HIV Podcast

How to End an Epidemic: HIV Testing and Linkage to Care

Michael Saag, MD; Aadia Rana, MD


March 01, 2022

This transcript has been edited for clarity.

Michael Saag, MD: Hello. I'm Dr Michael Saag, and welcome to Medscape InDiscussion: HIV. Today we're talking about HIV testing and linkage to care, a topic that is vital to our ability to end the HIV epidemic.

So let's start with a case. A 23-year-old woman presents to the emergency department for a fractured radius following a motor vehicle collision. On routine testing in the ER she is found to be HIV positive by rapid testing. She is sexually active, denies IV drug use, and estimates that she has had eight different sexual partners over the past 2 years. One year ago, she was diagnosed and treated for pharyngeal gonococcus in an urgent care center. She was not tested for HIV at that visit.

Today's guest to help us work through this topic is Dr Aadia Rana, an associate professor of medicine at the University of Alabama, Birmingham, and associate scientist with the UAB Center for AIDS Research (CFAR).

Dr Rana's work focuses on disparities in access and adherence to medical treatment among people with HIV and implementation of evidence-based interventions to improve engagement with HIV care. She leads the UAB CFAR's Ending HIV in Alabama Scientific Working Group, which includes a broad range of clinical epidemiologic, sociobehavioral researchers, as well as community engagement and public health partners catalyzing Birmingham and Alabama's progression toward the UNAIDS 90-90-90 goals. So, she is the perfect person to discuss this topic with us. Welcome, Aadia.

Aadia Rana, MD: Thank you, Dr Saag. So, so lovely to be here with you today.

Saag: Tell me, what are the challenges that you noticed in identifying patients who are at risk for HIV, and how do we get them tested?

Rana: One of the biggest challenges remains in that first part of your question: "at-risk" — people are terrible at identifying risk. And when I say "people," I mean both the people who need to be tested as well as the people who are doing the testing. It's estimated that nationwide, about 14%-15% of people with HIV are unaware of their status. One of the ways we have tried to overcome that is by making testing not necessarily risk based, at least once. The guidelines right now say that any person, starting at age 13-65, should have an HIV test at least once without any risk assessment at all. [Editor's note: The CDC guidelines recommend testing for ages 13-64.]

I think that's a great recommendation, but it's a little unclear how uniformly that's followed through because we are still trying to assess risk. When I give talks with primary care providers to try to get a sense of, "Hey, how many of your patients have you ever tested for HIV?", [I hear] "Oh, well, they're not at risk, they're married, or they're this age and they're that."

And we both could probably share hundreds of stories, if not more, of our 58-year-old woman who went through three bone marrow biopsies and multiple scans because she was pancytopenic and ultimately ended up having AIDS. Or a teenager who comes in with pneumonia and nobody ever tested them for HIV and they end up having it. So, I think the risk issue is something — or the need to assess for risk — that continues to influence our ability to test people.

Saag: I think your point is so well taken, that we do need to get away from this concept of "I'm not going to test this person because they don't appear to be at risk and therefore, I was going to skip that." No, that's the only way we're going to find people who might be at risk without knowing otherwise. We've got to test everyone. The line I used to use way back in the early '90s was that anyone who has been sexually active or even thought about being sexually active should be tested at least once for HIV, and that definitely holds true today. One of the things that we do talk about, and we've referenced it earlier, is this concept of 90-90-90. Can you explain what that is?

Rana: This is an initiative by UNAIDS, or the UN AIDS Association, which essentially used modeling data to estimate what it would take to end the transmission of the epidemic with the numbers that we have right now. What that sort of modeled into was that 90% of people globally are aware of their diagnosis. We do know that being aware of your diagnosis means you get linked to care. There's evidence that behavior changes after your diagnosis, so [the goal is] to get to that number of 90% of people being aware of their diagnosis.

Of those, 90% are linked to care, so you're referred to a clinic where you are able to access antiretroviral therapy and maybe even address other issues and other medical comorbidities.

And then of those, 90% achieve viral suppression. And as you know, limiting transmission is the ultimate goal — certainly, of course, in terms of good outcomes for the person who's been diagnosed as well as controlling the virus. The reason transmission is the goal, again, is for good outcomes for the person with HIV, but also because undetectable people do not transmit the virus. So, undetectable equals untransmittable. This was proposed as a great way for cities to track and target how they are doing in their battle against this epidemic.

