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.
Design/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).
Conclusion: 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.
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