Characteristics of Patients Who Acquired Human Immunodeficiency Virus (HIV) Infection Despite Accessing Healthcare: Implications for HIV Prevention Strategies

Abstract

Background. Cases in which patients who access care and test repeatedly for HIV before becoming HIV-infected (seroconverters) may represent missed opportunities for HIV prevention. We aimed to characterize patients who seroconverted despite accessing care at Montefiore Medical Center, the single largest health system in the Bronx, New York, one of the epicenters of the U.S. HIV epidemic. Methods. Adult patients in the Einstein/Rockefeller/Hunter Center for AIDS Research's HIV Clinical Cohort Database with at least one negative HIV test prior to a positive test between 2009 and 2014 were evaluated. Demographics (sex, age, race/ethnicity), HIV-related variables (number of HIV tests, risk factor, CD4 count, HIV-RNA level) were extracted from the database. Seroconversion was confirmed by chart review. Results. Among over 50,000 unique patients tested annually, we identified 220 seroconverters. 102 (46%) were female and 4 (2%) were MTF transgender. One hundred four (47%) seroconverters were non-Hispanic black and 88 (40%) were Hispanic. Median age at time of HIV diagnosis was 30 years (IQR 23-42). 97 (49%) reported heterosexual contact as their HIV transmission factor, 70 (35%) were MSM, and 4 (2%) used IV drugs. The proportion of individuals who reported heterosexual risk factor increased over time (56% in 2014 versus 24% in 2009, p = 0.03). Overall, patients had 2 (IQR 1-3) negative HIV tests before a positive test and median time between negative tests was 1 year (IQR 0.6-1.6). The median interval between last negative and the positive test was 2.1 years (IQR 1-3.8). Patients had a median of 3 (1-5) health-care encounters between their last negative and first positive tests. HIV was diagnosed by routine screening for 131 (59%) patients and as part of a diagnostic workup in 26 (12%) patients. Ninety-seven (51%) patients had CD4 count >500 cell/mcl at HIV diagnosis. No patients were receiving pre-exposure prophylaxis. Conclusion. We identified a population that became HIV-infected despite having multiple health-care encounters and undergoing testing almost yearly. These patients were mostly heterosexual and almost half were female. To avoid missed opportunities, HIV prevention efforts should include strategies tailored to this population that is already accessing care.