Saag: Let's dig in a little bit. Let's take this case. The woman comes in. She's traumatized because she had a car accident. And then, oh, by the way, we've let you know that we're going to test you for HIV and your test has come back positive. What are the challenges at that point?

Rana: I think that you want to be able to share what that test means. If it was a rapid test, you want to share what the rates are of false positives and what the conditions are — in the right clinical setting is what we always try to share, with the right history, that these tests are actually excellent. But we still wait for that. Folks, especially those who are not as informed and not as educated, still think that it means something that it doesn't mean. Now a person who's diagnosed with HIV, and in particular early asymptomatic, can start medication and take a pill a day, or soon to be an injection a month or an injection every 2 months, and live a long, healthy life. So you do want to make sure that somebody is there who can really tell them what the test means and what the potential implications are.

I think the challenge after that is, where is this test being shared? Is this a person who's being admitted with trauma or being in the ER? Because then that's where the next challenge comes: linkage. You want to get this person linked to care and in care.

I remember seeing patients in the hospital who would say, "I don't want to go to that clinic because if I walk in those doors, people will know what I have." I think among certain populations, they were so scared of people in the waiting room, knowing each other or knowing somebody there who would then disclose their status and make that public knowledge when they weren't ready to share. I mean, we all still have patients, don't you think, who I feel like we're the only other people that know their status. They're the same people who, 15 years after their diagnosis, are still crying about their diagnosis, no matter how much we encourage them to disclose.

But I think that's the challenging part and we've tried to overcome some of those challenges. Often our linkage and retention coordinators will meet patients in the hospital or in the ER to help link them to care or make that comfort call — you know, say, "Hey, I'm here for you." I think strategies like that have been helpful. And then the same thing with bringing them into our clinic and creating an environment, a team. "Here's your team here. We're here to care for you." That sort of approach and addressing wraparound services as soon as possible can help support it. But it's still a good amount to overcome.

Saag: Lots of barriers here. One is making sure that whoever informs them of their diagnosis is trained to deliver messages like that, which is a tough message. She came in for a fractured wrist and ends up with a diagnosis of HIV. Explaining, like you said, the nature of the test, that it could be wrong. We need to do follow-up, but the critical nature of linking to care is that if she indeed is positive, she can get started on therapy.

And the good news, the silver lining, of this diagnosis is, as you mentioned, that once somebody gets on their treatment, not only can they live a near-normal, if not normal, life, but they can also, once they're suppressed, not transmit the virus to others. And getting that message delivered in the emergency setting, or wherever it is that the individuals are being tested, is essential.

The second thing that I'd like you to talk about is the speed with which we get that appointment set up. So maybe you can talk a little bit about the data we know about the length of time between diagnosis and first visit.

Rana: That's a great segue to one of my latest passion projects, which is to try to get people linked as soon as possible. And when I say as soon, even within same day or 24 hours. We talked a little bit about the caveat about the rapid tests and false positivity and all of that. But at the same time, in the right clinical setting, we know that these tests are still excellent.

We try to make sure that the patient has the support as soon as possible. And we have started in our clinic what we call a fast-track program, where as soon as somebody is diagnosed with HIV, we try to get them linked to care, seeing our social workers, our linkage retention care coordinators, as well as a prescribing provider within 5 days. And often it's much sooner than that.

Saag: I want to segue to a couple of studies and thoughts about rapid initiation of therapy onsite at the testing center. So, in this case it would be the emergency department; it might be the public health department. What are your thoughts about that? The studies out of South Africa and other places showed that it was much better in terms of achieving viral suppression than if they delayed to another visit. What's your experience and your thoughts about it in the United States?

Rana: The caveat, of course, would be that in those settings, those are studies, right? So, all of the supportive services and stuff that are essential in those settings need to be taken into consideration when we want to translate to real life. So then we need to make sure that that same model is actually translated to real life. And what I'm trying to say is that when somebody is going to be started on ART in an emergency room or is going to be started on ART in a public health department, what is your plan for linkage? I would suggest that it can't be "Hey, here's the phone number for you to call to make your appointment" or "This is how you go." It has to be what we like to call a warm handoff.

So you are either physically meeting with somebody or somebody is bringing you over to clinic on that day that you're starting, or you're having that sort of transition as it were — maybe the first 10 days of medication are provided. But there is a plan for what we would call a warm handoff, and that has been modeled. Miami does that with their city's health department and with the clinic at Jackson Memorial. Other places around the country, San Francisco, New York, have done so successfully.

