Study Explores Universal HIV/HCV Screening in San Diego EDs

Universal screening identifies cases in those who do not consider themselves at risk and helps re-link previously known patients who have fallen out of treatment back to care.

Universal screening programs may identify HIV and hepatitis C virus (HCV) cases in those who are not likely to get tested and help reconnect patients with HIV who have fallen out of care to treatment, according to a new study by experts from the University of San Diego published in Scientific Reports.

Two emergency departments (ED) in San Diego conducted parallel opt-out HIV and birth-cohort HCV screening programs with an additional objective of determining the number of known HIV-positive individuals out of care identified through the programs.

Study authors pointed out that out-of-care HIV positive individuals now account for 61.3% of HIV transmissions in the United States, making reestablishing treatment an important measure in curbing the epidemic.

Investigators also noted that although targeted testing (for example, of men who have sex with men or people who inject drugs) tends to identify a higher number of HIV diagnoses, identifying outliers through universal testing is important given that in 2015, 165,000 individuals in the United States weren’t aware of their HIV-positive status.

Universal testing helps identify transmission among individuals who might not seek testing, such as young black or Latino men with heterosexual risk, or those in rural areas with economic barriers preventing them from regularly seeing a primary care physician.

The United States Centers for Disease Control and Prevention (CDC) recommends routine HCV testing for Baby Boomers born between 1945 and 1965 due to contaminated transfusions, which occurred in the 1970s and ’80s as well as the frequency of illicit drug use.

Investigators pointed to previous research demonstrating the ED setting as an effective screening site for HCV. Investigator Martin Hoenigl, MD, of the Division of Infectious Diseases and Global Public Health at the University of California San Diego, explained to Contagion® that there hadn’t been any ED screening for HCV in San Diego in the past.

Electronic medical record (EMR) based universal opt-out HIV screening was implemented from July 2017 to September 2018, and the 1-month pilot EMR based birth-cohort HCV screening program was initiated in March 2018. Both programs were conducted in parallel at the 2 academic EDs in San Diego, California.

Of 48,708 patients between 13-64 years of age who visited the EDs, 33,548 answered “No/Unknown” when asked if they had an HIV test recently or were HIV positive. Of those 33,548, 24,186 (72%) choose not to opt out of HIV testing. From there, 15,238 had at least 1 visit with a blood draw which resulted in an automatic EMR order of the HIV test, leading to an HIV test result in 12,575 cases.

Of the 12,575 individuals, 81 had a positive result. Of those who tested positive, 10 were found to be false positives after confirmatory HIV testing. The investigators learned that 38 had previously tested positive, as indicated in EMR searches or self-reporting during the HIV disclosure call. This resulted in 33 new HIV diagnoses. Of those newly diagnosed, 90% were successfully linked to care.

The number of new HIV diagnoses identified was lower than expected according to study authors “and may be explained by the high density of locally accessible HIV testing available in San Diego.” An average of 0.4% of new HIV diagnoses were previously reported in 9 United States EDs, versus a rate of 0.26% found in the San Diego EDs.

Altogether, 74 individuals living with HIV who had been out of care for >12 months were identified, including 5 individuals found to be co-infected with HCV. Of the individuals who had fallen off the care continuum, 68% were successfully relinked to care. Individuals who had stopped receiving care were thus more than twice as common as new HIV diagnoses, with over two-thirds relinked to care.

Hoenigl hopes that future research will investigate the durability of relinkage to care, and address background areas such as psychiatric, housing, and drug issues that lead to initial discontinuation of HIV treatment.

ED screening programs identified higher proportions of women, blacks, and individuals with heterosexual contact as a main risk factor when compared with community-based HIV screening. Investigators put forward that “both community-based HIV screening programs and routine testing in EDs may therefore have a combined effect on reducing HIV transmission and infection in the community.” Hoenigl told Contagion® that reaching these “hidden populations” was “a primary motivation to start working on establishing these opt-out screening programs.”

HCV testing for Baby Boomers born between 1945 and 1965 was conducted on 905 individuals and identified 18 new HCV diagnoses along with 13 previously known HCV RNA positive patients who had never been treated. Of these patients, 42% were successfully linked to care. The rate of newly diagnosed HCV infections exceeded the rate of newly diagnosed HIV infections by >7fold, highlighting the importance of HCV screening in the ED.

Hoenigl informed Contagion® that “a risk based approach is really not feasible” for HCV long-term in light of how difficult it is to screen people for risk factors, and that the initial intention was to consider broader HCV screening after studying birth cohort testing given the increase in HCV prevalence among younger people. Hoenigl continued that as of mid-October 2019, the EDs involved in the study had already moved on to implementing universal HCV screening for adults.