title: Missing the mark: ongoing missed opportunities for HIV diagnosis at an urban medical center despite universal screening recommendations.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors: Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA, aliggett@adolescentaids.org.|Department of Pediatrics, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA.
authors: Alisha
authors: A
authors: Liggett
authors: Department of Pediatrics, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA.
authors: Donna
authors: D
authors: Futterman
authors: Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
authors: Galina I
authors: GI
authors: Umanski
authors: Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
authors: Peter A
authors: PA
authors: Selwyn
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000592:standards / Q000706:statistics & numerical data*; D058070:Asymptomatic Diseases; D018791:CD4 Lymphocyte Count; D042241:Early Diagnosis; D004636:Emergency Service, Hospital / Q000592:standards / Q000706:statistics & numerical data*; D017050:Episode of Care; D005260:Female; D015658:HIV Infections / Q000097:blood / Q000175:diagnosis*; D006300:Health Services Misuse; D006786:Hospitals, Urban / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D011320:Primary Health Care / Q000592:standards / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D055815:Young Adult
keywords: HIV testing; HIV/AIDS; health disparities; missed opportunities; primary care; underserved populations.