Clinical Pearls & Morning Reports
According to data from the National HIV Surveillance System of the Centers for Disease Control and Prevention (CDC), more than 75% of persons at high risk for human immunodeficiency virus (HIV) infection who had seen a primary care provider within the previous year were not offered an HIV test, and many patients with undiagnosed HIV infection had multiple health care visits before receiving an HIV test. Read the NEJM Clinical Practice Article here.
Q: How common is it for persons with HIV infection in the United States to be unaware that they have the infection?
A: An estimated 1 in 7 persons with HIV infection in the United States is unaware of the fact that they have the infection. Up to 38% of new HIV infections are transmitted by persons who are unaware of their HIV status.
Q: Who should be screened for HIV?
A: U.S. guidelines recommend that all sexually active persons be tested at least once for HIV and that those who have an ongoing high risk of infection be tested at least annually. Persons with high risk are defined as those with an incident sexually transmitted infection; sexual partners of persons with sexually transmitted infections; persons who have had more than one sexual partner (or whose sexual partners have had more than one partner) since their most recent HIV test; injection-drug users; and persons who exchange sex for money or drugs. Testing is also recommended during pregnancy.
A: According to 2018 CDC surveillance data, only 78% of patients with HIV are linked to care within 30 days after diagnosis. The sooner that an initial clinic visit is scheduled after diagnosis, the more likely it is that the patient will show up for the visit. Establishing an active relationship with the patient, providing assistance in setting up the first appointment, maintaining contact with the patient until the first visit, and addressing any barriers to keeping the first appointment (e.g., transportation) are associated with an increased incidence of linkage to treatment. With rare exception, antiretroviral therapy (ART) should be initiated at the first clinic visit. Patients should be reassured that they can expect a near-normal life span and no risk of transmission to others once viral suppression is achieved and maintained with ART. From 2011 to 2017, among patients receiving standard ART regimens, the incidence of death at 5 years after diagnosis differed by only 2.7 percentage points from that of age-matched controls.
A: More than 42% of new HIV infections are transmitted by persons who are known to be infected with HIV but who are no longer receiving care; this fact underscores the need for effective strategies for retention in care. Best practices to achieve this goal are still being developed. Centralized care, the use of bilingual, bicultural teams, clinic-based buprenorphine treatment for patients with concomitant opioid use disorder, specialized services for the transition from jail to clinic, behavioral interventions, and enhanced patient contact through navigator programs have been successful. Calling patients on the telephone if they do not show up for scheduled appointments is one of the most effective means of retaining patients in care. An intervention that involved brochures, posters, and short verbal messages conveying the importance of continued health care visits was associated with a higher incidence of return for subsequent appointments than no such intervention.