Title: Missed Opportunities in HIV Screening and Transmission Prevention in Southeastern United States: A Retrospective Cohort Study

Authors: Cecily Kaufmann, BSN, RN, David Hudon, MPH, Phillip Moschella, MD, Heather Brown, MD, Caroline Derrick, PharmD, Sharon Weissman, MD, Divya Ahuja, MD, Sarah Battle, MD

Background: Despite extensive HIV prevention efforts, the high incidence of HIV in the Southeastern United States underscores the urgent need for enhanced public health initiatives. This study examined new HIV diagnoses in the Midlands of South Carolina and identified missed opportunities (MOs) for early detection in the 365 days prior to new HIV diagnosis. In addition, MOs for pre-exposure prophylaxis (PrEP) discussion for HIV transmission prevention were evaluated.

Methods: This retrospective cohort study analyzed 127 new HIV diagnoses in adults ≥ 18 years of age in the Midlands area of South Carolina between January 1, 2022 and December 31, 2023. Patient demographics, risk factors, and clinical characteristics of all healthcare visits from the 365 days prior to HIV diagnosis were evaluated. Descriptive statistical analysis focused on characterizing HIV screening MOs and PrEP discussion MOs.

Results: The cohort predominantly consisted of Black or African American males, but included 18.8% females and 12.5% Caucasians. While men who only have sex with men (MSM) was common (28.3%), exclusive heterosexual activity (43.3%) was surprisingly more prevalent. Of the 117 patients without a diagnosis of acute retroviral syndrome (ARS), 40.1% had severe immunosuppression (CD4 <200 cells/mm³). In the year prior to non-ARS HIV diagnosis, there were a total of 414 MOs for HIV screening (mean of 3.5 per patient), with 45.7% in the Emergency department visits and 12.1% in urgent care, and 42.3% in outpatient clinics. The most common clinics for screening MOs were Family Medicine, Internal Medicine, Cardiology, and Orthopedic Surgery. In the year prior to ARS diagnosis, there were 34 MOs for PrEP discussions (mean of 3.4 per patient). The most common clinics for PrEP MOs were Family Medicine and Orthopedic Surgery. For both types of MOs, patients were most frequently seen for chronic health conditions (10.5% of the MOs for screening and 14.1% of the MOs for HIV PrEP). Only ten patients (7.8%) had ever had a previous negative HIV screen, and only one (0.8%) had a screen done in the year prior to HIV diagnosis. Only seven patients had previously been offered PrEP.

Conclusions: This study highlights the substantial number of missed opportunities for HIV screening and PrEP discussions in all locations of medical care, from the Emergency Department to subspecialty clinics. Given the diverse risk factors seen in this study, not only should universal opt-out HIV screening be implemented in high incidence regions, but consideration should be given to frequent HIV screening and PrEP discussions in all adults irrespective of their sexual orientation.