Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2016 Jul 1.
Published in final edited form as: Am J Emerg Med. 2015 Apr 10;33(7):917–919. doi: 10.1016/j.ajem.2015.04.006

OPPORTUNITIES FOR EARLIER HIV DIAGNOSIS IN A PEDIATRIC EMERGENCY DEPARTMENT

Michelle D Eckerle 1, Madjimbaye Namde 2, Carolyn K Holland 1,2, Andrew H Ruffner 2, Kim W Hart 2, Christopher J Lindsell 2, Jennifer L Reed 1, Michael S Lyons 2
PMCID: PMC4797089  NIHMSID: NIHMS694134  PMID: 26008582

Abstract

Objectives

Emergency department HIV screening is recommended, but challenging to implement and of uncertain effectiveness in pediatric EDs (PEDs). We sought to determine whether there were opportunities for earlier HIV diagnosis in the PED for a cohort of young adults diagnosed with HIV.

Methods

This retrospective cohort study reviewed PED records of a group of young adults receiving HIV care in an urban hospital setting. PED visits were selected for review if they took place after the patient’s estimated time of HIV acquisition and before their eventual diagnosis. Charts were reviewed to determine whether HIV infection was suspected and whether testing was offered.

Results

Among a cohort of HIV-positive young adults, only 3 of 84 (3.6%; CI95 0.9 – 10.8) were seen in the PED during the time they were undiagnosed but likely to be infected with HIV. Among these subjects, there was no documentation that HIV testing was offered or refused, nor was there documented suspicion of HIV.

Conclusions

There are opportunities for earlier diagnosis of HIV in PEDs, affirming the importance of HIV screening implementation in these settings. However, PED’s are unlikely to have the same frequency of contact with undiagnosed individuals as do adult EDs. Alternative methods of accessing at-risk adolescent populations must be identified.

Keywords: HIV, Mass Screening, Emergency Medicine, Epidemiology, Adolescent

INTRODUCTION

Early HIV diagnosis leads to improved health outcomes for infected individuals and reduced transmission (1, 2). Emergency departments (EDs) in particular have been called to expand HIV screening (3–6). Although progress has been made, implementation of HIV screening recommendations remains suboptimal (7–10).

Adolescents are frequently infected and infrequently tested. They account for nearly 60% of all undiagnosed HIV infections in the US (11). Pediatricians in outpatient settings are less likely to recommend HIV testing as compared to other STI testing even for those who are at high risk (9, 12). While improvements are needed in that setting, extrapolation from adult studies suggests that pediatric emergency departments (PED) may also be an ideal venue to access high risk populations. However, HIV screening in PEDs has not been widely studied or broadly implemented. The few experiences that have been reported demonstrate acceptance of testing by adolescents but few new diagnoses (13–16).

Demonstration of unrecognized opportunities for HIV diagnosis has motivated screening implementation in adult EDs (17–20). Herein, we explore the extent to which there are opportunities for HIV diagnosis in a PED.

METHODS

This retrospective cohort study reviewed PED records for adolescents after their estimated time of HIV acquisition and before their eventual diagnosis. The study was approved by the university and the pediatric hospital IRBs.

Setting

This study was conducted at an urban, Midwest, academic health center in a region of lower HIV prevalence (21). This health center is characterized by: i) an affiliated pediatric hospital that provides the majority of regional pediatric (ages 0–21) emergency care, with an annual ED volume of approximately 90,000 visits, ii) an adult hospital whose ED features a publicly funded HIV counseling and testing program (22, 23) an infectious disease treatment center that provides the majority of regional HIV care.

Patient Selection

Adults who were newly diagnosed with HIV infection and had a CD4 count measured at the time of diagnosis were identified from two existing data sources: i) a retrospective chart review of patients receiving care at the HIV treatment center from 1999 to 2003, and ii) records from the ED HIV testing program. Methods for selecting this cohort have been described previously (18).

From this group, we included patients who were ≤ 25 years of age when diagnosed. For each subject, we then conservatively estimated the duration of time during which infection was likely but undiagnosed by calculating the difference between the lower limit of normal CD4 count (500/μL) and the CD4 count at diagnosis, divided by the lower limit of the average decrease in CD4 per year of infection (60/μL) (24–26). If initial CD4 was greater than 500/μL then we presumed infection had been present for one year. Any subject whose infection was not estimated to have been present prior to the age of 21 was then excluded.

