INFECTIOUS DISEASE/ORIGINAL RESEARCH
Implementing an HIV and Sexually Transmitted Disease
Screening Program in an Emergency Department
Abigail Silva, MPH
Nancy R. Glick, MD
Sheryl B. Lyss, PhD, MPH
Angela B. Hutchinson, PhD,
Thomas L. Gift, PhD
Lisa N. Pealer, PhD
Dawn Broussard, MPH
Steven Whitman, PhD
From the Sinai Urban Health Institute, Sinai Health System (Silva, Whitman) and Division of
Infectious Diseases (Glick), Mount Sinai Hospital, Chicago, IL; the National Center for HIV, STD,
and TB Prevention (Lyss, Hutchinson, Gift, Pealer) and Epidemic Intelligence Service, Epidemiology
Program (Pealer), Centers for Disease Control and Prevention, Atlanta, GA; the STD/HIV Prevention
and Care Program, Chicago Department of Public Health, Chicago, IL (Broussard).
Study objective: We assess the feasibility, effectiveness, and cost of routinely recommended
HIV/sexually transmitted disease screening in an urban emergency department (ED).
Methods: From April 2003 to August 2004, patients aged 15 to 54 years were offered rapid HIV
testing, and those aged 15 to 25 years were also offered gonorrhea and chlamydia testing (nucleic
acid amplification), Monday through Friday, 11 AM to 8 PM. Infected patients were referred for
treatment and care. Prevalence, treatment rates, and cost were assessed.
Results: Among 3,030 patients offered HIV testing, 1,447 (47.8%) accepted, 8 (0.6%) tested
positive, and 3 (37.5%) were linked to care. Among 791 patients offered sexually transmitted
disease testing, 386 (48.8%) accepted, 320 provided urine (82.9%), 48 (15.0%) tested positive, and
42 (87.5%) were treated for gonorrhea or chlamydia. The program cost was $72,928. Costs per
HIV-infected patient identified and linked to care were, respectively, $9,116 and $24,309; cost per
sexually transmitted disease–infected patient treated was $1,736. The program cost for HIV/sexually
transmitted disease screening was only $14,340 more than if we screened only for HIV.
Conclusion: Through ED-based HIV/sexually transmitted disease screening, we identified and treated
many sexually transmitted disease–infected patients but identified few HIV-infected patients and
linked even fewer to care. However, sexually transmitted disease screening can be added to HIV
screening at a reasonable cost. [Ann Emerg Med. 2007;49:564-572.]
0196-0644/$-see front matter
Copyright © 2007 by the American College of Emergency Physicians.
SEE EDITORIAL, P. 573.
Of the 925,000 to 1,025,000 persons in the United States
living with HIV, approximately one quarter are unaware of their
infection.1 To reduce the number of new infections, the Centers
for Disease Control and Prevention (CDC) recently unveiled a
strategy that included decreasing the number of HIV-infected
persons who are unaware of their infection and linking infected
persons to prevention, care, and treatment.2,3 Routine HIV
screening can potentially identify infected patients before they
develop an AIDS-defining illness, decrease continued HIV
transmission, and thus decrease the estimated $7 billion in
annual HIV-related health care costs.4
Sexually transmitted diseases such as gonorrhea and
chlamydia also pose a large public health problem. If untreated,
they can cause pelvic inflammatory disease, which may lead to
infertility, chronic pelvic pain, and ectopic pregnancy.5 The
high prevalence of gonorrhea and chlamydia in the United
States accounts for $10 billion in direct and indirect expenses.5
There is national recognition6,7 that HIV and sexually
transmitted disease prevention efforts should be integrated
for many reasons: similar behaviors (ie, sexual activity and
drug use) promote sexually transmitted disease and HIV
transmission; prevention of one will likely prevent the other;
564 Annals of Emergency Medicine Volume , . : May
HIV and sexually transmitted diseases disproportionately
affect the same marginalized populations, and infection with
one may facilitate transmission of the other.8 Although the
integration can be challenging, it can maximize the
effectiveness of sexually transmitted disease and HIV
Emergency departments (EDs) can play an important role in
reducing the morbidity and transmission of HIV and sexually
transmitted diseases for several reasons. First, studies have found
high HIV seroprevalence (3.5% to 11.8%)9-11 and
asymptomatic sexually transmitted disease prevalence rates
(9.7% to 13.6%)12-14 in some inner-city EDs. Second, EDs
serve populations that have limited access to health care,15-17
thus placing responsibility on EDs to provide preventive
care.18,19 Third, the availability of simple and noninvasive
HIV20 and sexually transmitted disease21 tests facilitates
screening interventions. Fourth, several studies in urban EDs
have demonstrated the feasibility and effectiveness of
implementing ED-based screening programs for HIV,22-28
although fewer have done so for sexually transmitted
Goals of This Investigation
Despite the recognition that HIV and sexually transmitted
disease prevention programs should be integrated and the
evidence that ED-based screening programs are feasible and
effective, we are unaware of combined ED-based HIV/sexually
transmitted disease screening programs. The purposes of this
study were to assess the feasibility and cost of implementing an
ED-based HIV/sexually transmitted disease screening program,
and evaluate its effectiveness in identifying infected patients and
linking them to treatment or care.
