To provide evidence of large numbers of missed opportunities for early HIV diagnosis we designed a retrospective cohort study linking surveillance data from the South Carolina HIV=AIDS Reporting System to a statewide all payer health care database. We determined visits and diagnoses occurring before the date of the first positive HIV test and medical encounters were categorized to distinguish visits that were likely versus unlikely to have prompted an HIV test. Of the 4117 HIV-positive individuals newly diagnosed between 2001 and 2005, 3021 (73.4%) visited a South Carolina health care facility one or more times prior to testing HIV positive. Of these 3021, 1311 (43.4%) were late testers, and 1425 (47.2%) were early testers. Females were less likely than males to be late testers (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.45-0.68), blacks were more likely than whites to be late testers (OR 1.37, 95% CI 1.10-1.71), and persons 50 years of age and older more likely to be late testers (OR 7.16,. A total of 78.8% of the 13,448 health care visits for both late and early testers were for health care diagnoses unlikely to prompt an HIV test. These findings underscore the need for more routine HIV testing of adults and adolescents visiting health care facilities in order to facilitate early diagnosis.

Public health benefits of expanded HIV screening will be adequately realized only if an early diagnosis is followed by prompt linkage to care. We characterized rates and factors associated with failure to enter into medical care within three months of HIV diagnosis and assessed the predictors of time to enter care over a follow-up period of up to 60 months. The study cohort included 3697 South Carolina (SC) residents' ≥13 years who were newly HIV-diagnosed in 2004-2008. Date of first laboratory report of CD4(+) T-cell count or viral load (VL) test after 30 days of confirmatory HIV diagnosis was used to define time to linkage to care. Results showed that of the total 3697 persons, 1768 (48%) entered care within three months, 1115 (30%) in four-12 months after diagnosis, and 814 (22%) failed to initiate care within 12 months of HIV diagnosis. At the end of study follow-up period of up to 60 months from the date of HIV diagnosis, 472/3697 (13%) individuals remained out of care. Multivariable Cox proportional hazards analysis showed that compared with hospitals, time to enter care was shorter in those diagnosed at state mental health/correctional facilities (adjusted hazards ratio [aHR] 1.16; 95% confidence interval [CI] 1.02-1.34) and longer in those diagnosed at county health departments (aHR 0.87; 95% CI 0.80-0.96) and at "Other/unknown" facilities (aHR 0.79; 95% CI 0.70-0.89). Time to entry into care was longer for men (aHR 0.82; 95% CI 0.75-0.89) compared with women, blacks (aHR 0.91; 95% CI 0.83-0.98) compared with whites, and males who have sex with males (MSM) (aHR 0.89; 95% CI 0.80-0.98) compared with heterosexual exposure. Delayed entry into HIV care remains a challenge in controlling HIV transmission in SC. Better integration of testing and care facilities could improve the proportion of newly HIV-diagnosed persons who enter care in a timely manner.

Disease stage, race, and insurance status strongly influence HIV primary care engagement and inpatient hospitalization. Admissions may be related to general medical conditions, substance abuse, or antiretroviral therapy.

Objective: To investigate opportunities for early human immunodeficiency virus (HIV) testing of women. Methods: A retrospective cohort study design linked case reports from HIV surveillance to several statewide health-care databases. Medical encounters occurring before the first positive HIV test (missed opportunities) were categorized by diagnosis/procedure codes to distinguish visits that were likely to have prompted an HIV test. Women were categorized as late testers (AIDS diagnosis < 12 months from first HIV test date), non-late testers (no AIDS diagnosis during study period or diagnosis of AIDS > 12 months of HIV diagnosis), of reproductive age (13-44 years old), and not of reproductive age ( > 44 years old). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were used to estimate risk and its statistical significance. Results: Of 3303 HIV-infected women diagnosed during the study period, 2408 (73%) had missed opportunity visits. Late testers (39%) were more likely to be black than white (aOR 1.48, 95% CI 1.12-1.95), be older ( > 44 years old; aOR 7.85, 95% CI 4.49-13.7), and have > 10 missed opportunity visits (aOR 2.17, 95% CI 1.62-2.91). Fifty-four percent of women > 44 years old were also late testers. Women > 44 years old had lower median initial CD4 counts ( p < 0.001). The top two procedures were the same for all groups of women but mammography was ranked fourth for women > 44 years old and Papanicolau smear was ranked fourth for late testers. Conclusions: Feasibility and acceptability of routine HIV testing in nontraditional health-care settings, such as mammography and Papanicolau screenings, should be explored to identify late testers and older (not of reproductive age) HIV-infected women.

To determine if HIV primary care engagement (PCE) is associated with Emergency Department (ED) utilization, a retrospective cohort study using the South Carolina HIV surveillance data from January 1986 to December 2006 linked to the hospital discharge data-set was used to assess utilization at statewide EDs during January 2007-December 2010. Suboptimal PCE was defined as <2 reports of a CD4 + T-cell count or viral load value to surveillance in each calendar year from January 2007 to December 2010. Multivariable logistic regression explored associations of HIV PCE with ED utilization after accounting for sociodemographic characteristics and disease stage. Poisson and negative binominal regression examined PCE, sociodemographic characteristics, and disease stage on the frequency of ED utilization. Suboptimal PCE was associated with increased odds of ED utilization for NIR/NRR (no identified risk/no risk reported; aOR [adjusted odds ratio] = 2.25; CI = 1.69-2.99), self-payers (aOR = 1.81; CI = 1.38-2.39), and those diagnosed with an AIDS-defining illness (ADI; aOR = 1.51; CI = 1.14-2.00), who also had the most median ED visits (six). More ED visits were associated with young age, female (incidence rate ratio [IRR] = 1.16; CI = 1.06-1.27), ADI (IRR = 2.17; CI = 1.93-2.45), Medicaid recipients (IRR = 1.34; CI = 1.21-1.49), indigent/charity recipients (IRR = 1.86; CI = 1.57-2.21), or AIDS > 1 year (IRR = 1.23; CI = 1.13-1.35). Fewer visits to the ED were associated with MSM (males having sex with males IRR = 0.81; CI = 0.72-0.90), NIR/NRR (IRR = 0.86; CI = 0.78-0.95), self-payers (IRR = 0.56; CI = 0.50-0.62), or Medicare recipients (IRR = 0.85; CI = 0.77-0.95). Disease stage and insurance type were differentially associated with primary care and ED utilization. There is a need to evaluate HIV primary care systems to increase access and develop interventions to reduce preventable ED visits.