title: Improvements in the continuum of HIV care in an inner-city emergency department.
abstract: OBJECTIVE
  The Johns Hopkins Hospital Emergency Department has served as a window on the HIV epidemic for 25 years, and as a pioneer in emergency department-based screening/linkage-to-care (LTC) programs. We document changes in the burden of HIV and HIV care metrics to the evolving HIV epidemic in inner-city Baltimore.
  
  
  METHODS
  We analyzed seven serosurveys conducted on 18 ,144 adult Johns Hopkins Hospital Emergency Department patients between 1987 and 2013 as well as our HIV-screening/LTC program (2007, 2013) for trends in HIV prevalence, cross-sectional annual incidence estimates, undiagnosed HIV, LTC, antiretrovirals treatment, and viral suppression.
  
  
  RESULTS
  HIV prevalence in 1987 was 5.2%, peaked at more than 11% from 1992 to 2003 and declined to 5.6% in 2013. Seroprevalence was highest for black men (initial 8.0%, peak 20.0%, last 9.9%) and lowest for white women. Among HIV-positive individuals, proportion of undiagnosed infection was 77% in 1987, 28% in 1992, and 12% by 2013 (P < 0.001). Cross-sectional annual HIV incidence estimates declined from 2.28% in 2001 to 0.16% in 2013. Thirty-day LTC improved from 32% (2007) to 72% (2013). In 2013, 80% of HIV-positive individuals had antiretrovirals ARVs detected in sera, markedly increased from 2007 (27%) (P < 0.001). Proportion of HIV-positive individuals with viral suppression (<400 copies/ml) increased from 23% (2001) to 59% (2013) (P < 0.001).
  
  
  CONCLUSIONS
  Emergency department-based HIV testing has evolved from describing the local epidemic to a strategic interventional role, serving as a model for early HIV detection and LTC. Our contribution to community-based HIV-screening and LTC program parallels declines in undiagnosed HIV infection and incidence, and increases in antiretroviral use with associated viral suppression in the community.
authors.affiliation: aDepartment of Emergency Medicine, Johns Hopkins University School of Medicine, BaltimorebDivision of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, BethesdacDepartment of PathologydDepartment of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
authors.forename: Gabor D
authors.initials: GD
authors.lastname: Kelen
authors.forename: Yu-Hsiang
authors.initials: YH
authors.lastname: Hsieh
authors.forename: Richard E
authors.initials: RE
authors.lastname: Rothman
authors.forename: Eshan U
authors.initials: EU
authors.lastname: Patel
authors.forename: Oliver B
authors.initials: OB
authors.lastname: Laeyendecker
authors.forename: Mark A
authors.initials: MA
authors.lastname: Marzinke
authors.forename: William
authors.initials: W
authors.lastname: Clarke
authors.forename: Teresa
authors.initials: T
authors.lastname: Parsons
authors.forename: Jordyn L
authors.initials: JL
authors.lastname: Manucci
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Quinn
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015142:Baltimore; D003266:Continuity of Patient Care; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000517:prevention & control / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011787:Quality of Health Care; D055815:Young Adult