During the height of the COVID-19 pandemic, the mournful wail of ambulance sirens became the soundtrack of collective anxiety and loss. Emergency rooms across the nation were bombarded with patients as resources grew scarce. While the nation’s health care workforce was tackling a new threat, the detection of other communicable diseases and chronic ailments waned.
Still, several researchers, advocates, and medical practitioners have viewed the epidemiological challenge of COVID-19 as an opportunity. The disparities that the pandemic unearthed mirrored the trajectory of other infections that no longer held the rapt attention of media companies and pharmaceutical conglomerates. The populations of people who were disproportionately affected by COVID-19 were the same individuals who experienced higher rates of heart disease, chronic obstructive pulmonary disorder, diabetes, and, in particular, HIV.
In a study published in the journal JAMA Internal Medicine in April, the University of Chicago Medicine (UCM) emergency department, in collaboration with 13 health care centers in Chicago, reviewed the incorporation of HIV screenings with COVID-19 testing to improve the detection of patients with acute HIV infection. Like many health centers around the nation, the UCM HIV Care Program had experienced a precipitous reduction in the number of HIV screenings.
According to data presented at the Conference on Retroviruses and Opportunistic Infections (CROI 2021) from eight HIV clinics around the U.S., the number of visits declined by 78%. Similarly, data from the U.S. Centers for Disease Control and Prevention’s (CDC) National Syndromic Surveillance Program revealed nearly 700,000 fewer HIV screening tests and 5,000 fewer diagnoses from March to September 2020.
The granular reasons for the decline are varied, including the temporary closing of and general hesitancy to enter medical spaces, limited financial and health care solvency due to higher rates of unemployment, and limited access to public transportation due to altered transportation schedules.
Yet, amid COVID-related declines in testing and care, the April study found that UCM’s emergency department was not only able to maintain its HIV screening numbers throughout the pandemic, but it saw an increase in the rate of acute HIV infection diagnoses per day that, the authors said, “was significantly higher during the pandemic compared with the prior four years.” Between Jan. 1 and Oct. 16, 2020, the screenings identified 12 patients with acute HIV infection, and all were rapidly linked to care and antiretroviral initiation.
ER Screening May Speed Up Linkage to Care
The results of the UCM analysis further endorse the emergency room as a key point of contact for HIV detection and the mitigation of viral load. “HIV testing in the emergency department is an important strategy for diagnosing new HIV infections and linking people to ongoing HIV care,” said Finn Schubert, M.P.H., the HIV program director at the Family Health Centers at NYU Langone Health. “But the fast-paced ED environment can make it challenging to successfully implement routine testing in this setting.”
Still, the emergency department at UCM shows us an efficacious example that could be replicated elsewhere. Their success in identifying acute HIV infections is particularly relevant because diagnosing HIV infection in the acute phase usually expedites when patients are able to enter treatment.
Secondly, acute HIV symptoms like chills, fatigue, and sore throat are similar to symptoms of COVID-19, and patients entering the ER for fear of COVID-19 may actually be experiencing acute HIV symptoms. “In addition to routine HIV screening, EDs can be an important source of PrEP [HIV pre-exposure prophylaxis] linkage for individuals who may come to the ED for PEP [HIV post-exposure prophylaxis] or STI-related concerns,” added Schubert.
But Is HIV Testing in the ER Feasible? Adequate?
There is no denying the scalable and operational opportunity that this study incentivizes, but what happens to the volume of emergency-room HIV detections as COVID-19 immunization increases and cases drop? Due to the limited capacity of the medical staff in most emergency departments, would HIV screenings in ERs still prove efficacious?
Data in fact show that not all emergency departments are well-equipped to incorporate rapid HIV screening within their workflows in the long term. Perhaps that may explain why only about 2% of ER visits nationally are associated with an HIV test, even though the CDC recommends HIV screening as part of such visits.
“The hospitals that are typically in the areas of urban centers that serve Brown and African-American populations do not have the resources to integrate any additional levels of routine testing,” said Ace Robinson, M.P.H., M.H.L., a leading HIV policy advocate, of concerns surrounding the real-world feasibility of ramped-up HIV testing in the ER. “Due to the high level of HIV-related stigma and the small levels of HIV-related education that exist, these emergency rooms end up asking, ‘Do we have the time to do more work because we’re going to have to talk to this person and guide them through their diagnosis?’”
Within the HIV advocacy community, medical mistrust, hesitancy, and misinformation is not a new phenomenon. Robust measures to educate Americans about HIV have stark delineations among race and class, and ER HIV screenings may not be able to address the gaps of education that exist within vulnerable populations and may not address medical biases that exist in determining the “high-risk behavior” that warrant HIV testing.
“In fact, I think that you can’t do this only as an emergency room—you need to be paired with an infectious-disease program, an HIV program, or an HIV care provider,” said David Pitrak, M.D., chief of the Section of Infectious Diseases and Global Health at the University of Chicago and one of the study’s co-authors. “Anyone who’s an HIV care provider usually has a social worker who can assist and can pick up the follow-up of care and education, and take that responsibility away from the emergency department. Even if you’re not a large institution, you can partner with another institution that can do this work. You can even be a clinic. We’ve had a number of acute infections identified at community health centers, and we’ve been able to get [them] linked to care through rapid linkage,” Pitrak said.
UCM’s successes highlight the fiscal importance of supporting HIV care centers that are able to provide intimate education services while partnering with emergency departments that advertise opt-out HIV testing to all patients. “Using an HIV program is important for public health because in our studies of mean viral load, we found it very important that patients have parties who talk to them about bringing down their viral load and going over risk reduction with them,” Pitrak added.
The research also emphasizes how beneficial it is when a ‘flat hierarchy’ exists within medical spaces—an organizational structure that understands the value of social workers, sexual health counselors, and infectious-disease specialists and streamlines their ability to reach their most vulnerable patients during and after COVID-19.