Data Collection

PED records for visits occurring during the estimated time period during which infection was likely but undiagnosed were independently reviewed and abstracted by two PED physicians. Data was entered into a standardized study form. Agreement between abstractors was verified by a third reviewer, and no significant discrepancies were identified.

Analysis

Analysis was descriptive, and limited by the number of individuals ultimately found to have opportunities to have been diagnosed in the PED. The primary outcome was the number and proportion of eligible patients with opportunities for diagnosis in the PED. Secondary outcomes included whether or not the opportunity was missed (i.e. infected but not tested) and potential indications for HIV testing during PED encounters, including (1) clinician suspicion of HIV infection, (2) symptoms potentially indicative of HIV illness (3) risk factors, and (4) diagnoses potentially related to HIV.

RESULTS

There were 84 subjects included. Mean age at diagnosis was 22 years (SD 2.3 years, range 17 – 25) with a mean CD4 of 448 (SD 251; range 1 – 1,305). Of these, 25 had prior visits to the PED. Twenty-one were excluded from further analysis as their PED encounters were prior to the estimated time at which they became infected with HIV. In three cases, subjects missed inclusion narrowly. The time between HIV diagnosis and most recent PED encounter was 14, 16, and 25 months and initial CD4 counts were 499, 807, 1030 cells/mm3 respectively.

There were 4 remaining subjects who were presumptively infected during visits to the PED. One had been diagnosed by the pediatric hospital two years prior to the repeat diagnosis as an adult, but the PED providers did not document awareness of that history. The remaining 3 (3.6%; CI95 0.9 – 10.8) subjects and their PED visits are described in Table 1. Among these subjects, there was no documentation that HIV testing was offered or refused, nor was there documented suspicion of HIV. None of the ED encounters resulted in subsequent hospitalization.

Table 1.

Patient Characteristics and Summary of ED Encounter History for Subjects with Missed Opportunities for Earlier HIV Diagnosis in the Pediatric ED

Subject Age at Diagnosis CD4 at Diagnosis Age of Infection* Years from 1st ED Missed Opportunity to Diagnosis* Number of Visits Between Infection and Diagnosis ED Encounters
Patient Factors and Characteristics Noted at Visits Discharge Diagnoses for Visits
Black; Male 19 246 15 3.8 8

  1. discharge, multiple sex partners

  2. Rash

  3. Rash

  4. Rash

  5. Abscess

  6. Rash

  7. STD exposure

  8. Urethral discharge, multiple sex partners

  1. STD/Gonorrhe a

  2. Shingles

  3. Insect bites

  4. Insect bites

  5. Abscess

  6. Urticaria

  7. STD exposure

  8. Urethral discharge
Black; Male 18 479 18 0.6 1

  1. Details unavailable

  1. Details unavailable
Black Male 19 217 14 1.5 4

  1. Details unavailable

  2. Fever, myalgias, lost appetite, cough

  3. Scrotal pain; past STD

  4. Sore throat

  1. Details unavailable

  2. Viral syndrome

  3. Epididymitis

  4. Allergic rhinitis
Open in a new tab
*

Conservatively estimated based on initial CD4 at diagnosis and typical rate of CD4 decline after infection

DISCUSSION

Expanded HIV screening for adolescents is a critical health goal, but the best ways to reach at-risk populations in this age group are unknown. PEDs are a promising possible venue, but evidence of this is lacking. Thus far, screening in PEDs has resulted in new diagnoses in 0 – 0.6% of tests (15, 16, 27, 28). This is generally above the recommended threshold for non-targeted screening (1/1000 tests positive) (29), but insufficient to emphasize PEDs as unusually effective venues for HIV screening. We sought to clarify the potential role of PEDs in HIV screening by determining whether individuals diagnosed with HIV are frequently encountered by PEDs prior to diagnosis. The number of individuals with opportunities for diagnosis in the PED was far less than we expected, suggesting that methods other than PED screening are required to reach at-risk adolescents. Nonetheless, our study affirms the importance of PED screening by demonstrating that there are some opportunities for earlier HIV diagnosis even in a region of lower HIV prevalence.

