To the Editor:
Earlier identification of HIV-infected patients reduces both mortality and the cost of treatment by keeping patients out of the hospital and encourages reduction of risk behaviors thus preventing further transmission.1,2 Unfortunately, despite the promulgation of national and societal guidelines that recommend routinely offering HIV testing, an estimated 21% of the 1.1 million HIV-infected persons in the United States are unaware of their status.3
We have previously developed and implemented a multimodal intervention that more than doubled HIV testing rates in individuals receiving care at 2 Veterans Health Administration (VHA) medical facilities.4 These results were robust with dramatic increases in test rates occurring across patient-level, provider-level, and subfacility level factors. Furthermore, the gains from this intervention were sustained after responsibility for maintenance of the program was largely transferred from the research implementation team to local staff.5 Finally, the rate of positive tests remained constant in the year before and after implementation of the intervention and well within the range at which the cost of HIV testing is less than $50,000 per quality-adjusted life year.4,6
We now compare the characteristics of patients newly diagnosed with HIV infection before and after implementation of this intervention and provide a long-term perspective on the effectiveness of the program. In addition, we compare our results from those of another VHA facility that implemented only the computerized decision support element of this program.
At site A, in July 2005, a multicomponent intervention that consisted of an electronic clinical reminder that prompted providers to offer HIV testing to persons with identifiable risk factors for HIV infection, streamlined HIV counseling processes, provider education and clinic-level feedback on HIV testing rates was implemented to promote HIV-testing.4,5 At site B, the electronic clinical reminder component of this program was put in place in January 2008. At both sites written informed consent, which had been required for HIV testing, was replaced by verbal consent in August of 2009. Subsequently, the electronic clinical reminder was modified to recommend once per lifetime HIV testing in all adults regardless of the presence or absence of identified risk factors. This modification was implemented at site A in December 2010 and at site B in June 2010.
The results of HIV diagnostic tests and laboratory results were extracted from the electronic medical records at each site. For patients receiving care at both sites, other data elements were obtained via retrospective review of electronic medical records. At site B, in addition, all outside medical records were reviewed. Care was taken to discriminate between newly diagnosed patients and patients with confirmatory testing for diagnoses made at other facilities. Patients who had previously tested positive for HIV infection were excluded from all analyses.
The study was approved by the Institutional Review Boards at the VA Greater Los Angeles Healthcare System and at Emory University.
At site A, 9697 tests were done in the pre-intervention period (1763 tests per year) versus 31,116 tests in the postintervention period (5657 tests per year; Table 1). As opposed to the earlier period, in the postintervention period, at the time of diagnosis, patients were less often hospitalized (12.5 vs. 35.4%, P = 0.001) and less frequently had CDC category B or C conditions7 (12.5% vs. 25.6%, P = 0.018) or fewer than 200 CD4 cells/μL (29% vs. 46%, P = 0.029). Although there was little change in the mean age at diagnosis, the proportion of newly diagnosed persons 60 years of age and older showed a nonsignificant increase from 7.5% to 15.3% (P = 0.12).
Similar results were found at site B, where 5432 tests were done in the pre-intervention period (1810 tests per year) versus 24,371 tests in the postintervention period (8124 tests per year; Table 1). At site B, postintervention patients were less likely to have CDC category B or C conditions (18.9% vs. 32.8%, P = 0.016), but similar number were hospitalized at the time of diagnosis in the 2 periods. The proportion of patients with fewer than 200 CD4+ cells per microliter at the time of diagnosis decreased from 43% to 29% (P = 0.036), and the proportion of patients 60 years of age and older was unchanged (20% vs. 22%).
Previous studies by our group demonstrated sustainable increases over a 2-year period of time in the rates of HIV testing after implementation of a multimodal program consisting of computerized decision support for HIV testing (ie, an electronic clinical reminder), provider education, feedback reports, and organizational changes to increase HIV testing.4,5 The current findings establish the long-term sustainability of this intervention at site A (ie, after 2007 when prior analyses ceased5) and demonstrate similar increases in HIV testing in site B, a facility that implemented the electronic clinical reminder without other program elements.
One of the goals of expanded HIV testing programs is to identify patients with higher CD4+ cell counts and thus maximize the immunological and clinical effectiveness of antiretroviral therapy.8,9 Thus it is important that at both sites we found that increased rates of HIV testing were accompanied by an increase in the CD4 count at the time of diagnosis. Furthermore, data from site A indicated that the expanded HIV testing program more often resulted in the diagnosis of HIV infection among asymptomatic patients receiving ambulatory care. Finally, despite markedly increased rates of testing, the rate of new diagnoses generally remained above the 0.1% threshold above which HIV testing remains cost-effective.6 Notably, in the postintervention period 15%-22% of newly diagnosed patients were 60 years of age and older.
Limitations of our work include the fact that the intervention relied heavily on the quality improvement infrastructure in the VHA, including the electronic medical record. This makes it difficult to generalize the intervention to healthcare systems that do not currently have access to these tools. However, such tools are becoming increasingly common. Although implementation of the electronic clinical reminder component alone resulted in highly significant increases in HIV testing at site B, which suggests that other program elements are not necessary, the degree to which this result is generalizable or contingent on special site characteristics is not known.
In summary, these data further demonstrate the sustainability and effectiveness of context-specific electronic clinical reminders for promoting HIV testing. In addition, these results substantiate that increased rates of testing can fulfill the promise of identifying substantial numbers of patients before the development of advanced clinical and laboratory findings. The findings also support the recommendations of the American College of Physicians that there not be an upper bound on the age at which HIV testing is offered and are consistent with prior data suggesting the presence of significant rates of undiagnosed HIV infection in older patients in the United States Veterans Administration Healthcare System.10,11 However, it will be useful to monitor the trends in the rates of new diagnoses in varying populations and geographical areas as the proportion of tests that resulted in new diagnoses at site A decreased to 0.09% in 2010. Finally, systems need to be developed to maximize the frequency with which newly identified patients are linked to care and remain in care.12
Matthew Bidwell Goetz*†
*Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA †Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA ‡Department of Medicine, VA Medical Center, Decatur, GA §Department of Medicine, Emory University School of Medicine, Atlanta, GA
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