Acute HIV Cases Double in ED. Is COVID-19 Responsible?

Marcia Frellick

October 27, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The number of patients who presented with acute HIV infections at the University of Chicago's emergency department (ED) more than doubled this year. At the same time, routine HIV visits dropped in the surrounding area.

David Pitrak, MD, an infectious diseases (ID) specialist at the University of Chicago Medicine (UCM) in Illinois, and colleagues found that the incidence ratio (IR) of acute HIV infection (AHI) jumped to 14.4 this year compared with the 6.8 average for the previous 4 years (IR, 2.14; 95% CI, 1.01 – 4.54; P < .05).

At a press conference at IDWeek 2020, he said that this year, acute patients made up one quarter of all new diagnoses (9 of 35), "the highest percentage we have ever seen.

"Patients with acute infection, especially those with symptoms, have extremely high viral loads and progress more rapidly. Because of those high viral loads, there's risk of transmission to others, so rapid linkage to care and ART [antiretroviral treatment] is really important," he said.

After the IDWeek abstract was submitted in September, Pitrak said, three additional AHI cases were diagnosed in the ED, bringing the IR of AHI during the pandemic to 2.57 (95% CI, 1.29 – 5.11).

Should All EDs Link HIV Screening to COVID-19 Testing?

The ED at UCM incorporated blood draws for HIV screening as part of COVID-19 evaluations early on during the pandemic, and they recommend that practice for EDs across the nation.

After a positive test result, the ID team was able to quickly link the HIV patients to care and initiation of antiretroviral treatment without adding staff or resources, Pitrak told Medscape Medical News.

Pitrak and colleagues reviewed data from 13 healthcare centers on the south and west sides of Chicago. At most of the centers, fourth- and fifth-generation antibody tests were available. The investigators found that the number of HIV screens that were conducted dropped significantly during the COVID-19 pandemic.

At the height of the pandemic, HIV screening at the sites decreased an average of 58%, the researchers found. As of the end of June, the number was decreased by 32%.

"This is a global problem," he said. "HIV services have been severely impacted worldwide, with the greatest impact on the LGBTQ community."

UCM performed 19,111 HIV screens (11,133 in the ED) between January 1 and August 17 this year. It performed 14,754 COVID polymerase chain reaction tests in the ED between March 17 and August 17. All of the acute cases were identified in the ED.

Pitrak mentioned some possible causes of an increase in the number of patients with acute cases who present in the ED. People who do not suspect they have AHI may be coming to the ED because they think they have COVID-19, inasmuch as many of the symptoms overlap. One of the AHI patients actually did have a coinfection, Pitrak noted.

"There is also the possibility that this could be bad news," Pitrak told Medscape Medical News. "It could be that there are more acute cases presenting because there are more community transmissions."

He noted that follow-up visits have been canceled or converted to telehealth visits during the pandemic, and the number of patients who are initiating preexposure prophylaxis has declined significantly.

"I hope we're not seeing an increase in new transmissions after so much work has been done to decrease transmissions over the past few years," he said.

Partnership With Emergency Physicians

Critical to screening these patients is building a solid partnership between ID and ED physicians.

Coauthor Kimberly Stanford, MD, MPH, an assistant professor in emergency medicine at UCM, said, "You need a champion within the emergency department who can help make sure that the workflow is not disrupted, that however you implement your screening program, you're not putting extra work on the staff.

"We can feel extremely confident that if I send a test and it comes back positive, I know someone is going to call that patient and make sure they get into care."

Although the testing is performed in the ED at UCM, the follow-up, linkage to care, and initiation of treatment are conducted by the ID specialists.

Beverly E. Sha, MD, professor in the Division of Infectious Diseases, Department of Internal Medicine, Rush Medical College in Chicago, told Medscape Medical News that although she agrees that HIV screening programs in EDs "make absolute sense," there are different ways to conduct such programs. Sha was not involved in Pitrak's study.

At Rush's ED, she says, HIV testing is linked with a complete blood count.

"If someone presents with fever, we would often be doing that test as well," she said. "I think just globally increasing screening [in the ED] is what makes the most sense."

Sha said they have not seen a similar surge in acute cases in the ED at Rush during the pandemic.

She noted, however, that UCM tested more than 11,000 people for HIV in the ED this year, whereas "we probably only did about 3500.

"The reason testing is so important, whether for HIV or COVID, is the more you test, the more you're going to find," she said, "especially in cities like Chicago."

Pitrak received grant support from Gilead Sciences. His coauthors and Sha reported no relevant financial relationships.

IDWeek 2020: Abstract LB-6, presented on October 24, 2020.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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