This preliminary study has several notable strengths. Use of a reasonably large cohort of HIV positive young adults in a setting where almost all pediatric emergency care is delivered by a single center, allowed us to explore the fundamental health services question of whether adolescents with undiagnosed HIV seek care in PEDs. Reasons why most subjects in this study did not utilize the PED for healthcare are unknown, but given patterns of health care utilization in our region, we do not expect that these patients received care in other EDs. One reason may be that adolescents are relatively unlikely to seek healthcare given their generally good health. Alternatively, our estimates for duration of infection prior to diagnosis may have been overly conservative, thus limiting the chances that a PED visit would have occurred. (30–32) However, even if we included the additional three cases that missed inclusion only narrowly, it would not substantially alter the magnitude and direction of our results. It is also possible that some patients using the PED for safety net care were not included in our study; our methods selectively included individuals who were ultimately able and willing to be linked to HIV care.

Although data in this study are not recent, we assert their utility for this study question, for three reasons. First, past or current screening practices are tangential to our primary finding. Regardless of whether the PED conducts screening to capitalize on those opportunities that do exist, we found that most young adults with undiagnosed HIV did not have prior visits to the PED. Second, we are unaware of any change in HIV epidemiology or the overall health care system that would have substantially changed the relationship between adolescents and how they access healthcare. Nonetheless, we acknowledge that this study does not address current screening practices, how to identify at risk adolescents in the PED setting, or estimation of the absolute number of opportunities for diagnosis within the ED population.

Even if the frequency of opportunities in the PED is low, the presence of undiagnosed HIV among adolescents and young adults suggests the urgent need for two parallel lines of investigation. First, there is a need for efficient methods to selectively identify the undiagnosed patients that do visit the PED. Second, further research is needed to identify methods, other than PEDs, to efficiently access at-risk adolescent populations.

CONCLUSIONS

There are opportunities for earlier diagnosis of HIV in PEDs, affirming the importance of HIV screening implementation in these settings. However, PED’s are unlikely to have the same frequency of contact with undiagnosed individuals as do adult EDs. Alternative methods of accessing at-risk adolescent populations must be identified.

Acknowledgments

Funding Source: This work was supported in part by NIAID K23 AI068453, in part by AHRQ R01 HS021749, and in part by an Institutional Clinical and Translational Science Award, NIH/NCRR Grant Number 5UL1RR026314.

Abbreviations

HIV

human immunodeficiency virus

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Financial disclosure: The authors have no financial disclosures relevant to this article to disclose.

Conflict of interest: The authors have no conflicts of interest to disclose.

Contributors Statement:

Dr. Lyons had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Lyons, Namde, Holland, Lindsell, Reed.

Acquisition of data: Ruffner, Holland, Namde, Eckerle, Reed.

Analysis and interpretation of data: Lyons, Hart, Ruffner, Eckerle.

Drafting of the manuscript: Lyons, Eckerle, Reed.

Critical revision of the manuscript for important intellectual content: all

Statistical analysis: Hart, Lindsell

Obtained funding: study conduct predominately unfunded; some investigator time supported by other sources

Administrative, technical, or material support: Ruffner, Hart, Holland, Lindsell, Reed.

Study supervision: Lyons, Lindsell.

