Journal of General Internal Medicine

, Volume 19, Issue 4, pp 349–356 | Cite as

Assessing missed opportunities for HIV testing in medical settings

  • Rebecca V. Liddicoat
  • Nicholas J. Horton
  • Renata Urban
  • Elizabeth Maier
  • Demian Christiansen
  • Jeffrey H. Samet
Original Articles


BACKGROUND: Many HIV-infected persons learn about their diagnosis years after initial infection. The extent to which missed opportunities for HIV testing occur in medical evaluations prior to one’s HIV diagnosis is not known.

DESIGN: We performed a 10-year retrospective chart review of patients seen at an HIV intake clinic between January 1994 and June 2001 who 1) tested positive for HIV during the 12 months prior to their presentation at the intake clinic and 2) had at least one encounter recorded in the medical record prior to their HIV-positive status. Data collection included demographics, clinical presentation, and whether HIV testing was recommended to the patient or addressed in any way in the clinical note. Prespecified triggers for physicians to recommend HIV testing, such as specific patient characteristics, symptoms, and physical findings, were recorded for each visit. Multivariable logistic regression was used to identify factors associated with missed opportunities for discussion of HIV testing. Generalized estimating equations were used to account for multiple visits per subject.

RESULTS: Among the 221 patients meeting eligibility criteria, all had triggers for HIV testing found in an encounter note. Triggers were found in 50% (1,702/3,424) of these 221 patients’ medical visits. The median number of visits per patient prior to HIV diagnosis to this single institution was 5; 40% of these visits were to either the emergency department or urgent care clinic. HIV was addressed in 27% of visits in which triggers were identified. The multivariable regression model indicated that patients were more likely to have testing addressed in urgent care clinic (39%), sexually transmitted disease clinic (78%), primary care clinics (32%), and during hospitalization (47%), compared to the emergency department (11%), obstetrics/gynecology (9%), and other specialty clinics (10%) (P<.0001). More recent clinical visits (1997–2001) were more likely to have HIV addressed than earlier visits (P<.0001). Women were offered testing less often than men (P=.07).

CONCLUSIONS: Missed opportunities for addressing HIV testing remain unacceptably high when patients seek medical care in the period before their HIV diagnosis. Despite improvement in recent years, variation by site of care remained important. In particular, the emergency department merits consideration for increased resource commitment to facilitate HIV testing. In order to detect HIV infection prior to advanced immunosuppression, clinicians must become more aware of clinical triggers that suggest a patient’s increased risk for this infection and lower the threshold at which HIV testing is recommended.

