While other medical systems across the country failed to maintain HIV screening volumes throughout the COVID-19 pandemic, the University of Chicago Medicine maintained screening volumes by including universal HIV screening alongside COVID-19 testing in its busy emergency department, according to a new report published April 12 in JAMA Internal Medicine. Through targeted efforts to maintain infrastructure and enthusiasm for HIV screening, the number of HIV tests remained at pre-pandemic levels while the rate of acute HIV diagnoses actually increased.
Widespread screening to diagnose individuals newly infected with HIV is a key part of Centers for Disease Control and Prevention's (CDC) plan to end the HIV epidemic in America. However, the COVID-19 pandemic presented a challenge, because changes to the logistics of running emergency departments during a pandemic led to reduced HIV screening across the country.
"At UChicago Medicine, we successfully maintained our screening volume because we implemented infrastructure to facilitate continued routine HIV screening alongside COVID-19 testing in our emergency department," said first author Kim Stanford, MD, MPH, Assistant Professor of Medicine.
"We wanted to test as many people as possible in the emergency department, and Kim's team was unique in having the foresight to include phlebotomy for HIV testing in evaluation of people who were otherwise being seen for COVID-19," said senior author David Pitrak, MD, Professor of Medicine.
The investigators found that the diagnosis rate of acute HIV infection at UChicago Medicine actually rose during the pandemic compared to the previous four years. Other emergency departments that did not implement HIV screening as a part of COVID-19 testing saw a reduction in their HIV diagnoses.
While UChicago Medicine did see a rise in the rate of new HIV diagnoses, which has large implications for public health, it is as of yet unclear what drove this increase.
"It's possible that through screening during a COVID-19 test, we are just detecting more infections than we would have otherwise, and there isn't actually more widespread transmission," said Pitrak "It's also possible that the pressures of social isolation and drop offs in routine visits for HIV care led people to engage in more high-risk behaviors, and that community transmission is actually up. We don't know yet, but finding that out will be important for strategizing how to continue to stem further HIV transmission."
The CDC recommends HIV screening as a part of emergency department visits, yet only about 2% of these visits nationally are actually associated with a test.
"Emergency departments really are the places in the medical center with the highest prevalence of undiagnosed HIV infection," said Pitrak.
According to Stanford, screening for HIV during emergency department visits is especially critical for people in low-resource settings, since they may be at elevated risk for HIV infection and may not undergo routine screening. That means an emergency department visit is a critical opportunity to diagnose new infections.
Both Pitrak and Stanford emphasized how critical it is for a HIV testing program to have strong advocates in both the emergency and infectious disease departments.
"You need a strong partnership between these two parts of the medical system for this type of screening program to succeed. Our teams have been able to work well together to implement this program," said Stanford.
"Many doctors think there are these barriers that prevent them from ordering testing: 'What do I do if the test comes back positive? How am I going to help these patients get care? How am I going to answer all of their questions?'" said Pitrak. "Here at UChicago Medicine, we have a strong program to link patients to care and make sure they can access needed resources, so doctors don't need to worry about any of these questions. It's all streamlined and handled for them."
Both Pitrak and Stanford see the strength of this program in both the ability to diagnose individuals who may not normally be screened and its use as a model for other screenings during emergency department visits.
"Some of these patients normally wouldn't have come in for testing, and only received a diagnosis because they visited the emergency department because they were concerned about having COVID-19," said Stanford.
The results of the HIV screening program also suggest that other screenings as part of emergency room visits may be similarly useful.
"Diabetes screenings would be especially useful here at UChicago Medicine, for example, given the high rates in our community," said Stanford. "This could be extremely valuable for helping patients with little access to resources get a proper diagnosis and get connected with necessary treatment before their condition becomes severe."
On the HIV front, UChicago Medicine is continuing to move forward. "We are building a plan to work with other emergency departments in Chicago to implement both HIV and Hepatitis C screening," said Pitrak. "This really has the potential to help patients across the region. It's very exciting."