Missing the mark: Ongoing missed opportunities for HIV diagnosis at an urban medical center despite universal screening recommendations

Background. Despite established recommendations from the Centers for Disease Control (CDC) to scale up testing efforts in the USA, this study shows full scale implementation of these recommendations may still be lacking. We hypothesize that patients experience ongoing missed opportunities for earlier diagnosis of HIV, despite frequent encounters to Montefiore Medical Center (MMC), an integrated hospital system in the Bronx, NY. Methods. Retrospective chart review via electronic medical records of patients newly diagnosed with HIV in 2012 and 2013 at varied MMC clinical sites. Missed opportunities were defined as > 1 prior health care encounter at MMC within three calendar years of diagnosis, in which HIV testing was not offered for those who had a prior negative test or no prior test. Results. There were 218 patients newly diagnosed with HIV at MMC during the study period; 31% presented with a CD4 < 200 cells/mm³; 22% were asymptomatic at diagnosis. Patients (56%) without a prior HIV test had an average 4.72 clinical encounters at MMC within the 3 years prior to their HIV diagnosis. Over 95% of visits prior to diagnosis occurred in emergency departments (EDs) or primary care outpatient department (OPDs) and accounted for the vast majority of missed opportunities. Conclusions. HIV infected patients continue to present late to care, with low CD4 and commonly utilize OPDs and EDs, where missed opportunities for earlier diagnosis are common. Practices that address augmentation of current HIV testing strategies are needed, especially in outpatient and first-contact acute care settings.