Nearly 25% of HIV Diagnosed in Emergency Rooms Is Acute Infection

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Only a small percentage of the more than 22,000 people tested for HIV at an emergency department in Phoenix were found to be infected, but of these nearly one-quarter had acute or recent infection, during which viral load is high and onward transmission is more likely, according to a study published in the June 22 advance edition of Annals of Emergency Medicine.

Kara Geren of Maricopa Integrated Health System and colleagues offered voluntary HIV screening to adult patients seen at the Maricopa Medical Center emergency department, using a fourth-generation combined antigen/antibody blood test that can detect acute infection.

Among 22,468 patients tested, 78 (0.28%) had a new HIV diagnoses. Of these, 18 (23% of all new diagnoses) had acute HIV infections, and 22 (28%) already had a CD4 count below 200 cells/mm3 or an opportunistic illness, indicating AIDS.

"One of the greatest concerns about this program was asking an already overburdened, under-resourced ED and its staff to perform a public health function," the study authors wrote. "By making non-targeted, opt-out HIV screening an organizational priority, the ED has become a long-term investment in the health of the community rather than simply a location for acute care."

Below is an edited excerpt from an American College of Emergency Physicians press release describing the study findings.

Many ER Patients Test Positive for HIV While in Most Infectious Stage

Washington -- June 24, 2014 -- Human Immunodeficiency Virus (HIV) screening for emergency patients at an institution with a large number of ethnic minority, underinsured and uninsured people reveals few are HIV positive, but of those who are, nearly one-quarter are in the acute phase and more than one-quarter have infections that have already advanced to Acquired Immune Deficiency Syndrome (AIDS). The results of the study were reported online yesterday in Annals of Emergency Medicine ("Identification of Acute HIV Infection Using Fourth Generation Testing in an Opt-Out Emergency Department Screening Program"). 

"People may believe that HIV and AIDS are diseases of the 20th century, but our results show that many people continue to be infected without being aware of it," said lead study author Kara Iskyan Geren, MD, MPH, of Maricopa Integrated Health System in Phoenix, Ariz. "Proper diagnosis before HIV progresses to AIDS allows for interventions that can extend life as well as minimize the risk of transmission to other people. Of the patients with confirmed HIV diagnosis, we were able to connect 72 percent with HIV care within 90 days."

Of 22,468 patients who were tested for HIV, 78 (0.28 percent) had new HIV diagnoses. Of those, 23 percent had acute HIV infections and 28 percent had a T-cell count below 200 or an opportunistic infection (in other words, had AIDS). Eighty-two percent of patients with confirmed HIV did not have health insurance. Patients excluded from testing included those who had an altered level of consciousness and had higher risk profiles, such as prison inmates.

Dr. Geren and her team used a fourth generation antigen/antibody HIV test with rapid results which has only been available since 2009. The relatively new test allows for earlier and easier detection of HIV. 

"In 2006, the Centers for Disease Control and Prevention (CDC) suggested universal screenings for patients in populations with a prevalence of undiagnosed infections greater than 0.1 percent, which would include our patient population," said Dr. Geren. "However, it is difficult to ask an already overburdened, underfunded emergency department and its staff to perform a public health function. The reality is that the lack of organizational support and upfront costs will likely be major barrier to implementing this type of testing in many emergency departments across the country."

Annals of Emergency Medicineis the peer-reviewed scientific journal for the American College of Emergency Physicians, the national medical society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. For more information, visit www.acep.org.

6/27/14

Reference

KI Geren, F Lovecchio, J Knight, et al. Identification of Acute HIV Infection Using Fourth-Generation Testing in an Opt-Out Emergency Department Screening Program. Annals of Emergency Medicine. June 22, 2014 (Epub ahead of print).

Other Source

American College of Emergency Physicians. Many ER Patients Test Positive for HIV While in Most Infectious Stage. Press release. June 24, 2014.