Strategies to Identify Undiagnosed HIV Infection in the Emergency Department

描述（由申请人提供）：该候选人是丹佛健康医疗中心（DHMC）和科罗拉多大学丹佛分校和健康科学中心的急诊医学助理教授。他的主要长期职业目标是开展高质量的协作卫生服务研究，重点是紧急医疗服务提供，艾滋病毒预防和改善公共卫生。为了实现这一目标，候选人将获得卫生服务研究博士学位；将在DHMC进行一系列相关研究，DHMC是一家城市安全网医院和综合医疗保健系统，为大部分得不到充分服务的患者提供服务；并受益于持续的高质量指导。研究计划：据估计，美国每年有4万例新的艾滋病毒感染病例，这一比率在过去十年中几乎没有变化。新的艾滋病毒感染似乎在非传统风险群体中增加最多，包括种族和少数民族。大多数艾滋病毒感染者直到病程晚期才接受检测，主要原因是无症状期较长，而且他们获得常规医疗护理的机会相对较少。每年有超过1亿人到急诊科就诊，急诊科通常是患者获得医疗护理的唯一来源，因此也是检测HIV感染的唯一潜在机会。此外，最有可能将急诊科作为唯一护理来源的患者往往是那些艾滋病毒传播最严重的患者。为了提高对未确诊的艾滋病毒感染的识别，疾病控制和预防中心最近呼吁在大多数医疗机构（包括急诊科）广泛开展非定向选择退出艾滋病毒筛查。然而，这种策略尚未经过测试，对于美国绝大多数急诊科来说可能不是最理想的。本研究的具体目的是：(1)利用丹佛公共卫生中心（Denver Public Health）前瞻性收集的性病诊所（STD Clinic）大型数据库，建立一种准确识别HIV血清阳性的临床预测工具；(2)开展嵌套前瞻性队列研究，从外部验证该临床预测工具在DHMC急诊科的应用；(3)开展准实验等效时间样本临床试验，以评估使用经验性临床预测工具（传统的HIV行为风险筛查工具）的临床有效性；这些研究的结果将提高我们对如何在急诊科提供有效的快速艾滋病毒检测的理解，并可能导致在其他“高风险”医疗保健环境中提供此类服务的新方法。

DESCRIPTION (provided by the applicant): The candidate is an Assistant Professor in Emergency Medicine at Denver Health Medical Center (DHMC) and the University of Colorado at Denver and Health Sciences Center. His principal long-term career goal is to conduct high-quality collaborative health services research with emphasis on emergency medical care delivery, HIV prevention, and improved public health. In order to accomplish this goal, the candidate will obtain his PhD in Health Services Research; will perform a series of related studies at DHMC, an urban, safety-net hospital and integrated healthcare system that serves a large proportion of underserved patients; and benefit from continued high-quality mentorship. Research Plan: An estimated 40,000 new HIV infections occur annually in the United States, and this rate has changed very little in the last decade. New HIV infections appear to be increasing most in non-traditional risk groups, including racial and ethnic minorities. Most persons infected with HIV still do not get tested until late in their disease courses, primarily due to its long asymptomatic period and their relatively poor access to routine medical care. Over 100 million people visit emergency departments (EDs) annually, and the ED commonly serves as a patient's only source fro medical care, and thus the only potential opportunity to be tested for HIV infection. Also, patients who are most likely to use the ED as their only source of care are often those for whom the HIV epidemic is spreading most. To improve identification of undiagnosed HIV infection, the Centers for Disease Control and Prevention recently called for widespread non-targeted opt-out HIV screening in most healthcare setting, including EDs. This strategy however remains untested and is likely to be suboptimal for the vast majority of EDs in the United States. The specific aims of the proposed research are: (1) to use a large prospectively-collected STD Clinic database from Denver Public Health to derive a clinical prediction instrument to accurately identify HIV seroposistivity; (2) to conduct a nested prospective cohort study to externally validate this clinical prediction instrument in the ED at DHMC; and (3) to conduct a quasi-experimental equivalent time-samples clinical trial to assess the clinical effectiveness of using an empirically-derived clinical prediction instrument, a conventional HIV behavioral risk screening instrument, or no screening as a means to stratify ED patients into groups at risk for HIV infection in the ED. The results of these studies will improve our understanding of how to provide effective rapid HIV testing in EDs and may lead to novel approaches to providing such services in other "high-risk" medical care settings.