Acute HIV Infections Increased During COVID-19

New research from a team in Chicago shows a significant increase in the number of patients with acute HIV infections who sought treatment in their emergency department during the COVID-19 pandemic, according to a study presented at the 2020 virtual IDWeek conference.

In this exclusive MedPage Today video, Timothy P. Lahey, MD, of the University of Vermont Medical Center, discusses the study caveats and the main take-home messages regarding HIV screening.

Following is a transcript of his remarks:

So as you know, this is important because acute HIV infection is underdiagnosed chronically, and this leads to late engagement and care and missed opportunities for prevention. And enhanced acute HIV infection screening can identify otherwise missed high risk individuals. This has been shown in inpatients in high-prevalence areas as well as STI clinics and other settings. And of course the COVID-19 pandemic intensifies the threat to misdiagnoses of acute HIV infection through lower engagement to care, among other problems.

And this is a problem that's going to preferentially affect our most vulnerable populations who could be adversely affected by both COVID-19 and the risk of undiagnosed HIV. So the authors did an excellent study building on work they'd already done in a collaboration of a consortium of 15 different HIV screening sites in various neighborhoods in Chicago called the Expanded HIV Testing and Linkage to Care Program or xTLC. And they used a pre-existing workflow through collaborating emergency rooms to identify people at high risk of having acute HIV infection and followed how that program was going early in the COVID-19 pandemic; they saw that there was a detriment from about 20,000 screens to about 11,000 screens and said, wait a second, let's re-intensify this connection. So they did that quality improvement work and then saw how it went. Defining acute HIV as a positive HIV immunoassay with a negative supplemental antibody test and a positive confirmatory PCR viral load.

And so, what they showed was a massive surge at their hospital, as all hospitals experienced, in diagnostic screening for infectious diseases of various types with a COVID-19 surge, dwarfing screening for all other diagnostic infections. But of course, there were a number of respiratory infections like influenza, RSV, that were checked for early on in 2020, dropping off as the spring progressed.

They saw a decrease in 22,502 tests in January/February ... just shy of 12,000 tests in May. And, this constituted a reduction in HIV screens of about 58%. They also saw that they were able with re-intensified connections to the emergency departments, to enhance acute HIV infection screening in patients who are suspected of having COVID-19 once they sort of had people know the overlap in symptoms and therefore the need to do some testing.

So, ultimately they were able to boost up testing rates to 19,111 tests between January and August of 2020, screens just for acute HIV infection. And they saw actually that they were able to diagnose 19 otherwise missed cases of acute HIV infection through that screening effort. And when they compare the number of acute HIV infection cases that were identified thus far in 2020 and those eight months, it actually equalled the total number of acute HIV cases that had been identified in 2019, and was more than double those identified in 2018. So they saw a surge in acute HIV infection diagnoses. That was what they reported in the abstract that they submitted to IDWeek that actually, subsequent to them, they found three additional cases and they say that this is an increase in the total incidents.

Caveats: They did not present formal data on the percentage of people with influenza-like illnesses, including COVID-19 screening, who did undergo acute HIV infection screening, nor the percentage of those tests that were positive. And so exactly whether the incidence rates are clearly higher than they would have been of acute HIV infection identifications, and what statistics were used to make these comparisons were not given. But the numbers are intriguing. And I think importantly, we have to grapple with whether this is generalizable to populations where the likelihood of acute HIV infection is lower, or programs that have a less mature language to their HIV screening and emergency rooms.

But the take-homes are that while acute HIV infection screening probably is threatened by the COVID-19 pandemic disruptions to healthcare in general, that re-intensified screening efforts can help. And that there is a chance that we can actually identify more acute HIV infections either because we're intensifying our diagnostic workup, or there's more public concern and people are coming forward with overlapping symptoms, or perhaps because risk behaviors have changed. So I think overall an important contribution and something that we'll look forward to the publication on.

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