Key words

multiple informants delay HIV screening AIDS risk factors 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    McQuillan GM, Khare M, Karon JM, Schable CA, Vlahov D. Update on the seroepidemiology of human immunodeficiency virus in the United States household population: NHANES III, 1988–94. J Acquir Immune Defic Syndr Hum Retrovirol. 1997;14:355–60.PubMedGoogle Scholar
  2. 2.
    CDC. Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. MMWR Recomm Rep. 1999;48:1–31.Google Scholar
  3. 3.
    CDC. HIV and AIDS cases reported through June 2000. HIV AIDS Surveill Rep. 2000;12:1–41.Google Scholar
  4. 4.
    Bacchetti P, Moss AR. Incubation period of AIDS in San Francisco. Nature. 1989;338:251–3.PubMedCrossRefGoogle Scholar
  5. 5.
    Morgan D, Mahe C, Mayanja B, Okongo JM, Lubega R, Whitworth JA. HIV-1 infection in rural Africa: is there a difference in median time to AIDS and survival compared with that in industrialized countries? AIDS. 2002;16:597–603.PubMedCrossRefGoogle Scholar
  6. 6.
    Wortley PM, Chu SY, Diaz T, et al. HIV testing patterns: where, why, and when were persons with AIDS tested for HIV? AIDS. 1995;9:487–92.PubMedCrossRefGoogle Scholar
  7. 7.
    Samet JH, Freedberg KA, Savetsky JB, Sullivan LM, Stein MD. Understanding delay to medical care for HIV infection: the long-term non-presenter. AIDS. 2001;15:77–85.PubMedCrossRefGoogle Scholar
  8. 8.
    Samet JH, Retondo MJ, Freedberg KA, Stein MD, Heeren T, Libman H. Factors associated with initiation of primary medical care for HIV-infected persons. Am J Med. 1994;97:347–53.PubMedCrossRefGoogle Scholar
  9. 9.
    Samet JH, Freedberg KA, Stein MD, et al. Trillion virion delay: time from testing positive for HIV to presentation for primary care. Arch Intern Med. 1998;158:734–40.PubMedCrossRefGoogle Scholar
  10. 10.
    Turner BJ, Cunningham WE, Duan N, et al. Delayed medical care after diagnosis in a US national probability sample of persons infected with human immunodeficiency virus. Arch Intern Med. 2000;160:2614–22.PubMedCrossRefGoogle Scholar
  11. 11.
    Berrios DC, Hearst N, Coates TJ, et al. HIV antibody testing among those at risk for infection. The National AIDS Behavior Surveys. JAMA. 1993;270:1576–80.PubMedCrossRefGoogle Scholar
  12. 12.
    Coates TJ. Efficacy of voluntary HIV-1 counseling and testing in individuals and couples in Kenya, Tanzania, and Trinidad: a randomized trial. The Voluntary HIV-1 Counseling Testing Efficacy Study Group. Lancet. 2000;356:103–12.CrossRefGoogle Scholar
  13. 13.
    Higgins DL, Galavotti C, O’Reilly KR, et al. Evidence for the effects of HIV antibody counseling and testing on risk behaviors. JAMA. 1991;226:2419–29.CrossRefGoogle Scholar
  14. 14.
    Rhame FS, Maki DG. The case of wider use of testing for HIV infection. N Engl J Med. 1989;320:1248–54.PubMedCrossRefGoogle Scholar
  15. 15.
    Samet JH, Libman H, LaBelle C, et al. A model clinic for the initial evaluation and establishment of primary care for persons infected with human immunodeficiency virus. Arch Intern Med. 1995;155:1629–33.PubMedCrossRefGoogle Scholar
  16. 16.
    Freedberg KA, Samet JH. Think HIV: why physicians should lower their threshold for HIV testing. Arch Intern Med. 1999;159:1994–2000.PubMedCrossRefGoogle Scholar
  17. 17.
    Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics. 1986;42:121–30.PubMedCrossRefGoogle Scholar
  18. 18.
    Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika. 1986;73:13–22.CrossRefGoogle Scholar
  19. 19.
    Horton NJ, Laird NM, Zahner G. Use of multiple informant data as a predictor in psychiatric epidemiology. Int J Meth Psychiatr Res. 1999;8:6–18.CrossRefGoogle Scholar
  20. 20.
    Horton NJ, Laird NM, Murphy JM, Monson RR, Sobol AM, Leighton AH. Multiple informants: mortality associated with psychiatric disorders in the Stirling County Study. Am J Epidemiol. 2001;154:649–56.PubMedCrossRefGoogle Scholar
  21. 21.
    Pepe MS, Whitaker RC, Seidel K. Estimating and comparing univariate associations with application to the prediction of adult obesity. Stat Med. 1999;18:163–73.PubMedCrossRefGoogle Scholar
  22. 22.
    Stover E, Steinberg L. Early detection of HIV: implications for prevention research. J Acquir Immune Defic Syndr. 2000;25:S93.Google Scholar
  23. 23.
    Choi KH, Coates TJ. Prevention of HIV infection. AIDS. 1994;8:1371–89.PubMedCrossRefGoogle Scholar
  24. 24.
    Ho DD. Time to hit HIV, early and hard. N Engl J Med. 1995;333:450–1.PubMedCrossRefGoogle Scholar
  25. 25.
    Kaplan JE, Masur H, Holmes KK, et al. USPHS/IDSA guidelines for the prevention of opportunistic infections in persons infected with human immunodeficiency virus: an overview. USPHS/IDSA Prevention of Opportunistic Infections Working Group. Clin Infect Dis. 1995;21:S12–31.PubMedGoogle Scholar
  26. 26.
    Centers for Disease Control and Prevention. A Glance at the HIV Epidemic. Available at: Accessed July 21, 2003.Google Scholar
  27. 27.
    Dybul M, Bolan R, Condoluci D, et al. Evaluation of initial CD4+ T cell counts in individuals with newly diagnosed human immunodeficiency virus infection, by sex and race, in urban settings. J Infect Dis. 2002;185:1818–21.PubMedCrossRefGoogle Scholar
  28. 28.
    Weis SE, Foresman B, Cook PE, Matty KJ. Universal HIV screening at a major metropolitan TB clinic: HIV prevalence and high-risk behaviors among TB patients. Am J Public Health. 1999;89:73–5.PubMedGoogle Scholar
  29. 29.
    Samet JH, Mulvey KP, Zaremba N, Plough A. HIV testing in substance abusers. Am J Drug Alcohol Abuse. 1999;25:269–80.PubMedCrossRefGoogle Scholar
  30. 30.
    Batal H, Biggerstaff S, Dunn T, Mehler PS. Cervical cancer screening in the urgent care setting. J Gen Intern Med. 2000;15:389–94.PubMedCrossRefGoogle Scholar
  31. 31.
    Walensky RP, Losina E, Steger-Craven KA, Freedberg KA. Identifying undiagnosed human immunodeficiency virus. The yield of routine, voluntary inpatient testing. Arch Intern Med. 2002;162:887–92.PubMedCrossRefGoogle Scholar
  32. 32.
    Anonymous. Advancing HIV Prevention: New Strategies for a Changing Epidemic-United States, 2003. MMWR April 18, 2003.Google Scholar
  33. 33.
    Spielberg F, Kassler WJ. Rapid testing for HIV antibody: a technology whose time has come. Ann Intern Med. 1996;125:509–11.PubMedGoogle Scholar
  34. 34.
    Irwin K, Olivo N, Schable CA, Weber JT, Janssen R, Ernst J. Performance characteristics of rapid HIV antibody assay in a hospital with a high prevalence of HIV infection. CDC-Bronx-Lebanon HIV Serosurvey Team. Ann Intern Med. 1996;125:471–5.PubMedGoogle Scholar
  35. 35.
    Stein MD, Crystal S, Cunningham WE, et al. Delays in seeking HIV care due to competing caregiver responsibilities. Am J Public Health. 2000;90:1138–40.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2004

Authors and Affiliations

  • Rebecca V. Liddicoat
    • 6
  • Nicholas J. Horton
    • 5
  • Renata Urban
    • 1
    • 3
  • Elizabeth Maier
    • 1
    • 3
  • Demian Christiansen
    • 4
  • Jeffrey H. Samet
    • 1
    • 2
  1. 1.the Clinical Addiction Research and Education UnitBoston University Schools of Medicine and Public HealthBoston
  2. 2.Section of General Internal Medicine and the Clinical A1DS Program, Department of MedicineBoston University Schools of Medicine and Public HealthBoston
  3. 3.Department of Social and Behavioral SciencesBoston University School of Medicine and Public HealthBoston
  4. 4.Data Coordinating CenterBoston University Schools of Medicine and Public HealthBoston
  5. 5.Department of MathematicsSmith CollegeNorthampton
  6. 6.General Medicine Division, Department of MedicineMassachusetts General HospitalBoston

Personalised recommendations