Prevalence Study of HIV Infection Analysis

Background

In 2007, the World Health Organization estimated 33.2 million individuals as being infected with the human immunodeficiency virus (HIV). Statistics also showed that approximately 2.5 million individuals are newly infected annually (Guss, 1994). The HIV epidemic in the United States involved urban heterosexual adults, specifical women in ethnic minority groups. The introduction of active antiretroviral therapy (AART), has increased the life expectancy of individuals with HIV tremendously. Recent data has given the mean rise in life expectancy for a 20-year-old HIV-infected adult as increasing from 9.2 years in 1993-1995 to 23.6 years in 2002-2004 (UNAIDS, 2007). The high increase in life expectancy which largely is attributed to AART has also changed the spectrum of illness for HIV-positive adults (Kelen, Shahan & Quinn, 1999). Recent surveys have indicated that hospitalizations due t opportunistic diseases such as Cryptosporidium and Mycobacterium avium have decreased drastically whereas conditions related to cardiovascular disease and malignancies have increased. Mostly, the ED emphasizes the treatment of opportunistic infections in HIV-infected individuals. A previous case study based on ED found an HIV-infected patient who was diagnosed with conditions unrelated to HIV (Pulivrenti et al., 2007). These changing spectrums of individuals with HIV have put physicians in the spotlight and require them to have a better understanding of the conditions to handle ED effectively. In addition, it would also be useful to emergency doctors and infectious disease physicians to determine if preventable factors are associated with ED diagnoses (Kelen, Shahan & Quinn, 1999).

Objectives

The purpose of this study is to determine the occurrence of HIV infection among adults aged 18-60 who present themselves for care to the ED at Franklin Square Hospital by testing for serum HIV antibodies. The study will also identify adults with HIV infection who are not receiving care and refer these patients for primary and HIV care. Formal education will be conducted to teach Family Medicine residents in the design, conduct, and analysis of a community-based research study as well as provide free HIV serum antibody testing to uninsured adults presenting for ED care.

Rationale

The rationale behind this study is that the CDC has recommended an HIV screening in ED settings to be considered in areas where the prevalence of HIV infection exceeds 0.3-0.4% (300-400/100,000). The ED at FSH may consider offering HIV screening if the prevalence warrants it. In addition, HIV-infected adults may not know where the prevalence warrants it. We will also base this work on the rationale that, persons who know they are HIV infected change behaviors to reduce transmission. The CDC is also making an effort to include all 50 states in HIV surveillance with 10-25% of patients who test positive reporting no high-risk behaviors.

Literature review

health departments continue to look for ways to enhance their HIV prevention portfolios (Silva, et al. 2007). This includes identifying policies to strengthen HIV screening and counseling programs to increase their effectiveness in identifying persons who have undiagnosed HIV infection and linking them with care and treatment. Therefore, EDs and other urgent care facilities are of particular interest since they are high-volume facilities, serve persons who may not seek health care in other venues and they do not routinely recommend or offer HIV testing. With the recent publication of the CDC on ‘revised recommendations for HIV testing of adults, adolescents and pregnant women in health care settings, interest in screening HIV in EDs has intensified among health departments, federal agencies, and among EDS. The National Alliance of State and Territorial AIDS Directors (NASTAD) convened in 2007 to give the green light on the implementation of HIV testing in EDs (Silva, et al. 2007). Many institutions have added their voices in calling for HIV routine screening to adults and adolescents regardless of perceived risk. The CDC calls for the screening of all adults and teenagers where the prevalence is high. A recent study indicated that ED utilization among HID-positive adults in the AART era was associated with a considerable low-income level and greater mean viral load (Guss, 1994). However, centers in high prevalence regions are associated with problems such as lack of knowledge of underlying HIV status and lack of access to clinical resources to manage the HIV infections (Talan & Kennedy, 1991). Health departments have reported several factors that led to a critical examination of HIV counseling and testing services. Some of the underlined factors include; epidemiological data, blinded seroprevalence surveys, data of individuals who know they are HIV infected and they are not in care as well as constrained funding issues. Health departments and EDs recognize the importance of clinical and prevention benefits of HIV screening in the EDs. However, the extent to which the implementation of HIV screening is feasible is not entirely clear. Screening programs may be difficult in situations where high numbers of patients are seen in EDs. In addition, in high prevalence areas where a large number of patients with undiagnosed HIV infection may be seen in EDs, the practicability of screening is challenging due to the intensity and amount of effort that may be required for patient follow up and assistance to facilitate healthy medical care (Lyons, et al. 2005).

Reasons for carrying out the research

The main reason why health departments have implemented HIV screening in EDs is an effort to enhance prevention efforts. Other health departments that have implemented ED-based testing indicate having critically examined HIV prevention efforts in particular the effectiveness of HIV counseling and testing activities. Although the CDC has recommended HIV screening in adults where the prevalence exceeds 300-400/100,000, at the Baltimore FSH emergency department, with 44-126/100,000, the HIV screen should be conducted. To support our study, we will base our arguments on the influential ACP guidelines (Lyons, et al. 2005). The American College of Physicians (ACP) recently endorsed a policy of all screening as well. They also noted that 10 to 25 % of persons who test HIV-positive report no high-risk behaviors. Early screening is beneficial to HIV victims as they stand to reap full benefit from active antiretroviral treatment (Silva, et al. 2007). The number of transmissions is reduced when persons learn about their status. Statistics have also confirmed that screening is cost-effective even to those communities with low-risk prevalence (Hunt et al., 2006). Moreover, screening in at FSH will help in medical follow since the number is not escalating (Lyons, et al. 2005).

