Most People Who Inject Drugs Miss Opportunities for HIV, HCV Testing

More than 90% of people who inject drugs missed opportunities for HIV and hepatitis C (HCV) testing, according to an analysis of a nationwide insurance database for claims paid between 2010 and 2017.

The study, published in The Journal of Infectious Diseases, examined records for 844,242 people who inject drugs (PWID), finding that 8.6% were tested for HIV and 7.7% were tested for HCV within 1 year of a clinical encounter consistent with injection drug use.

Male residents of rural areas who sought care for skin infections or endocarditis were found to be the most likely to miss testing opportunities.

The study, conducted by investigators with the US Centers for Disease Control and Prevention, noted the importance of testing to stem the spread of the infections, referencing that about 1 in 7 people living with HIV were unaware of their infection as of 2015, and only 55.6% of those with HCV were aware of their infection during 2013-16. The problem has been exacerbated by the opioid crisis, with an estimated 2.4 million people in the United States having a substance use disorder related to prescription opioid pain relievers.

“Identifying missed opportunities at clinical encounters by PWID can guide development of interventions to increase HIV and HCV testing, but identifying PWID by using claims data or other health services databases is complex,” the study authors noted.

Insurance claims do not include coding to indicate injection drug use, so the investigators considered those whose medical diagnosis, procedure or medication dispensed indicated injection drug use during 2010-16. Four risk groups were selected: those with codes related to nonmedical drug use or dependence, those with claims related to overdose or suicide attempt by drug misuse, those who received medication-assisted therapy for overdose, and those with skin infections or endocarditis consistent with injection drug use.

The primary outcome was HIV and HCV testing within 1 year of the first clinical encounter consistent with injection drug use.

Among the 844,242 patients evaluated, 64.9% had infections related to injection drug use and 31.9% had a diagnosis of drug abuse or dependence.

Overall, 8.6% were tested for HIV and 7.7% for HCV. Among men, 6.5% received an HIV test and 6.7% received an HCV test, compared with 10.8% and 8.7% of women respectively. Those ages 20-29 years had the highest testing rate at 13.7% for HIV and 10.9% for HCV. Higher testing rates also were found among those living in the Northeast (10.5% for HIV and 9.7% for HCV) and in urban areas (9% for HIV and 8% for HCV).

“Although competing priorities during clinical encounters might be a barrier to HIV and HCV testing, persons with substance use disorders can be successfully engaged and entered into care,” the study noted. “Algorithms can be developed that use diagnoses, procedures, tests, and medications in a patient’s electronic health record (EHR) as indicators of IDU, and these algorithms can be used to generate EHR prompts for healthcare providers to perform HIV testing. Such prompts in electronic medical records might be effective in increasing HIV and HCV testing.”

Increasing testing has been the subject of numerous recent studies. One recent study explored universal HIV and HCV testing in 2 emergency departments in San Diego, finding that such testing could help identify new cases and reconnect previously diagnosed patients to care.

In November, the World Health Organization released new testing guidelines encouraging all countries to adopt a standard HIV testing strategy using 3 consecutive reactive tests to confirm a diagnosis, recommending use of self-tests, and emphasizing the importance of using social network-based HIV testing to reach at-risk individuals.