Missed Opportunities for HIV Screening Prior to Diagnosis Among a Cohort of Youth Living with HIV
PURPOSE: Routine HIV screening reduces the risk of HIV progression and secondary transmission in adolescents and young adults, a group at disproportionate HIV risk. Our aims were to: 1) Determine prevalence and correlates of missed opportunities for prior HIV screening among a cohort of youth living with HIV (YLWH) and 2) describe the prevalence of seroconversion symptoms.
METHODS: Retrospective chart review of YLWH aged 14–26 years initiating care from 2009–2015 at the Children's Hospital of Philadelphia (CHOP) adolescent HIV clinic. Of subjects seen at CHOP primary or acute care sites prior to HIV diagnosis, we compared clinical and demographic characteristics of those with and without completed HIV screening in the one and three years prior to diagnosis using chi-squared, fisher's exact and two-sample t-test if data were normally distributed and Wilcoxon rank-sum testing if not. Variables with a pvalue <.1 in bivariate analysis were entered into univariate logistic regression models to identify factors associated with prior HIV testing. Variables remaining significant in univariate analyses were included in multivariable logistic regression models adjusted for insurance status, race and gender.
RESULTS: The majority of subjects (n = 301) were male (88%), African-American (87%), acquired HIV through male-male sexual transmission (84%). At diagnosis, the median age at HIV diagnosis was 19 (IQR 17- 21), CD4 count was 472 cells/lL (IQR 329–614), and HIV-1 viral load 19,745 (IQR 5,732.5-69,940). Symptoms of possible seroconversion were reported by 132/301 (44.2%) at the first HIV clinic visit. There were 79 subjects (26%) seen in the 36 months prior to their HIV diagnosis who contributed 325 visits to the analysis. HIV testing was performed in 31 (39%) of subjects in the three years prior to diagnosis. In the bivariate analysis examining the probability of completed HIV testing in the year prior to diagnosis among patients seen in the healthcare system during that time period, subjects with younger age at HIV diagnosis (p = .004) and presenting with symptoms compatible with acute HIV infection (p = .008), were less likely to be tested for HIV in the year prior to diagnosis. In the bivariate analysis of those seen in the three years prior to diagnosis, lack of a documented sexual history (p < .001) was associated with not having received HIV testing. In the multivariate logistic regression model examining HIV screening in the year prior to diagnosis, adjusting for insurance, race and gender, younger age at diagnosis was associated with decreased odds of HIV screening (aOR .7, 95% CI (.5 -.9). In the multivariable model examining receipt of HIV testing within three years prior to diagnosis, absence of a documented sexual history was significantly associated (aOR 0 .1, 95% CI (.04–.4) with lack of screening.
CONCLUSIONS: In this cohort of YLWH, we identified missed opportunities for HIV testing in one and three years prior to HIV diagnosis. Lack of a documented sexual history and younger age were associated with not receiving HIV testing, underscoring the need for comprehensive sexual health screening and HIV testing in younger adolescents.