SAN DIEGO – Only 39% of patients hospitalized for pneumonia underwent HIV testing, even though federal recommendations for universal HIV screening in all health care settings have been in place since 2006, according to the results of a retrospective, single-center study.
“Despite universal recommendations for HIV screening in all health care settings, HIV testing rates remain low among patients hospitalized with pneumonia,” Dr. Dana C. Clifton said at an annual scientific meeting on infectious diseases. “A number of patients were subsequently diagnosed with HIV after a prolonged delay.”
Dr. Dana C. Clifton
Of patients newly diagnosed with HIV in the United States, 41% report no prior HIV testing and an estimated 14%-25% of those living with HIV are undiagnosed, said Dr. Clifton, an internist at Duke University Medical Center, Durham, N.C. In 2006, the Centers for Disease Control and Prevention recommended routine HIV screening in all health care settings for all patients aged between 13 and 64 years old. “Multiple studies have shown that routine screening is cost effective, compared with screening tests for colon cancer, diabetes, and breast cancer,” Dr. Clifton said. In addition, bacterial pneumonia “is a predictor of HIV infection, and the clinical manifestations of bacterial pneumonia are similar whether one has HIV or not. So the question is, how do you decide whom to screen for HIV at hospital admission for pneumonia?”
Dr. Clifton and her associates retrospectively evaluated patients admitted to Duke University Health System between Jan. 1, 1996 and Dec. 31, 2014 with a first primary diagnosis of pneumonia. They used ICD-9 codes for primary diagnosis of pneumonia at time of hospital admission, reviewed a subset of charts to validate the diagnosis, and conducted a random sample of those without prior HIV diagnosis to evaluate HIV testing. The primary outcome was HIV testing during pneumonia admission. Secondary outcomes were documented prior HIV testing in the electronic medical record and subsequent new HIV diagnosis following pneumonia admission.
During the time period studied, 6,858 patients were admitted with a primary diagnosis of pneumonia. Their median age was 50 years, 49% were male, 53% were white, 41% were African American, and the rest were from other ethnic groups. In all, 5,133 (75%) were discharged by general medicine or pulmonary service.
Of the 6,858 patients, 6,513 (95%) were not previously known to be HIV positive (95%), while 345 (5%) were previously known to be HIV positive. Of the 6,513 not previously known to be HIV positive, 19 (0.3%) were diagnosed with HIV during hospital admission and 46 (0.7%) were diagnosed with HIV a median of 807 days after admission.
When the researchers evaluated a random sample of 207 patients not previously known to be HIV positive, the researchers found that only 69 (33%) had an HIV test result ever documented before or during admission, while 16 (8%) were tested for HIV sometime after discharge.
The researchers noted a slight but nonsignificant improvement in the proportion of patients with pneumonia who were ever tested for HIV before or during admission, before and after implementation of the CDC guidelines in 2006 (from 28% to 39%; P = .09). Dr. Clifton pointed out that the 5% prevalence of HIV observed in patients admitted with pneumonia is 10 times higher than the prevalence of HIV in the general population (.47%).
Limitations of the study, she said, include its retrospective, single-center design and the fact that it relied on an administrative database. “There’s also potential for coding bias using ICD-9 codes,” she said. “However, prior studies using ICD-9 codes for diagnosis of pneumonia show reasonably good specificity.”
She concluded her presentation by calling for “more studies to evaluate HIV testing and diagnosis in this higher-risk population of patients admitted with pneumonia. Opt-out HIV testing among pneumonia inpatients should be implemented for earlier HIV diagnosis and improved outcomes.”
IDWeek marks the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. The researchers reported having no financial disclosures.
The researchers reported having no financial disclosures.