Incorporating HIV Screening With COVID-19 Testing in an Urban Emergency Department During the Pandemic

The COVID-19 pandemic has had negative consequences on HIV care and prevention programs, including routine HIV screening in health care settings.¹ This has serious implications for the Ending the HIV Epidemic plan for the United States.² Herein, we report the results of incorporating phlebotomy for universal HIV screening into COVID-19 testing at The University of Chicago Medicine (UCM) emergency department (ED) for the purpose of maintaining screening volumes.

The institutional review board at the UCM Medical Center granted exemption for this project because the data set analyzed contained deidentified data. We reviewed data from the Expanded HIV Testing and Linkage to Care Program, a collaboration between 13 health care centers on the South and West sides of Chicago, during the COVID-19 pandemic.³ Sites include community health centers, community hospitals, and academic hospitals, including 5 EDs, all of which implemented opt-out HIV screening according to guidelines.⁴ Since 2016, sites perform combination HIV antigen-antibody testing and have processes for rapid linkage to care and antiretroviral initiation for patients with acute HIV infection (AHI).⁵ The ED at UCM designed a rapid COVID-19 testing area to seamlessly incorporate phlebotomy for HIV screening without any additional personnel. Responsibilities for test review, patient notification, and linkage to care were assigned to the HIV Care Program. Statistical analysis was an interrupted time series Poisson regression comparing the rate of AHI diagnoses per day for the 1461 days prior to January 1, 2020, and the 290 days between January 1 and October 16, 2020. Analyses were completed using SAS, version 9.4 (SAS Institute Inc), and 2-sided P < .05 was considered statistically significant.

Most sites experienced significant reductions in HIV screens during the pandemic, and overall, the program saw a 49% reduction in testing events from January 1 to April 30, 2020. The ED at UCM, however, maintained HIV screening volumes throughout the pandemic (Figure) and performed 19 111 HIV screens (14 215 in the ED) between January 1 and October 16, 2020, along with 112 242 COVID-19 polymerase chain reaction (PCR) tests (18 830 in the ED). Twelve patients were diagnosed with AHI after the first COVID-19 diagnosis in Cook County on January 24, 2020 (Table). The rate of AHI diagnoses per day was significantly higher during the pandemic compared with the prior 4 years (incidence rate ratio, 2.43; 95% CI, 1.22-4.83; P = .01). Other EDs not incorporating HIV screening into COVID-19 testing saw a 25% decrease in AHI diagnoses (incidence rate ratio, 0.75; 95% CI, 0.26-2.14; P = .59) that was not statistically significant.

Patients with AHI comprised 12 of 46 (26.1%) new diagnoses at UCM, the highest proportion on record. Included were 9 men (6 men who have sex with men, 2 heterosexual, and 1 undisclosed) and 3 cisgender women with a median (range) age of 25 (21-28) years. The median (range) viral load was 6 million (115 000 to >6 million) copies/mL. Eleven of 12 patients presented with symptoms consistent with COVID-19. One patient had COVID-19 infection and AHI. All were linked and initiated antiretroviral therapy by a median (range) of 1 (0-38) day from the time of PCR result but 3 (1-41) days from sample collection owing to delays in reflex PCR confirmatory testing, a result of high demands on laboratory personnel and scarcity of supplies (eg, amplification and testing trays) owing to COVID-19 testing volumes.

The COVID-19 pandemic is superimposed on the HIV pandemic, jeopardizing progress toward HIV elimination. Routine HIV screening in health care settings is a key elimination strategy that has been negatively affected during the pandemic. A limitation to this study is that the reasons for refusal of HIV screening by patients or health care professionals are not known. Also, we do not know how many COVID-19 tests were triggered by symptoms or were screening of asymptomatic patients owing to exposures or screening of potential admissions for infection control purposes. However, we saw a considerable increase in AHI diagnoses with incorporating HIV screening into COVID-19 testing in the ED at UCM. This could be because of increased screening. Alternatively, patients with AHI may be more likely to present for care because of concern for COVID-19 infection. Finally, new transmissions may be increasing owing to disrupted HIV care and prevention efforts. Thus, HIV screening programs, particularly in EDs, should incorporate or even link HIV screening to COVID-19 testing. Modeling suggests this would reduce HIV incidence and health care costs.⁶

Accepted for Publication: February 11, 2021.

Published Online: April 12, 2021. doi:10.1001/jamainternmed.2021.0839

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2021 Stanford KA et al. JAMA Internal Medicine.

Corresponding Author: David Pitrak, MD, Section of Infectious Diseases and Global Health, The University of Chicago Medicine, 5841 S Maryland Ave, MC 5065, Chicago, IL 60637 (dpitrak@medicine.bsd.uchicago.edu).

Author Contributions: Dr Pitrak 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.

Concept and design: Stanford, McNulty, Eller, Pitrak.

Acquisition, analysis, or interpretation of data: Stanford, Schmitt, Eller, Ridgway, Beavis, Pitrak.

Drafting of the manuscript: Stanford, Eller, Pitrak.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Eller, Pitrak.

Obtained funding: Schmitt, Pitrak.

Administrative, technical, or material support: Stanford, McNulty, Schmitt, Beavis.

Supervision: Schmitt.

Conflict of Interest Disclosures: Mr Eller reports grants from Gilead Sciences during the conduct of the study and outside of the submitted work. Dr McNulty reports grants from Gilead Sciences outside of the submitted work. Ms Schmitt reports grants from Gilead Sciences as part of the FOCUS (Frontlines of Communities in the United States) Program. Dr Stanford reports grants from the Chicago Department of Public Health during the conduct of the study and grants from Third Coast Center for AIDS Research outside of the submitted work. Dr Pitrak reports grants from Gilead Sciences as part of the FOCUS Program. No other disclosures were reported.

Funding/Support: This work was supported by the Chicago Department of Public Health and the Gilead Sciences FOCUS Program.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the following individuals who were key to program implementation, data collection and management, and clinical care: Eleanor Friedman, PhD, Aniruddha Hazra, MD, Michelle Moore, RN, APN, and Michelle Taylor, LCSW, of the Section of Infectious Diseases and Global Health at The University of Chicago Medicine. We also thank our Expanded HIV Testing and Linkage to Care collaborating sites: Beloved Community Family Wellness Center, Chicago Family Health Center, Community Health, Friend Family Health Center, Howard Brown Health, Lawndale Christian Health Center, Mercy Medical Center, Rush University Medical Center, Sinai Health System, TCA Health Inc, and the University of Illinois at Chicago. No additional compensation was provided for these contributions.