Case Presentation: A 54 year old African-American male presented to a Baltimore emergency department with complaints of shortness of breath, chest pain and melena. He was admitted to family medicine for evaluation of acute coronary syndrome. Troponins were monitored and a stress test performed, ruling out myocardial infarction. He received intravenous fluids for possible rhabdomylisis, thought to be caused by muscle spasms. Occult blood stool tests were negative and hemoglobin and hematocrit were within normal limits. Patient’s urine was positive for cocaine.  The patient was offered an HIV test on admission per hospital protocol and the HIV AG/AB combo assay was ordered. The patient was discharged with a diagnosis of myalgia and non-cardiac chest pain, before his HIV test was resulted. The patient’s HIV test returned “reactive,” confirmed by Western Blot. The medical team informed a designated HIV Linkage to Care Navigator (LCN). Several phones calls were made to the patient, but the LCN was unable to make contact. One week later, the LCN conducted a home visit, where the patient was informed of HIV results. He was provided information for a walk-in linkage to care clinic. The patient presented to the clinic next business day. Routine blood work was run, including CD4 (543 cells/ml) and viral load (6424 copies/ml). The LCN addressed psychosocial barriers including: 1) transportation; 2) completion of a Maryland AIDS Drug Assistance Program application (covers co-pays for HIV-related medications); 3) Qualified Medicare Beneficiary application (supports out-of-pocket Medicare expenses). The patient was started on Atripla, antiretroviral therapy (ART) four months after diagnosis. When he presented to clinic, the patient brought a female friend who was known HIV+ but not in care. Both the patient and his friend were successfully engaged in outpatient HIV medical care.

Discussion: The HIV prevalence in Baltimore is 2.5%, constituting a generalized epidemic. Approximately 18% of persons living with HIV do not know they are infected and less than 25% are virally suppressed on ART. Engagement in primary medical care after a diagnosis is essential to initiate ART, maximizing individual and public health (Cohen et al., 2011; Department of Health and Human Services, 2014). The Centers for Disease Control recommends routine HIV screening in healthcare settings (Branson et al., 2006).  In areas where the epidemic is generalized, annual screening is recommended. In many urban areas, the acute care setting is the patient’s primary health care setting. In order to close the gaps in the continuum of care for HIV, this academic medical institution implemented a routine HIV testing program. This patient did not present with any clinical signs or symptoms suggestive of HIV. By implementing a multidisciplinary workflow for routine HIV testing and partnership with an HIV service organization there are increased opportunities for early HIV diagnosis and linkage to care. This includes partnership with an HIV service organization for the purpose of referral to HIV care and supportive services by a LCN.

Conclusions: Physicians can play a key role in diagnosing new cases of HIV and identifying patients who have a previous diagnosis but are not in care. Purposeful partnership with HIV specialty organizations can facilitate the process of post-test counseling and linkage to care.