRose, Jason Zucker, David Cennimo, Shobha Swaminathan.
Newark, New Jersey, is disproportionally affected by HIV with one of the highest prevalence rates in the United States. Rutgers New Jersey Medical School is a major healthcare provider to Newark’s underserved population and has implemented a HIV testing program that can diagnose and link newly diagnosed individuals to care. We conducted a retrospective chart review of all new patients seen in the Infectious Disease Practice from January 1, 2013, to December 31, 2014, to determine the proportion of patients with a missed testing opportunity (MTO) (patients with a new HIV diagnosis with an encounter at the institution in the 1 year prior to their first appointment). 117 newly diagnosed patients were identified. 36 (31%) had at least one MTO. A total of 34 (29%) of newly diagnosed patients had AIDS at presentation and 17% had CD4 counts of 50 cells/μL (p value 0.5). The two most common locations of a missed testing opportunity were the hospital ED (45%) and subspecialty clinics (37%). This study demonstrates that, even in a high prevalence institution with HIV counseling, testing, and referral service, HIV screening is lacking at multiple points of care and patients are missing opportunities for earlier diagnosis and treatment.
The Centers for Disease Control and Prevention (CDC) estimates that over 150,000 people living in the United States with human immunodeficiency virus (HIV) are unaware of their diagnosis . In addition, there is growing evidence that initiating antiretroviral therapy (ART) early can reduce HIV viral load as well as the number of infections and can help reduce HIV transmission at the population level . Access to free HIV testing services is available in all fifty of the United States and Washington DC . Despite the improvement and availability of HIV testing centers and programs to facilitate linkage to care and treatment, 49% of those testing positive for HIV are not in care and an additional 11% of those in care are not receiving ART . Of the patients receiving ART, only 30% are able to achieve adequate HIV virologic suppression . Many of these challenges can contribute to the approximately fifty thousand new HIV infections per year in the United States .
We conducted a retrospective chart review study in which we reviewed patient records from the Rutgers New Jersey Medical School Infectious Disease Practice (IDP) located at University Hospital, Newark. The IDP is the single largest provider of HIV primary care in Newark, NJ, and the majority of patients tested within UH are referred to the IDP for care and treatment. All new patients seen in the IDP from January 1, 2013, to December 31, 2014, were included in the analysis. “New patients” were defined as patients 18 years of age and older with no previous documentation of HIV infection or designated as “newly diagnosed” in the initial clinic visit documentation. Review of medical records was conducted using outpatient Centricity Electronic Medical Record (EMR) and inpatient Epic EMR.
We reviewed a total of 314 patients and identified 117 newly diagnosed patients. Table 1 demonstrates the demographics of newly diagnosed patients. The mean age of the patients was 37 years (range 18–68). The most common self-identified race was African American (71%), followed by Hispanic (6%). The majority of patients were men (62%) and the most common risk factor recorded was heterosexual sex (50%).
Earlier diagnosis and treatment of HIV have led to substantial benefits including reduction in rates of transmission, adoption of safer behaviors, and a decrease in both morbidity and mortality [13–16]. Implementation of policies advocating for increased HIV testing, linkage to care, and early ART are key factors responsible for the decreases. The START study recently showed that HIV infected individuals have a considerably lower risk of developing AIDS or other serious complications when antiretrovirals are started earlier in their disease course, even when they are asymptomatic and have higher CD4 counts . Furthermore, previous studies have demonstrated that earlier initiation of therapy not only limits complications but also reduces the rates of HIV transmission [16, 17]. For those reasons, it is critical that all PLWH (persons living with HIV infection) be diagnosed, linked to care, and started on antiretroviral therapy as early as possible. At our institution, despite the availability of on-site HIV testing, there were many patients who had >1 missed testing opportunity. This could certainly account in part for the large portion of patients (29%) who were seen with AIDS at the time of their new HIV diagnosis. Another explanation for the number of patients seen with AIDS at the time of diagnosis may be a population of “late testers.” Many reasons for “late testing” have been hypothesized in the literature  including late testing being more common in groups who do not consider themselves at high risk for infection (e.g., heterosexual contact acquisition). In our patient population, the most common risk factor for a patient with a missed testing opportunity was heterosexual contact further strengthening the concern for early and appropriate testing for patients. Routine screening for HIV in all health care encounters is one way to lead to better outcomes allowing patients who are unaware of their disease to be diagnosed and linked to care earlier on in their illness.