Entry into care and clinician management of acute HIV infection in New York City.
- SourceAvailable from: NM Zetola[Show abstract] [Hide abstract]
ABSTRACT: HIV infection starts as an acute, systemic infection, followed by a chronic period of clinical latency, usually lasting 3 to 10 years, which precedes the eventual collapse of the immune system. It is increasingly recognized that events occurring during acute HIV infection may determine the natural course of the disease. The very dynamic events of acute HIV infection provide multiple opportunities for biologic interventions, such as anti-retroviral or immune-based therapies. Similarly, the implementation of public health measures during acute HIV infection could help control epidemics or outbreaks. Many of the dramatic possibilities for intervention in acute HIV infection remain unproved, not the least because of traditional difficulty of diagnosing patients during this early period. This article reviews the natural history, pathogenesis and clinical presentation of acute HIV infection, and suggests a diagnostic and therapeutic approach to guide clinicians dealing with patients with suspected or confirmed acute HIV infection.Infectious Disease Clinics of North America 04/2007; 21(1):19-48, vii. DOI:10.1016/j.idc.2007.01.008 · 2.31 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: The full benefit of timely diagnosis of human immunodeficiency virus (HIV) infection is realized only if there is timely initiation of medical care. We used routine surveillance data to measure time to initiation of care in New York City residents diagnosed as having HIV by positive Western blot test in 2003. The time between the first positive Western blot test and the first reported viral load and/or CD4 cell count or percentage was used to indicate the interval from initial diagnosis of HIV (non-AIDS) to first HIV-related medical care visit. Using Cox proportional hazards regression, we identified variables associated with delayed initiation of care and calculated their hazard ratios (HRs). Of 1928 patients, 1228 (63.7%) initiated care within 3 months of diagnosis, 369 (19.1%) initiated care later than 3 months, and 331 (17.2%) never initiated care. Predictors of delayed care were as follows: diagnosis at a community testing site (HR, 1.9; 95% confidence interval [CI], 1.5-2.3), the city correctional system (HR, 1.6; 95% CI, 1.2-2.0), or Department of Health sexually transmitted diseases or tuberculosis clinics (HR, 1.3; 95% CI, 1.1-1.6) vs a site with colocated primary medical care; nonwhite race/ethnicity (HR, 1.8; 95% CI, 1.5-2.0); injection drug use (HR, 1.3; 95% CI, 1.1-1.5); and location of birth outside the United States (HR, 1.1; 95% CI, 1.0-1.2). A total of 1597 persons (82.8%) diagnosed as having HIV in 2003 ever initiated care, most within 3 months of diagnosis. Initiation of care was most timely when diagnosis occurred at a testing site that offered colocated medical care. Improving referrals by nonmedical sites is critical. However, because most diagnoses occur in medical sites, improving linkage in these sites will have the greatest effect on timely initiation of care.Archives of internal medicine 07/2008; 168(11):1181-7. DOI:10.1001/archinte.168.11.1181 · 13.25 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: In 2005 we implemented an emergency department HIV testing program that emphasized screening by nurses but also allowed for clinician diagnostic testing. We noted that clinicians often ordered tests that proved to be positive on patients who had been missed by screening, while others who tested positive had made previous visits when screening was available, but were not tested. The study objective was to quantify missed screening opportunities and assess the extent to which diagnostic testing contributes to the detection of HIV infection. Triage nurses were to offer screening to medically stable patients 12 years of age or older. Clinicians could order diagnostic testing in patients with signs and symptoms concerning for HIV. Nurses performed rapid HIV tests on oral fluid specimens. Charts of all patients testing positive between April 1, 2005 and November 31, 2006 were reviewed. The 2006 annual census was 75,000 visits with 47% of patients black, 32% Hispanic, 44% female, and 98% 12 years of age or older. Ninety-five patients tested HIV positive; 66 (69.5%) were diagnosed on their first visit but 29 (30.5%) made a total of 59 visits (range, 1-8) before testing positive. Patients were screening eligible during 54 (91.5%) of these 59 visits but screening was not offered during 34 (63.0%) of them, representing missed screening opportunities. On the day of diagnosis, 80 (84.2%) of the 95 patients were screening eligible but 20 (25.0%) of them were not offered screening, representing missed screening opportunities. Diagnostic testing identified HIV in 44 patients; 15 were screening ineligible, 20 were not offered screening, and 9 declined screening. Missed opportunities for earlier diagnosis occurred frequently despite an HIV screening program. Clinician diagnostic testing was an important adjunct to screening.AIDS patient care and STDs 04/2009; 23(4):245-50. DOI:10.1089/apc.2008.0198 · 3.58 Impact Factor