PUBLIC HEALTH UPDATE

COVID-19 Surveillance Reveals Benefits of Opt-Out HIV Screening in Emergency Departments

BY: DELECIA VELASQUEZ-STUMP, MPH & HEMAL PARIKH, MPH

Throughout the course of the COVID-19 pandemic we have seen decreases in the cases of disease across the board. In fact, in 2020, San Joaquin County (SJC) saw a decrease in almost every reportable disease except for one: Human Immunodeficiency Virus (HIV). SJC has seen a steady increase in new HIV cases since 2017. As of April 2021, there has been 41 new HIV cases compared to 26 last year and 19 in 2019. One way that the SJC emergency departments (ED’s) can help end the HIV epidemic is to start implementing routine “opt-out” screening. Opt-out screening is the stigma-reducing method of notifying a patient that an HIV screening will be conducted during the other standard preemptive tests and they have the right to decline the test.4 The U.S. Centers for Disease Control and Prevention (CDC) recommends testing all health care patients for HIV - using an “opt-out” approach.1

Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2017 . . . 2018 . . . 2019 . . . .2020 . . % Change HIV71 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72 . . . . . . 82 . . . . . . 89 . . . . . .8 .5% . . . . . . . . . . . . Syphilis, primary and secondary . . . . . .376 . . . . 275 . . . . . 201 . . . . .173 . . . . . . -13 .9% Chlamydia . . . . . . . . . . . . . . . . . . . . . . . . . .3977 . . . 4313 . . . 4803 . . . .3928 . . . . . -18 .2% Gonorrhea . . . . . . . . . . . . . . . . . . . . . . . . . .1360 . . . 1398 . . . 1708 . . . .1055 . . . . . -38 .2% Syphilis, congenital . . . . . . . . . . . . . . . . . .15 . . . . . . 27 . . . . . . 44 . . . . . .26 . . . . . . . -40 .9%

HIV may present similar symptoms to many other viral infections, such as COVID-19, but rather than being transmitted via airborne droplets, it is transmitted by direct contact from infected bodily fluids. These two viruses are very different but one of their first similarities is the psychological toll it has caused in the community. Although we are still learning about COVID-19, it is known to

have symptoms such as fever, cough, shortness of breath, fatigue, body aches, diarrhea, and rashes.2 HIV’s symptoms include, but are not limited to, fever, chills, night sweats, muscle aches, fatigue, swollen lymph nodes, mouth ulcers and rashes.3 Most commonly, a patient infected with HIV experiences symptoms within 6 weeks after their exposure. Early HIV diagnosis is ideal so medication can be started to keep the immune system healthy and decrease further communicable spread.

Patients presenting to health care providers in SJC for possible COVID-19 have instead been found to have HIV. The phenomenon was first noticed by an HIV communicable disease investigator (CDI) who brought to attention a recent uptick in cases being discussed by the State HIV team. The CDI was able to determine that many of the newly diagnosed HIV patients had COVID-19 like symptoms and went to their doctor or emergency room to be tested. However, when they received a negative COVID-19 test, other communal screening tests (including an HIV) were performed and came back positive. A local ED began routine opt out screening for HIV in 2019. Generally, the number of HIV tests performed is expected to increase when routine opt-out screening is initiated. During the COVID-19 pandemic, routine opt-out screening for this local ED yielded approximately 2.5 more HIV tests than previously counted in 2019. They were able to identify 37.5% of the county’s new HIV cases. Routine screenings are vital for preventative care which contribute to better health outcomes for patients. Primary care providers are the ideal providers to conduct preventative screenings but have been affected greatly due to the pandemic and its new precautions. Patients experienced longer wait times for in-person appointments while telehealth became the new norm. This resulted in a flood of emergency room visits that diagnosed many health conditions, such as HIV, that may have not been identified if routine opt-out testing was not offered. Routine opt-out HIV screening in the ED is a key strategy to achieve a 90% reduction of HIV infections in the US by 2030.1

About Ending the HIV Epidemic Initiative. CDC.gov. https:// www.cdc.gov/endhiv/about.html. Last reviewed April 21, 2021. Accessed May 12, 2021.

Symptoms of COVID-19. CDC.gov. https://www.cdc.gov/ coronavirus/2019-ncov/symptoms-testing/symptoms.html. Last reviewed February 22, 2021. Accessed May 13, 2021

About HIV. CDC.gov. https://www.cdc.gov/hiv/basics/ whatishiv.html. Last reviewed April 7, 2021. Accessed May 11, 2021.

Opt-Out Screening. CDC.gov. https://www.cdc.gov/hiv/ clinicians/screening/opt-out.html. Last reviewed March 4, 2020. Accessed May 14, 2021.