MATERIALS AND METHODS
Between April 23, 2003, and August 5, 2004, we routinely
offered HIV/sexually transmitted disease testing to as many age-
eligible patients as possible who came into the ED during study
hours, Monday to Friday, 11 AM to 8 PM. The study was
approved by the appropriate institutional review boards.
This study was performed in an urban, nonprofit hospital
ED. The ED receives 44,000 visits annually and is classified as a
Level I trauma center, certified to treat the most critically
injured patients at all times. The patient population is
predominantly black or Hispanic and low income; 10% of
patients have private health insurance.
The AIDS prevalence rate of the community surrounding
the hospital is 409.4 cases per 100,000 persons compared to the
city rate of 329.8 and US rate of 144.2.31 Similarly, the
gonorrhea and chlamydia rates in this community are twice as
high as the city rate and 5 to 8 times as high as the national
rate.31 Additionally, a 2001 targeted HIV testing project found
a 3.0% HIV positivity rate among high-risk patients attending
this ED.25 Finally, in 2003, 1.0% of the patients who visited
the ED had an HIV diagnostic code (the CDC recommends
that settings with a prevalence rate ?1% consider routinely
offering HIV testing.)32
Selection of Participants
Eligible ED patients had to meet age criteria and be able to
provide informed consent. Patients aged 15 to 54 years were
eligible for HIV screening. Patients aged 15 to 25 years were
also eligible for gonorrhea and chlamydia screening. The age
criteria were selected according to the recommended age ranges
for HIV32 and sexually transmitted disease33 testing.
Patients were ineligible if they were in critical condition, had
an unstable psychiatric condition, were under the influence of
alcohol or drugs, or were prisoners or detainees. Documented
(as noted in the medical record) HIV infection or documented
HIV test in the previous 3 months was an additional exclusion
criterion for HIV screening. Receipt of sexually transmitted
disease testing by Gen-Probe (Gen-Probe, Inc., San Diego, CA)
during the ED visit or documented sexually transmitted disease
test in the previous 2 weeks was another exclusion criterion for
sexually transmitted disease screening.
Editor’s Capsule Summary
What is already known on this topic
Early detection of HIV disease and other sexually
transmitted diseases is an important means of controlling
spread in populations and improving the outcomes of
those infected. However, the cost-effectiveness of routine
screening for HIV and other sexually transmitted diseases
in emergency departments (EDs) is unclear.
What question this study addressed
This study measured the costs and effect of concurrent
screening for HIV and sexually transmitted diseases in a
single urban ED.
What this study adds to our knowledge
In this ED, slightly less than half of eligible patients
consented to HIV or sexually transmitted disease
screening. Positive screening rates were less than 1% and
15%, respectively. The program cost more than $9,000
per identified HIV patient and $1,736 per treated patient
with sexually transmitted disease. The cost of adding
sexually transmitted disease screening to HIV screening
was relatively low.
How this might change clinical practice
This study may cause advocates of routine ED HIV
screening to reconsider their position, given the low yield
and high costs in this urban ED.
Silva et alScreening Programs in the Emergency Department
Volume , . : May
Annals of Emergency Medicine 565
Two study staff members received training on HIV/sexually
transmitted disease prevention and counseling and testing at the
local health department. They were also trained by the HIV test
kit manufacturer to properly conduct and interpret the rapid
Before the initiation of the project, HIV and sexually
transmitted disease screening were performed only when
clinically indicated. HIV testing was rarely offered to ED
patients. Patients with sexually transmitted disease symptoms
were generally tested and empirically treated before the return of
the test results.
During the study period, study staff approached potentially
eligible patients in their examination room to confirm
eligibility, explain the study, offer confidential HIV/sexually
transmitted disease testing, and ask for consent. Before
obtaining consent, the study staff briefly described the rapid
test, discussed HIV/sexually transmitted disease transmission
and prevention, and assessed the patient’s preparedness to
receive same-day HIV results.
Whole-blood samples (by fingerstick or venipuncture)
obtained from patients who consented to HIV screening were
tested using the OraQuick Rapid HIV Antibody Test (Orasure
Technologies, Inc., Bethlehem, PA), which provides results in
20 to 40 minutes. Patients who had preliminary positive results
were retested in duplicate with OraQuick. Repeatedly reactive
tests were considered preliminary HIV positive, and a whole-
blood sample was sent to the state’s public health laboratory for
confirmation by Western blot.* Those patients who tested
positive by Western blot were considered to be HIV infected.
During the ED visit, the patient and attending physician
received the rapid HIV test result. The result was also entered
into the patient’s medical record. During discussion of the test
result, condoms and pamphlets about HIV and sexually
transmitted diseases were provided. Patients with preliminary
positive HIV test results were scheduled for an appointment at
the hospital’s infectious diseases clinic within 2 weeks of the ED
visit. The infectious diseases clinic attendance was confirmed
using the hospital’s medical information system. Study staff
attempted to contact by telephone or certified mail those
patients who did not keep scheduled appointments. Patients
who could not be contacted were referred to the local health
department for field investigation.
