Journal of the Louisiana State Medical Society
long as it does not interfere with the primary mission and is integrated into the healthcare systemwith linkage to care, 16 which this testing programhas accomplished. One of the key components of the rapid testing programat our hospital was the 24-hour availability of the test and the rapid turnaround of results. In a busy emergency room, rapid turnaround of test results ensures that patient discharges are not delayed, and is an important part of physician buy-in of rapid testing. In our facility, which is a Level 1 trauma center, the blood bank was most suited for this project because it is staffed by trained technicians 24/7. The patient’s receipt of test results prior to discharge is an important aspect of linkage to care and linkage numbers would likely have been lower if results were provided post-discharge. Eighty-six percent of the patients were referred for sub- specialty care, and the majority (60%) of the patients were seen at the HIV clinic affiliated with the hospital. Most had early entry to care, defined as entry less than three months from diagnosis (78%). Patients who were referred to other HIV clinics or followed up at other HIV clinics were not counted in the number of patients linked to care - unless these records were available in the chart at ILPH - because there was no access to records at these outside clinics. This is unlikely to represent a large number of patients as only five of the unlinked patients were referred elsewhere, three were referred out of state because they lived out of state, and two to a community HIV clinic. This linkage to care is slightly lower than other studies in similar populations, which ranged from 77% to 88%, 2,10 but this may reflect the population in this study and the passive nature of the link- age as compared with these other studies. More than half of the patients had presented for care at ILPH in the past five years, and more than a quarter of the patients had been seen three or more times in the past five years without being tested and diagnosed. This demon- strates significant missed opportunities for early diagnosis. Since there was no general screening in place prior to the initiation of the rapid HIV test in February of 2008, these patients were likely not offered testing because they did not meet physician-directed testing for either their clinical picture or their reported risk behaviors. These missed op- portunities reinforce the importance of opt-out screening as compared with physician directed screening in finding patients with undiagnosed HIV. The strengths of this study lie in the large number of patients diagnosed and the breadth of data on the emer- gency roomvisit, hospital admission, and laboratory values on these patients. It is one of the largest studies of its kind and the first in this urban population in New Orleans. The study also provides insight into the population of patients missed by physician-directed screening, whichwere young, African-American men without traditional risk factors. Its limitations are primarily the use of retrospective data, which rely on the physician-documented referral, risk factors, and risk behaviors, which may underestimate the real values. Another limitation is the lack of an active linkage, which resulted in lower clinic attendance than seen in other stud-
ies. The use of the Oraquick, which is a rapid antibody test, precluded the inclusion of any patient with acute HIV in our study. The diagnosis of acute HIV would require clinical suspicion and an HIV viral load test. In summary, rapidHIV testing in the emergency depart- ment at the Interim LSU Public Hospital in New Orleans successfully identified 99 patients with a new diagnosis of HIV in the first year and linked the majority of these patients to an HIV specialist. ACKNOWLEDGEMENTS We would like to thank the ILPH administration, emergency room physicians, and the personnel for their time and efforts regarding administering the HIV tests, as well as the laboratory personnel for processing the tests and the Infection Control personnel for their role in linking patients to care. We would also like to thank the Louisiana Office of Public Health for providing the funding for rapid HIV testing kits. REFERENCES 1. CDC. HIV in the United States Fact Sheet. July 2010. <http:// www.cdc.gov/hiv/resources/factsheets/PDF/us.pdf>. 2. CDC. Rapid HIV Testing in Emergency Departments--- Three U. S. Sites, January 2005- March 2006. MMWR 2007;56:597-601. 3. Dieffenbach CW, Fauci A. Universal Voluntary Testing and Treatment for Prevention of HIV Transmission. JAMA 2009;301:2380-2. 4. Paltiel AD, WeinsteinMC, Kimmel AD, et al. Expanded Screening for HIV in the United States—An Analysis of Cost-Effectiveness. N Engl J Med 2005;352:586-95. 5. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-Analysis of High-Risk Sexual Behavior in Persons Aware and Unaware They are Infected With HIV in the United States. J Acquir Immune Defic Syndr 2005;39:446-453. 6. CDC. Notice to Readers: Approval of a New Rapid Test for HIV Antibody. MMWR 2002;51:1051-1052. 7. CDC. Rapid HIV Test Distribution --- United States, 2003—2005. MMWR 2006;55:673-676. 8. Kassler WJ, Dillon BA, Haley C, et al. On-site, Rapid HIV Testing with Same-Day Results and Counseling. AIDS 1997; 11:1045-1051. 9. Kelen GD, Hexter DA, Hansen KN, et al. Trends in Human Immunodeficiency Virus (HIV) Infection Among a Patient Population of an Inner-City Emergency Department:Implications for Emergency Department-Based Screening Programs for HIV. Clin Infect Dis 1995;21:867-75 10. Lyss SB, Branson BM, Kroc KA, et al. Detecting Unsuspected HIV Infection with Rapid Whole-Blood HIV Test in an Urban Emergency Department. J Acquir Immune Defic Syndr 2007;44:435- 442. 11. Kelen GD, Shahan JB, Quinn TC. Emergency Department Based HIV Screening and Counseling: Experience with Rapid and Standard Serologic Testing. Ann Emerg Med 1999;33:147-55. 12. Louisiana Department of Health and Hospitals, Office of Public Health, HIV/AIDS Program. Louisiana HIV/AIDS Surveillance Quarterly Report, March 31, 2010. Pages 1-39. 13. Louisiana Department of Health and Hospitals, Office of Public Health, 2007/2008 HIV/AIDS Program Report. Pages 1-90.
32 J La State Med Soc VOL 166 January/February 2014
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