Diagnosing HIV Infection in Primary Care Settings: Missed Opportunities

Abstract

In the United States, 20% of HIV-infected persons are unaware of their diagnosis. Improved application of HIV screening recommendations in healthcare settings may facilitate diagnosis. Clinical patient data and previous healthcare visits were reviewed from medical records of newly diagnosed HIV-infected persons in Durham County, North Carolina, who initiated HIV care at Duke University Medical Center in 2008-2011. Comparisons were made to similar data from 2002-2004 using the Pearson's chi-square test and logistic regression. 101 consecutive newly diagnosed patients were identified: 67 males; 73 black, 20 white, and 8 Hispanic/Latino. Mean age was 39 years (range, 17-69), and 73 had health insurance. Median baseline CD4 count was 313 cells/μL (range, 4-1302), and HIV-1 viral load was 45,700 copies/mL (range, 165-10,000,000). One-third had a baseline CD4 count <50 cells/μL, and 15% presented with opportunistic infections. Compared to patients newly diagnosed in 2002-2004, significantly greater proportions were black and less immunocompromised in 2008-2011. Most had been seen at least once by a healthcare provider in the year prior to HIV diagnosis: 72 had ≥1 prior visits, and 47 had ≥2 visits. Among those with prior visits, 37/72 (51%) were seen in an emergency department on the first or second visit. Men were three times more likely than women to be diagnosed at their first healthcare encounter (p=0.03, OR=3.2). Despite CDC recommendations for widespread HIV screening in healthcare settings, HIV diagnosis remains delayed, even among those with frequent healthcare encounters. Educating providers and removing barriers to HIV screening may improve this problem.

Late HIV Diagnosis: Differences by Rural/Urban Residence, Florida, 2007–2011

“…Late diagnosis has generally been found to be more common among men and older adults in multiple studies in the US, Australia, Europe, and Asia. 13,28,[41][42][43][44][45][46][47][48][49][50][51] Health care providers may be less likely to consider HIV infection in an older adult, and older adults may perceive themselves as at lower risk than younger adults. 51 Rapid disease progression, which would appear as a late diagnosis, has been reported in older adults.…”

Uptake of Testing for HIV and Syphilis Among Men Who Have Sex with Men in Baltimore, Maryland: 2004–2011

“…A study by D. German et al [16] demonstrated that high percentages of non-Hispanic/non-Latino black and younger MSM in Baltimore were unaware of their HIV infections and hypothesized that testing efforts were not adequately reaching these groups. Other studies have demonstrated that opportunities for HIV testing are often missed during health care visits [20][21][22].…”

Black:White Disparities in HIV Mortality in the United States: 1990–2009

“…Additionally, factors such as poor reimbursement for HIV tests, competing health needs, and possible provider biases or comfort level in providing positive results to certain patients have been cited as potential barriers to HIV testing by clinicians [54][55][56]. Thus, even when connected to health care, certain populations are less likely to be offered testing [57,58].…”