key: cord-0942122-ofgfqvb0 authors: Niu, Jianli; Sareli, Candice; Eckardt, Paula A. title: Impact of the COVID-19 pandemic on an emergency department-based opt-out HIV screening program in a South Florida hospital: An interrupted time series analysis, July 2018-March 2021 date: 2022-05-14 journal: Am J Infect Control DOI: 10.1016/j.ajic.2022.05.004 sha: 7930a058bfb1de4da7252dfb50738eb4bea906b0 doc_id: 942122 cord_uid: ofgfqvb0 BACKGROUND: The COVID-19 pandemic has posed a tremendous burden on healthcare services. We evaluated its impact on an emergency department (ED)-based opt-out HIV testing in a public healthcare system. METHODS: The programmatic data of ED-based HIV testing from July 2018 to March 2021 at the Memorial Regional Hospital, Hollywood, Florida was analyzed by interrupted time series analysis to evaluate the immediate and gradual effects of the COVID-19 pandemic on the number of monthly HIV tests, with an interruption point at March 2020. RESULTS: The average number of monthly HIV tests were significantly lower during the pandemic than the pre-pandemic (791±187 versus 1745± 266, p<0.001). There were a slight decline trend in the number of monthly HIV tests before the pandemic (estimate -10.29, p=0.541). HIV testing dramatically decreased during the initial seven months of the pandemic, compared to the pre-pandemic period, with the largest decline in the number of HIV tests on March 2020 (estimate -678.48, p=0.007). HIV testing slightly increased every month (estimate 4.84, p=0.891) during the pandemic period, and the number of HIV tests per month rebounded to the pre-pandemic levels by October 2020. CONCLUSIONS: ED-based HIV testing significantly decreased during the initial seven months of the pandemic in south Florida. Multiple strategies are necessary to maintain HIV testing during this pandemic era. Human immunodeficiency virus (HIV) infection remains an important public health problem throughout the world. It is estimated that more than 1.2 million people are living with HIV in the U.S., while approximately 13% of those with HIV are unaware they are infected. 1 The new guidelines recommended routine opt-out HIV screening in health care settings, including emergency departments (EDs), where the prevalence of undiagnosed infection is 0.1% or greater. 3, 4 ED-based HIV screening approach has been shown to identify HIV prevalence rates of 0.1%-1.7%. 5, 6 In July 2018 we implemented the ED-based opt-out HIV screening program at The Memorial Healthcare System (MHS) in south Florida and identified HIV prevalence rate of 0.5%. 7 Routine HIV screening can prove challenging due to the ED's complexity and competing priorities. The COVID-19 pandemic, caused by the acute respiratory coronavirus 2 (SARS-COV-2), became a serious challenge to health care systems globally since its first report in December 2019. 8 COVID-19 control measures such as lockdowns, ED priorities, and/or social distancing were vital for containing the spread of the COVID-19 pandemic, but might have had severe collateral effects on existing health care services, like ED-based HIV screening programs. 9 The COVID-19 pandemic across the U.S. with extensive publicity and lockdowns began in mid-March 2020. Herein, we report the results of ED-based opt-out HIV tests between July 2018 and March 2021 at MHS. We defined the COVID-19 pandemic that interrupted the time series as the month of March 2020, the month strict COVID-19 lockdown measures went into effect in South Florida. We quantified the impact of the COVID-19 pandemic on the number of HIV tests per month using direct before-and-after comparison and interrupted time series analysis (ITS) with segmented regression models. This institution based retrospective cohort study was conducted at MHS, Hollywood, Florida between July 2018 and March 2021. HIV testing was offered on an "opt-out" basis to patients aged 16 years or older who presented to the EDs for routine blood tests. "Opt-out" HIV screening orders were automatically initiated in the electronic medical record admission orders to be authorized by the trained nurse. Patients were given information related to an additional blood test to screen for HIV, unless they declined, during the ED registration process. Patients who were offered blood tests had their decision documented and coded in their electronic files. Patients were excluded from testing if they opted out, had a previous diagnosis of HIV infection or clinical evidence of HIV infection in the admitted patient's medical record or if they did not understand their right to opt-out. Data on the number of HIV tests done per month at the ED were routinely recorded in the programmatic database of MHS. The number of ED-based HIV tests per month from July Descriptive statistics of mean, standard deviation (SD), and range were calculated before and during the pandemic. There were 33 calendar months in time series, with 20 months pre-pandemic (July 2018February 2020) and 13 months during the pandemic (March 2020March 2021) segments. First, we computed mean number of monthly HIV tests for the periods before and during the pandemic and Student's t-test was used to determine whether these numbers differed significantly before-and-after pandemic, as all data were found to be normally distributed (Kolmogorov-Smirnov test). To better understand the trends of the number of HIV tests per month during the COVID-19 pandemic, we performed an ITS segmented regression analysis 10, 11 to examine changes in the number of HIV tests per month over time, with an interruption point that began on March 2020, using the following autoregressive error linear regression model: Yt = β 0 +β 1 T+β 2 Xt+β 3 TXt, where Yt represents the number of HIV tests per month; T represents time in months since the start of the study period; Xt is binary variable indicating the pre-pandemic (coded 0) or the post-pandemic period (coded 1); TXt represents the number of months after the pandemic at time t, coded 0 before the pandemic and coded 1-13 after the pandemic. β 0 estimates the baseline level of HIV tests per month at T = 0, β 1 is the baseline slope that estimates the change in HIV tests