The overall mortality rate among human immunodeficiency virus (HIV)-infected patients has significantly declined in the era of highly active antiretroviral therapy (HAART). However, little is known about the causes of death for HIV-infected patients who are hospitalized in acute care hospitals.

BackgroundEarly identification and treatment of HIV infection reduces morbidity and mortality and the likelihood of transmission to others. In 2010, the Spencer Cox Center for Health at St Luke's and Roosevelt Hospitals partnered with the emergency department to move from a counsellor-based to an integrated model of oral rapid HIV antibody (RHIV) testing in the hospital's two emergency rooms in New York City. For this descriptive study, we collected data for patients seen in the emergency department, and new HIV-positive patients linked to care between 2011 and 2012, to understand barriers to programme implementation and improve quality of routine rapid HIV testing services.MethodsOver 24 months between Jan 1, 2011, and Dec 31, 2012, we implemented the integrated HIV testing model and conducted several monitoring and quality improvement projects. Every month, we measured the number of patients eligible, triaged, offered, accepted, and completed the RHIV test, and the number who tested positive and were linked to care. Data were collected from emergency department, outpatient, and inpatient electronic health records, and were compiled as a necessary part of quality management and the provision of linkage to care. Additional analyses included acceptance rate by site and by triage nurse. Nurses with fewer than 20 triage visits were excluded. Acceptance rate data were extracted from the emergency department electronic health record in aggregate form on a monthly basis, and entered into SPSS for statistical analysis.FindingsModel change resulted in a six-fold increase in testing within 6 months. Of the 339 449 triaged visits, patients from 323 575 (95·3%) visits were eligible for screening (>13 years, triage acuity level III or higher), 305 791 (90·1%) patients were offered the RHIV test, and 34 598 (11·3%) eligible people accepted HIV testing. Among these, 25 690 (74·3%) tests were completed. 81 (0·32%) new HIV cases were identified, of which 61 (75·3%) had an HIV primary care visit within 90 days of preliminary test. In subanalyses, we identified significant differences in individual and site performance for test acceptance and test completion. Among the 105 nurses included in the analysis, acceptance rates ranged from 0·4% to 30·8% (mean 10·8%). Nurses at one emergency room had a significantly higher mean acceptance rate (0·13, SD 0·06) than did nurses at the other (0·08, SD 0·07; p<0·0001). Linkage to care improved over time.InterpretationIntegrating routine, near-universal screening into a high-volume emergency department is feasible. From these results, five quality gaps were identified for targeted intervention: eligibility, test offer, acceptance rate, test completion, and linkage to care. These gaps are likely to exist in other routine screening programmes, and each can be targeted with additional measurement and quality interventions. Interventions that we have evaluated include changes in the emergency medical room, dissemination of individual performance reports, and collaboration with the local health department to reach patients lost to follow-up.FundingThe St Luke's and Roosevelt Hospitals routine RHIV testing programme receives grant funding from the New York City Department of Health and Mental Hygiene for costs associated with RHIV testing of uninsured patients.

To determine the proportion of patients with a new diagnosis of HIV who presented to our hospital system in the three years prior to diagnosis. Secondary goals are to describe the characteristics of newly diagnosed HIV positive patients and of "late testers" (patients with CD4 < 200 at the time of HIV diagnosis) in whom prior health care encounters represent clear examples of missed opportunities for earlier diagnosis. We performed a chart review of patients who tested newly positive for HIV infection between May 1, 2006 and December 31, 2009 at St. Luke's-Roosevelt Hospital Center, the site of an EM residency and a 2009 annual census of approximately 150,000 adult visits. We identified all patients that tested HIV positive for the first time in the ED, inpatient setting, outpatient clinics, OB/GYN unit, and community outreach programs as part of a public health grant used to establish and offer free rapid testing. Electronic medical records were searched to characterize newly positive patients and to identify all of their ED, inpatient, and outpatient visits for the three years prior to the diagnosis. Prior ED visits were included as missed opportunities if they occurred while HIV testing was available in the ED. Data abstractors were blinded to hypothesis, instructed by investigators in formal training sessions, and data forms were formatted with all terms defined before abstraction. Investigators reviewed abstracted records for agreement and accuracy. Investigators used common descriptive statistics for analysis. During the study period, 23271 HIV tests were performed, and 253 persons were newly diagnosed with HIV (1.1%). The average age of persons newly diagnosed was 37.8 years; 70% were male, and minorities comprised the majority (59% black and 26% Hispanic). Medicaid was the primary insurance for 40% of new positives, and 28% were uninsured. A total of 154 new positives (61%) made at least one visit for medical care to one of our facilities in the three years prior to their positive test, for a total of 958 visits. The average number of prior visits was 6.2 per person for people with at least one prior visit. The mean duration between first presentation within a three-year period and date of positive HIV test was 338 days. 42% (n=407/958) of prior visits were to the ED, 47% (n=454/958) were to outpatient facilities and 10% (n=97/958) were inpatient admissions. The average CD4 count of patients in whom that number was available (n=184) was 247. A total of 108, or 59% of newly diagnosed patients, were late testers with a CD4 count <200. Late testers made 439 prior visits total, or an average of 4.1 visits per person. 45% (196/439) of late tester visits were to the ED, 46% (202/439) were to outpatient facilities, and 9% (41/439) were inpatient admissions. The mean duration of time between first visit and date of diagnosis was 310 days. Most of the newly diagnosed HIV positive patients had multiple health care encounters prior to their diagnosis. A large proportion of these presented with AIDS, indicating that multiple opportunities to identify HIV infection, engage patients in care, and potentially reduce spread of the disease were missed. This work supports increased efforts to implement routine HIV testing in health care settings including the ED as part of a public health strategy to decrease morbidity and mortality, and reduce spread of the disease.