Factors associated with no or delayed linkage to care in newly diagnosed human immunodeficiency virus (HIV)-1-infected patients identified by emergency department-based rapid HIV screening programs in two urban EDs.

OBJECTIVES: The objective was to describe the proportions of successful linkage to care (LTC) and identify factors associated with LTC among newly diagnosed human immunodeficiency virus (HIV)-positive patients, from two urban emergency department (ED) rapid HIV screening programs. METHODS: This was a retrospective analysis of programmatic data from two established urban ED rapid HIV screening programs between November 2005 and October 2009. Trained HIV program assistants interviewed all patients tested to gather risk behavior data using a structured data collection instrument. Reactive results were confirmed by Western blot testing. Patients were provided with scheduled appointments at HIV specialty clinics at the institutions where they tested positive within 30 days of their ED visit. "Successful" LTC was defined as attendance at the HIV outpatient clinic within 30 days after HIV diagnosis, in accordance with the ED National HIV Testing Consortium metric. "Any" LTC was defined as attendance at the outpatient HIV clinic within 1 year of initial HIV diagnosis. Multivariate logistic regression was performed to determine factors associated with any LTC or successful LTC. RESULTS: Of the 15,640 tests administered, 108 (0.7%) were newly identified HIV-positive cases. Nearly half (47.2%) of the patients had been previously tested for HIV. Successful LTC occurred in 54% of cases; any LTC occurred in 83% of cases. In multivariate analysis, having public medical insurance and being self-pay were negatively associated with successful LTC (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.12 to 0.96; OR = 0.34, 95% CI = 0.13 to 0.89, respectively); being female and having previously tested for HIV was negatively associated with any LTC (OR = 0.30, 95% CI = 0.10 to 0.93; OR = 0.23, 95% CI = 0.07 to 0.77, respectively). CONCLUSIONS: In spite of dedicated resources for arranging LTC in the ED HIV testing programs, nearly 50% of patients did not have successful LTC (i.e., LTC occurred at >30 days), although >80% of patients were LTC within 1 year of initial diagnosis. Further evaluation of the barriers associated with successful LTC for those with public insurance and self-pay is warranted.

Outcomes and cost analysis of 3 operational models for rapid HIV testing services in an academic inner-city emergency department.

OBJECTIVE: We compare the outcomes and costs of alternative staffing models for an emergency department (ED) rapid HIV testing program. METHODS: A rapid oral-fluid HIV testing program was instituted in an inner-city ED in 2005. Three staffing models were compared during 24.5 months: indigenous medical staff only, exogenous staff only, or exogenous staff plus medical staff (hybrid). Personnel obtained written consent and provided brief pretest counseling, obtained kits, collected specimens, returned specimens to the ED satellite laboratory, and performed posttest counseling and referral to care. Cost analysis was performed to estimate cost per patient tested and cost per patient linked to care. RESULTS: Overall, 44 of 2,958 (1.5%) patients tested received confirmed positive results and 30 (68%) were linked to care. The exogenous staff only model yielded the highest number tested per month (587), and indigenous medical staff only yielded the lowest (57). Significantly higher positivity rates were found in both indigenous medical staff only (2.2%) and hybrid (2.0%) models versus the exogenous staff only model (0.6%) (prevalence rate ratio: 3.7 [95% confidence interval {CI}1.5 to 9.3] versus 3.4 [95% CI 1.5 to 7.8], respectively). All patients with confirmed positive results were linked to care in the indigenous medical staff only model but only approximately 60% were linked to care in the 2 other models (linked to care rate ratio versus exogenous staff only: 1.8 [95% CI 1.1 to 4.4]; versus hybrid: 1.7 [95% CI 1.2 to 2.5]). The indigenous medical staff only model had the highest cost ($109) per patient tested, followed by the hybrid ($87) and the exogenous staff only ($39). However, the indigenous medical staff only model had the lowest cost ($4,937) per patient linked to care, followed by the hybrid ($7,213) and exogenous staff only ($11,454). CONCLUSION: The exogenous staff only model tested the most patients at the least cost per patient tested. The indigenous medical staff only model identified the fewest patients with unrecognized HIV infection and had the highest cost per patient tested but the lowest cost per patient linked to care.