References

  • 1.Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. The New England journal of medicine. 2011;365(6):493–505. doi: 10.1056/NEJMoa1105243. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Thompson MA, Aberg JA, Hoy JF, Telenti A, Benson C, Cahn P, et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society-USA panel. JAMA: the journal of the American Medical Association. 2012;308(4):387–402. doi: 10.1001/jama.2012.7961. [DOI] [PubMed] [Google Scholar]
  • 3.Emmanuel PJ, Martinez J. Adolescents and HIV infection: the pediatrician’s role in promoting routine testing. Pediatrics. 2011;128(5):1023–9. doi: 10.1542/peds.2011-1761. [DOI] [PubMed] [Google Scholar]
  • 4.Qaseem A, Snow V, Shekelle P, Hopkins R, Jr, Owens DK, Clinical Efficacy Assessment Subcommittee ACoP Screening for HIV in health care settings: a guidance statement from the American College of Physicians and HIV Medicine Association. Annals of internal medicine. 2009;150(2):125–31. doi: 10.7326/0003-4819-150-2-200901200-00300. [DOI] [PubMed] [Google Scholar]
  • 5.Rothman RE, Lyons MS. HIV screening in emergency departments. Introduction. Annals of emergency medicine. 2011;58(1 Suppl 1):S1. doi: 10.1016/j.annemergmed.2011.03.049. [DOI] [PubMed] [Google Scholar]
  • 6.Centers for Disease Control and Prevention. Missed opportunities for earlier diagnosis of HIV infection–South Carolina, 1997–2005. MMWR Morbidity and mortality weekly report. 2006;55(47):1269–72. [PubMed] [Google Scholar]
  • 7.Beckmann KR, Melzer-Lange MD, Cuene B, Dietz M, Havens PL. The effectiveness of a follow-up program at improving HIV testing in a pediatric emergency department. WMJ: official publication of the State Medical Society of Wisconsin. 2002;101(8):30–4. [PubMed] [Google Scholar]
  • 8.Bernstein KT, Begier E, Burke R, Karpati A, Hogben M. HIV screening among U.S. physicians, 1999–2000. AIDS patient care and STDs. 2008;22(8):649–56. doi: 10.1089/apc.2007.0261. [DOI] [PubMed] [Google Scholar]
  • 9.Henry-Reid LM, O’Connor KG, Klein JD, Cooper E, Flynn P, Futterman DC. Current pediatrician practices in identifying high-risk behaviors of adolescents. Pediatrics. 2010;125(4):e741–7. doi: 10.1542/peds.2009-0271. [DOI] [PubMed] [Google Scholar]
  • 10.Hoover JB, Tao G, Heffelfinger JD. Monitoring HIV testing at visits to emergency departments in the United States: very-low rate of HIV testing. Journal of acquired immune deficiency syndromes (1999) 2013;62(1):90–4. doi: 10.1097/QAI.0b013e3182742933. [DOI] [PubMed] [Google Scholar]
  • 11.Chen M, Rhodes PH, Hall IH, Kilmarx PH, Branson BM, Valleroy LA. Prevalence of Undiagnosed HIV Infection Among Persons Aged >/=13 Years - National HIV Surveillance System, United States, 2005–2008. Morbidity and mortality weekly report Surveillance summaries. 2012;61(2):57–64. [PubMed] [Google Scholar]
  • 12.Burstein GR, Lowry R, Klein JD, Santelli JS. Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics. 2003;111(5 Pt 1):996–1001. doi: 10.1542/peds.111.5.996. [DOI] [PubMed] [Google Scholar]
  • 13.Freeman AE, Sattin RW, Miller KM, Dias JK, Wilde JA. Acceptance of rapid HIV screening in a southeastern emergency department. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine. 2009;16(11):1156–64. doi: 10.1111/j.1553-2712.2009.00508.x. [DOI] [PubMed] [Google Scholar]
  • 14.Minniear TD, Gilmore B, Arnold SR, Flynn PM, Knapp KM, Gaur AH. Implementation of and barriers to routine HIV screening for adolescents. Pediatrics. 2009;124(4):1076–84. doi: 10.1542/peds.2009-0237. [DOI] [PubMed] [Google Scholar]
  • 15.Mollen C, Lavelle J, Hawkins L, Ambrose C, Ruby B. Description of a novel pediatric emergency department-based HIV screening program for adolescents. AIDS patient care and STDs. 2008;22(6):505–12. doi: 10.1089/apc.2007.0098. [DOI] [PubMed] [Google Scholar]
  • 16.Mehta SD, Hall J, Lyss SB, Skolnik PR, Pealer LN, Kharasch S. Adult and pediatric emergency department sexually transmitted disease and HIV screening: programmatic overview and outcomes. Academic emergency medicine. 2007;14(3):250–8. doi: 10.1197/j.aem.2006.10.106. [DOI] [PubMed] [Google Scholar]