Setting

The study center is a hospital with an ED that sees approximately 45,000 patients per year. The hospital is located in a state with an estimated prevalence of acquired immunodeficiency syndrome (AIDS) patients between 44-126/100,000 residents. The ED is dedicated to conducting screening tests on local patients as well as those from adjacent states. The hospital’s responsibilities will be to provide free HIV antibody testing to uninsured persons (Silva, et al. 2007).

Study population criteria

This will include the nursing responsibilities as well as the family medicine resident and faculty members. The nurse’s duty will be to urge the adults with phlebotomy conditions at the ED to have an HIV test. In addition, the patient’s name, address, and phone number will be recorded in an electronic database to which the investigating physicians have access. On the other hand, the family medicine and the faculty members’ duty will be to check for the test results weekly by the research team. Each patient with a positive test result will be contacted by Family Medicine residents or faculty, namely Dr. Babu Subrahmanyam, Dr. Mario Ghanem, or Dr. Emily Richie and medical care for the patient will be arranged. This may be at Franklin Square Family Medicine or another location, depending on patient preference.

Data collection and processing

To investigate this case effectively, a standardized case report will be used to abstract specific demographic and HIV-specific variables such as CD4 counts (cells/ml) and viral loads (copies/ml) (Smith & Stein, 2002). The case report form will also be used to record whether a subject has been seen in the ED or was admitted to the hospital and what their ICD-9 coded ED and hospital discharge were (Haukoos et al., 2002). Within their demography, sex, race, and income level relative to FPL will be indicated. The hospital information desk which maintains a database of the hospital’s medical and discharges billing records will be required to check whether HIV-infected persons visit the ED during the study period (Silva, et al. 2007). The information desk is expected to provide a list of ED visit dates whether the patient was discharged from or admitted to the hospital. The ICD-9 coded ED and hospital discharge diagnoses will also be tabulated to complete the investigation. The collected data will be entered by the investigators into a Microsoft Excel spreadsheet and numerous checks were performed to verify the accuracy of data entry.

Statistical analysis

To characterize the demographic and HIV-specific characteristics of the subjects in ED, descriptive statistics such as percents, means and standard deviation will be used. SPSS for Windows v. 15.0 will be used to create a multivariable logistic regression model and compute odd ratios with 95% confidence intervals for the associations of the variables to be analyzed for patients present in ED (Kozak, DeFrances & Hall, 2006).

Conclusion

The univariate analysis data obtained will categorize the patients in the FSH into various classes. The fundamental outcome measure in this study will be whether an HIV-infected adult followed at the FSH HIV clinic during the study period will utilize the ED. The analytical strategy will be used to identify whether demographic and HIV laboratory variables distinguish those who visit the ED from those who did not (Hafner & Brillman, 1997).

References

1. Guss, D. (1994). The acquired immune deficiency syndrome: an overview for the emergency physician, Part 1. Journal of Emergency Medicine, 12(3), 375– 384.
2. Hafner, J. J. & Brillman, J. (1997). Symptomatology of HIV-related illness and community-acquired illness in an HIV-infected emergency department population. Annals of Emergency Medicine, 29(1), 151–157.
3. Haukoos, J., Witt, M., Zeumer, C. et al., (2002). Emergency department triage of patients infected with HIV. Academic Emergency Medicine, 9(9), 880–888.
4. Hunt, K., Weber, E., Showstack, J. et al., (2006). Characteristics of frequent users of emergency departments. Annals of Emergency Medicine, 48(1), 1–8.
5. Kelen, G., Shahan, J. & Quinn, T. (1999). Emergency department-based HIV screening and counseling: experience with rapid and standard serologic testing. Annals of Emergency medicine, 33(2), 147-55.
6. Kozak, L., DeFrances, C. & Hall, M. (2006). National hospital discharge survey: 2004 annual summary with detailed diagnosis and procedure data. Vital Health Statistics, 13(162), 1–209.
7. Kozak, L., McCarthy, E. & Moien, M. (1993). Patterns of hospital use by patients with diagnoses related to HIV infection. Public Health Reports, 108(5), 571–581.
8. Lima, V., Hogg, R., Harrigan, P. et al., (2007). Continued improvement in survival among HIV-infected individuals with newer forms of highly active antiretroviral therapy. AIDS, 21(6), 685–692.
9. Lyons, M., Lindsell, C., Ledyard, H. et al. (2005). Emergency department HIV testing and counseling: an ongoing experience in a low-prevalence area. Annals of Emergency medicine 46(1), 22-8.
10. Pulivrenti, J., Muppidi, U., Glowacki, R. et al (2007). Changes in HIV-related hospitalizations during the HAART era in an inner-city hospital. AIDS, 17(8), 390–394, 397–401.
11. Silva, A., Glick, N., Lyss, S. (2007). Implementing an HIV and sexually transmitted disease screening program in an emergency department. Annals of Emergency medicine, 49(5), 564-72.
12. Smith, C. & Stein, G. (2002). Viral load as a surrogate end point in HIV disease. Annals of pharmacotherapy, 36, 280–287.
13. Talan, D. & Kennedy, C. (1991). The management of HIV-related illness in the emergency department. Annals of Emergency Medicine, 20(12), 1355–1365.
14. UNAIDS, World Health Organization (2007). AIDS epidemic update, 2007 edn. United Nations, Geneva.
15. Zuckerman, S. & Shen, Y. (2004). Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter? Medical Care, 42(2), 176–182.