I think that is a promising model. The challenge will be to make sure that it is a well-resourced model because if you start it without being resourced, it's going to "fail." I'm putting that in quotes for listeners here. And it's not that it failed at that. You did not set it up to succeed. And so I think that that is another great strategy, potentially. The other challenge, of course, is again making sure it's resourced even on the medication end.

Saag: Let me finish up with the question to you about this case again. We have a woman who a year ago was treated for a sexually transmitted infection and that apparently was successful, but she was not tested for HIV on that visit. Seems like that's a huge missed opportunity. So maybe you can comment on how we can do better as a general medical providing society in terms of finding folks earlier who are at risk or actually infected with HIV.

Rana: Yeah, missed opportunity. Like, that's the headline, right? So many missed opportunities. In her particular case, she wasn't a missed opportunity of somebody who had presented to the emergency room with just a cough, and we could have tested. She actually presented with — if we were going to put her in that category of at risk, that's literally somebody who's at risk for HIV.

I think this actually goes back to the same point we were making previously: Don't assess risk, just test. There have been a lot of studies that looked at people who presented to emergency rooms and eventually were diagnosed with HIV. Looking back, you see how many different healthcare interactions they had, and oftentimes it was more than one, where they presented with vague symptoms or unclear URI, headache, whatever, which probably ended up being either HIV or an opportunistic infection.

Our diagnoses are still plagued with all of those; the number of people that we have who even have primary care doctors is a little disturbing to me. They come in and they have a primary care doctor. They've just maybe never talked about sex or haven't talked about needing to get tested. So I think we still have a good amount to train our own providers on. Anyone who presents in a clinical setting should probably get tested. I think that's, unfortunately, what happened. In this case, she presents to an urgent care center. Is there an additional cost? This urgent care center is taking that into consideration, but it's yet another missed opportunity.

Saag: Unfortunately, the time, as I knew it would, has gone by very quickly, and we're going to have to wrap up. What's the one thing that you want to pass on to listeners that might be useful for the patients that they're seeing?

Rana: Test everyone. You don't need to say, "Oh, wait, did I get a sexual history on them? Did I talk about that?" No. Test everyone. And make that a part of your routine practice. Anyone who's coming in for clinical care — just like everybody gets a lipid panel or everybody gets a CBC or creatinine that you're starting. Make this part of your care. Take the exceptionalism out of it and make it part of your routine care. We're bad at assessing risk; you're bad at assessing risk; the community's bad at assessing risk. Let's take that equation out of it.

Saag: Thank you so much, Aadia, for being with us today. It's been enlightening and it's really critical information that's been shared. To recap, everyone is at risk for HIV, and therefore we should be testing everyone. At the time we get a positive test, it's really important to have a plan in place on how to link that individual to care very quickly, within days — no more than 4 days, in my opinion — and try to get them into the service center, a place where they can be taken care of not just for their HIV, but a comprehensive approach that addresses the HIV along with other barriers that they may have from homelessness, substance use. [A place where they can receive] general support to deal with the stigma of the diagnosis and help them manage the shock of this new diagnosis.

A lot of people are infected with HIV and don't know it; oftentimes they have no idea how they might have become infected. It's usually through a sexual exposure, but once we get them treated and in care, and they stay in care, that's how we're going to turn the tide on the epidemic — achieve not just 90-90-90, but hopefully 95-95-95, where we have been shown through models that that bends the curve of the epidemic. It starts to reduce the total number of cases, and we can start looking for an exit ramp out of the HIV epidemic.

I'm going to close here with that optimistic statement. Thanks, everybody, for joining. We'll see you next time.


90-90-90 Treatment for all

Too Many People Living with HIV in the U.S. Don’t Know It

CDC: HIV Testing Guidelines

The science is clear: with HIV, undetectable equals untransmittable

Initiating Antiretroviral Therapy for HIV at a Patient's First Clinic Visit: The RapIT Randomized Controlled Trial

Implementation of an Immediate HIV Treatment Initiation Program in a Public/Academic Medical Center in the U.S. South: The Miami Test and Treat Rapid Response Program

Development of a Citywide Rapid Antiretroviral Therapy Initiative in San Francisco

Immediate Initiation of HIV Treatment

Follow Medscape on Facebook, Twitter, Instagram, and YouTube


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.