Jeffrey D. Schulden

Results of a Rapid HIV Screening and Diagnostic Testing Program in an Urban Emergency Department

STUDY OBJECTIVE We describe outcomes of a rapid HIV testing program integrated into emergency department (ED) services, using existing staff. METHODS From April 2005 through December 2006, triage nurses in an urban ED offered HIV screening to medically stable patients aged 12 years or older. Clinicians could also order diagnostic testing according to presenting signs and symptoms and suspicion of HIV-related illness. Nurses obtained consent, performed rapid testing, and disclosed negative test results. Clinicians disclosed positive test results and arranged follow-up. Outcome measures included number and proportion of visits during which screening was offered, accepted, and completed; number of visits during which diagnostic testing was completed; and number of patients with confirmed new HIV diagnosis and their CD4 counts. RESULTS HIV screening and diagnostic testing were completed in 9,466 (8%) of the 118,324 ED visits (14.2% of the 60,306 unique patients were tested at least once). Screening was offered 45,159 (38.2%) times, accepted 21,626 (18.3%) times, and completed 7,923 (6.7%) times; diagnostic testing was performed 1,543 (1.3%) times. Fifty-five (0.7%) screened patients and 46 (3.0%) of those completing diagnostic testing had confirmed positive HIV test results. Median CD4 count was 356 cells/microL among screened patients and 99 cells/microL among those who received diagnostic testing. CONCLUSION Although existing staff was able to perform HIV screening and diagnostic testing, screening capacity was limited and the HIV prevalence was low in those screened. Diagnostic testing yielded a higher percentage of new HIV diagnoses, but screening identified greater than 50% of those found to be HIV positive, and the median CD4 count was substantially higher among those screened than those completing diagnostic testing.

Rapid HIV Testing in Transgender Communities by Community-Based Organizations in Three Cities

Objectives. This article describes the demographic and behavioral characteristics, human immunodeficiency virus (HIV) testing history, and results of HIV testing of transgender (TG) people recruited for rapid HIV testing by community-based organizations (CBOs) in three cities. Methods. CBOs in Miami Beach, Florida, New York City, and San Francisco offered TG people rapid HIV testing and prevention services, and conducted a brief survey. Participants were recruited in outreach settings using various strategies. The survey collected information on demographic characteristics, HIV risk behaviors, and HIV testing history. Results. Among 559 male-to-female (MTF) TG participants, 12% were newly diagnosed with HIV infection. None of the 42 female-to-male participants were newly diagnosed with HIV. A large proportion of MTF TG participants reported high-risk behaviors in the past year, including 37% who reported unprotected receptive anal intercourse and 44% who reported commercial sex work. Several factors were independently associated with increased likelihood of being newly diagnosed with HIV infection among MTF TG participants, including having a partner of unknown HIV status in the past year; being 20–29 or ≥40 years of age; having last been tested for HIV more than 12 months ago; and having been recruited at the New York City site. Conclusions. Based on the high proportion of undiagnosed HIV infection among those tested, TG people represent an important community for enhanced HIV testing and prevention efforts. MTF TG people should be encouraged to have an HIV test at least annually or more often if indicated, based upon clinical findings or risk behaviors. Efforts should continue for developing novel strategies to overcome barriers and provide HIV testing and prevention services to TG people.

Patient and Regimen Characteristics Associated with Self-Reported Nonadherence to Antiretroviral Therapy

Background Nonadherence to antiretroviral therapy (ARVT) is an important behavioral determinant of the success of ARVT. Nonadherence may lead to virological failure, and increases the risk of development of drug resistance. Understanding the prevalence of nonadherence and associated factors is important to inform secondary HIV prevention efforts. Methodology/Principal Findings We used data from a cross-sectional interview study of persons with HIV conducted in 18 U.S. states from 2000–2004. We calculated the proportion of nonadherent respondents (took <95% of prescribed doses in the past 48 hours), and the proportion of doses missed. We used multivariate logistic regression to describe factors associated with nonadherence. Nine hundred and fifty-eight (16%) of 5,887 respondents reported nonadherence. Nonadherence was significantly (p<0.05) associated with black race and Hispanic ethnicity; age <40 years; alcohol or crack use in the prior 12 months; being prescribed ≥4 medications; living in a shelter or on the street; and feeling “blue” ≥14 of the past 30 days. We found weaker associations with having both male-male sex and injection drug use risks for HIV acquisition; being prescribed ARVT for ≥21 months; and being prescribed a protease inhibitor (PI)-based regimen not boosted with ritonavir. The median proportion of doses missed was 50%. The most common reasons for missing doses were forgetting and side effects. Conclusions/Significance Self-reported recent nonadherence was high in our study. Our data support increased emphasis on adherence in clinical settings, and additional research on how providers and patients can overcome barriers to adherence.

Prevalence of malaria parasitemia among clients seeking treatment for fever or malaria at drug stores in rural Tanzania 2004

Objective  To determine the prevalence of malaria parasitemia and other common illnesses among drug store clients in one rural community, with a view to the potential role of specialist drug stores in expanding coverage of effective malaria treatment to households in highly endemic areas.

coStS and effectIveneSS of fIndIng neW HIv dIagnoSeS By uSIng rapId teStIng In tranSgender communItIeS

We assessed the costs and effectiveness of rapid HIV testing services provided to transgender communities in New York City and San Francisco from April 2005 to December 2006. Program costs were estimated based on service providers perspective and included the costs attributable to staff time, incentives, transportation, test kits, office space, equipment, supplies, and utilities. The average annual numbers of persons tested were 195 and 106 persons and numbers notified of new HIV diagnoses were 35 (18.2%) in New York City and 8 (7.3%) in San Francisco, respectively. The estimated annual program costs were

Substance abuse in the United States: Findings from recent epidemiologic studies

125,879 and

Psychological responses to the sniper attacks: Washington DC area, October 2002

64,323 and average costs per person notified of new diagnosis were

HIV Testing Histories and Risk Factors Among Migrants and Recent Immigrants Who Received Rapid HIV Testing from Three Community-Based Organizations

3,563 and

Brief reportPsychological Responses to the Sniper Attacks: Washington DC Area, October 2002

8,284 in New York City and San Francisco, respectively. The primary reason for differences in program costs by site was differences in the proportion of undiagnosed HIV infection among persons tested. Our findings can inform decisions about program planning and allocation of limited HIV testing resources.