  • 17.Jenness SM, Murrill CS, Liu KL, Wendel T, Begier E, Hagan H. Missed opportunities for HIV testing among high-risk heterosexuals. Sexually transmitted diseases. 2009;36(11):704–10. doi: 10.1097/OLQ.0b013e3181ab375d. [DOI] [PubMed] [Google Scholar]
  • 18.Lyons MS, Lindsell CJ, Wayne DB, Ruffner AH, Hart KW, Fichtenbaum CJ, et al. Comparison of Missed Opportunities for Earlier HIV Diagnosis in 3 Geographically Proximate Emergency Departments. Annals of emergency medicine. 2011;58(1):S17–S22. e1. doi: 10.1016/j.annemergmed.2011.03.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.White DA, Warren OU, Scribner AN, Frazee BW. Missed opportunities for earlier HIV diagnosis in an emergency department despite an HIV screening program. AIDS patient care and STDs. 2009;23(4):245–50. doi: 10.1089/apc.2008.0198. [DOI] [PubMed] [Google Scholar]
  • 20.Liddicoat RV, Horton NJ, Urban R, Maier E, Christiansen D, Samet JH. Assessing missed opportunities for HIV testing in medical settings. Journal of general internal medicine. 2004;19(4):349–56. doi: 10.1111/j.1525-1497.2004.21251.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Ohio Department of Health. Current HIV Infection Annual Surveillance Tables, 2008–2012. Available from http://www.odh.ohio.gov/healthstats/disease/hivdata/hcty1.aspx. Last Accessed June 28, 2014.
  • 22.Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Emergency department HIV testing and counseling: an ongoing experience in a low-prevalence area. Annals of emergency medicine. 2005;46(1):22–8. doi: 10.1016/j.annemergmed.2004.12.022. [DOI] [PubMed] [Google Scholar]
  • 23.Lyons MS, Lindsell CJ, Ruffner AH, Wayne DB, Hart KW, Sperling MI, et al. Randomized comparison of universal and targeted HIV screening in the emergency department. Journal of acquired immune deficiency syndromes (1999) 2013;64(3):315–23. doi: 10.1097/QAI.0b013e3182a21611. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Lang W, Perkins H, Anderson RE, Royce R, Jewell N, Winkelstein W., Jr Patterns of T lymphocyte changes with human immunodeficiency virus infection: from seroconversion to the development of AIDS. Journal of acquired immune deficiency syndromes (1999) 1989;2(1):63–9. [PubMed] [Google Scholar]
  • 25.Samet JH, Freedberg KA, Savetsky JB, Sullivan LM, Stein MD. Understanding delay to medical care for HIV infection: the long-term non-presenter. Aids. 2001;15(1):77–85. doi: 10.1097/00002030-200101050-00012. [DOI] [PubMed] [Google Scholar]
  • 26.Kirschner D, Webb GF, Cloyd M. Model of HIV-1 disease progression based on virus-induced lymph node homing and homing-induced apoptosis of CD4+ lymphocytes. Journal of acquired immune deficiency syndromes (1999) 2000;24(4):352–62. doi: 10.1097/00126334-200008010-00010. [DOI] [PubMed] [Google Scholar]
  • 27.Hack CM, Scarfi CA, Sivitz AB, Rosen MD. Implementing routine HIV screening in an urban pediatric emergency department. Pediatric emergency care. 2013;29(3):319–23. doi: 10.1097/PEC.0b013e3182850910. [DOI] [PubMed] [Google Scholar]
  • 28.Moyer VA. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Annals of internal medicine. 2013;159(1):51–60. doi: 10.7326/0003-4819-159-1-201307020-00645. [DOI] [PubMed] [Google Scholar]
  • 29.Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recommendations and reports: Morbidity and mortality weekly report Recommendations and reports/Centers for Disease Control. 2006;55:1–17. [PubMed] [Google Scholar]
  • 30.Mellors JW, Munoz A, Giorgi JV, Margolick JB, Tassoni CJ, Gupta P, Kingsley LA, Todd JA, Saah AJ, Detels R, Phair JP, Rinaldo CR., Jr Plasma viral load and CD4+ lymphocytes as prognostic markers of HIV-1 infection. Ann Intern Med. 1997;126:946–54. doi: 10.7326/0003-4819-126-12-199706150-00003. [DOI] [PubMed] [Google Scholar]
  • 31.Samet JH, Freedberg KA, Savetsky JB, Sullivan LM, Stein MD. Understanding delay to medical care for HIV infection: the long-term non-presenter. Aids. 2001;15:77–85. doi: 10.1097/00002030-200101050-00012. [DOI] [PubMed] [Google Scholar]
  • 32.Girardi E, Arici C, Ferrara M, Ripamonti D, Aloisi MS, Alessandrini A, Scalzini A, d’Arminio Monforte A, Serraino D, Ippolito G. Estimating duration of HIV infection with CD4 cell count and HIV-1 RNA at presentation. Aids. 2001;15:2201–3. doi: 10.1097/00002030-200111090-00021. [DOI] [PubMed] [Google Scholar]

RESOURCES