monthto-month before the pandemic, β 2 estimates the immediate change in HIV tests at the time the pandemic occurred, β 3 represents the slope change following the pandemic. The retrospective chart review protocol was approved by the MHS Institutional Review Board (MHS.2019.119). Written informed consent was waived as this study involved only secondary data analysis. A total of 45,185 HIV tests were recorded at MHS over the study period, of which 77% were tested before the pandemic (July 2018  February 2020, 20 monthly time points) and 23% were tested during the pandemic period (March 2020March 2021, 13 monthly time points) ( Table 1) . Analyses were performed to compare data from the 20 months before the pandemic with data from the 13 months of the pandemic period. Table S1 ). The trend of HIV tests per month was decreasing before the pandemic, however, after the pandemic, the number of HIV tests per month is increasing (Supplementary Figure S1 ). Supplementary Table 2 shows the results of ITS analysis based on the number HIV tests per month between pandemic was in an emerging phase in the U.S., but rebounded to a lesser degree from July 2020 to January 2021 (all p>0.05). However, the estimated number of HIV tests in February 2021 increased by 442, which was higher than the pre-pandemic level (p=0.041). Importantly, these findings should only be considered valid for the duration of the study period. The COVID-19 outbreak has had significant impacts on global healthcare systems. 12 This large population-based study in South Florida explored trends in ED-based "opt-out" Despite worldwide evidence showing that HIV testing has declined during the COVID-19 pandemic, data on the extent of these changes from the U.S. is very limited, with mixed trends in HIV tests, with some sites reporting decreases and some reporting no change. Moreover, most reports have focused on the first 3-6 months of the pandemic, and unlike our analysis, they do not account for long-term trends, which might have influenced outcomes. In our study, analyses were performed to compare data from the 20 months before the pandemic with data from the 13 months of the pandemic period. Our findings in South Florida area are in agreement with previous studies reporting a downward trend in HIV tests in diverse regions of the U.S. during the initial nine months of the pandemic, compared to 2019. 18 We also conducted a direct comparison of the number of HIV tests 12 months before the pandemic versus 12 months during the COVID-19 pandemic, and the results show a somewhat consistent pattern in terms of HIV testing changes, suggesting that the trends of HIV testing changes during the pandemic are real. Several previous studies on the effect of COVID-19 on ED volume in the U.S. show a significant drop in ED visits compared to the same period a year earlier. [16] [17] [18] The measures used to control the COVID-19 pandemic, such as stay-at-home orders, quarantine, and excessive demands on laboratories tests for COVID-19 have likely contributed to the substantial decrease in ED visits during the pandemic. It is also possible that those experiencing mild symptoms opted to avoid ED visits because of lockdown restrictions and risks of COVID-19 infection. In this study, we observed a sharp decrease in the mean of monthly ER visits relative to a similar period of time pre-pandemic. As a consequence, this decline in ER visits was most likely contributing to the decline in HIV tests during the pandemic period. Identification of HIV-infected persons early and timely initiation of ART play a key role in HIV prevention and treatment outcomes. 19, 20 Being unable to maintain HIV testing during the COVID-19 pandemic is a significant hindrance to the achievement of UNAIDS 95-95-95 goals by 2030. 16, 21 Our findings indicate that ED-based opt-out HIV screening has been negatively affected during the pandemic, suggesting innovative strategies should be made to reattain appropriate HIV testing even during the pandemic surges. HIV self-testing (HIVST) was reported to provide access to HIV testing safely while maintaining social distancing. 22 Additionally, HIVST affords individuals privacy and convenience that help expand the coverage of HIV testing to reach persons hindered from accessing facility-based testing. 23 As the COVID-19 crisis continues, the HIVST may be an alternative approach to maintain HIV testing among the general population in this era, 24,25 even though routine opt-out HIV testing remains the standardized test in healthcare settings. Moreover, individuals who seek care for COVID-19 should incorporate or even link HIV screening to COVID-19 testing as the previous report has demonstrated a considerable increase in HIV diagnoses with incorporating HIV screening into COVID-19 testing in the ED. 26 There are several limitations to our study. First, a single healthcare system's data was used and the demographic information related to individuals and their presentations to HIV tests was not available. We were unable to examine potential subgroup differences, such as age, gender, or race related to HIV tests during the pandemic. Second, the ED in our sample represents only Broward & Miami-Dade counties and surrounding areas, which is located in the pandemic's hotspots for both HIV and COVID-19. So the findings of this study might not be generalized to other geographically diverse sites. Lastly, the findings of this study should only be considered valid for the duration of the study period. In conclusion, this study represents the assessment of pandemic-related changes in EDbased opt-out HIV testing in a community hospital in South Florida, and indicates that the COVID-19 pandemic has had negative consequences on HIV screening in emergency department. As the COVID-19 pandemic continues to cause challenges to the public health in the coming years, suitable strategies (e.g., incorporating or even linking HIV screening to COVID-19 testing) should be implemented to enhance ED-based HIV screening programs, thus yielding more success for EDs in diagnosing HIV infection and linking patients to care. 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