A man becomes ill with a deadly virus and seeks care at an emergency room only to be sent away, misdiagnosed, with a prescription for useless antibiotics. The patient is not Thomas Eric Duncan – the first person to be diagnosed with Ebola in the United States, the infection is not that West African virus, and this is not an isolated and headline-making mistake.
It is a scenario that plays out thousands of times a year as people unaware they are infected with HIV present to hospitals and clinics, but, as in Duncan’s case, their infection goes unsuspected and undetected. One study from South Carolina found that three-quarters of people testing HIV-positive had visited a medical facility prior to being diagnosed – many had repeatedly sought care but were not HIV-tested even when they had telltale symptoms.
As we saw in Dallas, such missed opportunities for diagnosing a serious and contagious virus can be devastating. By the time a person with HIV is diagnosed, the immune system strength is typically at a third of normal, indicating years of undetected infection. The failure to detect HIV not only is catastrophic for the individual but also places others at risk. The Centers for Disease Control and Prevention estimate that 1.1 million Americans – one in 300 – are living with HIV and that 20 percent are unaware they harbor the virus. These individuals are responsible for over 50 percent of the 40,000 transmissions that occur annually.
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Finding those unaware they are infected with HIV is a first and critical step to stemming its spread and is a focus of the White House National AIDS strategy, as well as state-run public health initiatives here in North Carolina. Studies find that most who test HIV-positive take steps to protect others. Furthermore, detection of HIV should lead to medical care, including the initiation of antiretrovirals, which researchers from our university have found to profoundly reduce infectiousness and the risk of transmission.
However, before there can be the diagnosis of a disease, there has to be the consideration of its possibility. In Duncan’s case, his clinicians did not consider Ebola because they failed to obtain or appreciate the significance of a very important piece of his history – his return from Liberia, where he reportedly cared for a relative sickened by Ebola. This jewel of information slipped through their fingers, as did Duncan. Sadly, the story is the same when it comes to HIV. Valuable information regarding potential risks for exposure to this virus is either not sought or is disregarded.
Part of the problem is that clinicians, unfazed by the sight of blood, are often squeamish when it comes to talking about sex. Questions regarding sexuality are often not asked and, when they are, they are asked poorly. Many providers are particularly uncomfortable in asking about gay sex. Clinicians who are expert at inquiring about alcohol use and substance abuse stumble when trying to ask a man whether he has sex with another man. Given that over 50 percent of new cases of HIV infection are now among men who have sex with men, such questions are literally vital to efforts to prevent HIV transmission.
In other cases, the risks seem to be staring the clinician in the face but nonetheless are unseen. In a study one of us conducted, even when people presented to a North Carolina emergency department with a sexually transmitted infection, remarkably few were tested for HIV. Nothing screams “test me for HIV” like being diagnosed with syphilis or gonorrhea.
So, what will it take to find those who are unknowingly infected? The CDC recommends adolescents and adults be offered HIV testing when seeking medical care. While universal screening casts a broad net to snare HIV, it does not obviate the need for health providers to learn more about their patients’ sexual and drug-use risk. Health care providers also need to become more comfortable and committed to recommending HIV testing.
The misdiagnosis of Duncan revealed deficiencies in our fractured health care system. The lapses that have been reported in his case including a lack of communication among staff, an electronic medical record that impeded rather than facilitated information-sharing and suboptimal medical history taking occur every day in those infected with another virus – one that also came from West Africa, decades ago.
David Alain Wohl, M.D., and Cynthia Gay, M.D., are doctors in the Division of Infectious Diseases at the University of North Carolina at Chapel Hill.