Urine specimens obtained from patients who consented to
sexually transmitted disease screening were tested with the
BDProbeTec amplified DNA Assay (Becton Dickinson,
Franklin Lakes, NJ) at the state public health laboratory; study
staff received test results within 5 working days. All sexually
transmitted disease test results were entered into the patient’s
medical record. Patients who tested positive for either gonorrhea
or chlamydia were notified by telephone or certified mail and
referred to a local health department or hospital-affiliated clinic
for free sexually transmitted disease treatment. Study staff
referred sexually transmitted disease–infected patients whom
they were unable to contact to the local health department for
The local health department helped train study staff, paid for
HIV confirmatory and sexually transmitted disease testing,
provided referral sites for free sexually transmitted disease
treatment, and assisted with field investigations.
Data Collection and Processing
Using a standardized form, study staff collected (by medical
record or patient report) the following information on all
patients who visited the ED during study hours: basic
demographics, eligibility or reason for ineligibility, and reason
for study refusal, if applicable. Medical records, local health
department reports, and patient reports were used to document
sexually transmitted disease treatment and linkage to HIV care
information. Risk factor information was not collected, because
screening was routinely recommended and not risk based.
For the cost analysis, an observer collected time-motion data
to determine the amount of staff labor time required to conduct
HIV/sexually transmitted disease screening. Data were collected
from July to August 2004, during which time 107 patients were
screened, of whom 81 were approached and 49 consented to
HIV/sexually transmitted disease screening. Tasks were
designated as HIV-only (collecting whole-blood specimens,
conducting the rapid test, running controls, entering test results
into medical records, delivering test results, and attempting to
contact infected patients who missed their infectious diseases
clinic appointment) or sexually transmitted disease–only
(obtaining urine specimens, preparing specimens for
transportation to the laboratory, delivering positive test results,
and referring patients for treatment). Nonspecific tasks included
activities such as assessing patient eligibility, approaching
patients, offering and discussing HIV/sexually transmitted
disease testing, and obtaining informed consent. Time
commitments for these activities were multiplied by staff wages
of approximately $18 an hour, including 15% for fringe
benefits, to determine labor costs associated with HIV and
sexually transmitted disease screening separately. The cost
estimate also included test kit costs, specimen processing,
educational materials, office supplies, and treatment visit
(existing literature estimates were used).34,35 A 33%
administrative cost estimate was also added to account for
clerical work, supervision, and other nonpatient costs.36 We
measured the impact of the HIV/sexually transmitted disease
screening program against the baseline of no program, thereby
assuming that patients would not have been screened in the
absence of the program. To estimate the costs of sexually
transmitted disease screening alone, we assumed sexually
transmitted disease screening would be an addition to HIV
screening and calculated only the costs of obtaining and
processing sexually transmitted disease specimens. Because we
*Since the writing of the study protocol, the US Food and Drug
Administration no longer requires that reactive rapid tests be
Screening Programs in the Emergency DepartmentSilva et al
566 Annals of Emergency Medicine Volume , . : May
assumed that the hospital had the capacity to conduct
HIV/sexually transmitted disease testing and related services, we
did not include startup costs (eg, training and most overhead
costs). The cost analysis was conducted from the hospital’s
perspective; patient and sequelae costs were excluded. Costs
were standardized to 2004 dollars.
Primary Data Analysis
The data, excluding identifying information, were entered
into a password-protected database and analyzed using SAS
version 9.1.3. (SAS Institute, Inc., Cary, NC). Each patient visit
was analyzed as a unique patient. Patients who tested positive
for gonorrhea or chlamydia were considered sexually
transmitted disease–infected. Patients were considered
HIV-infected if the repeatedly reactive rapid test was confirmed
with a positive Western blot result. Consenting, testing, and
positivity rates were assessed by demographic characteristics
and as a whole.
Characteristics of Study Subjects
Approximately 37,085 patients attended the ED during the
study period, of whom 11,716 attended during the study hours.
Patients treated during study hours were primarily women
(56.0%) and non-Hispanic black (61.7%) or Hispanic (30.8%).
The majority (62.9%) of patients were aged 15 to 54 years
(16.6% were aged 15 to 25 years).
Among the 11,716 patients who visited the ED, eligibility
for HIV screening was determined for 9,490 (81.0%) patients
(Figure). HIV screening eligibility for the remaining 19.0% of
patients could not be assessed because the study staff were
consulting with other patients or engaged in follow-up activities.
For the 9,490 patients for whom eligibility was determined,
3,030 (31.9%) were eligible for HIV testing. Among the 6,460
(68.1%) ineligible patients, the primary reasons were age
(67.1%), unstable psychiatric condition (17.0%), documented
recent testing (6.3%), and existing (per medical record) HIV
Among the 3,030 patients eligible for HIV screening, 1,447
(47.8%) accepted testing, of whom most (1,428) were tested.
Non-Hispanic black patients were more likely to accept HIV
testing (49.9%) than Hispanic (45.5%) or non-Hispanic white
patients (36.2%) (Table 1). Hispanic patients were also more
likely to accept testing than non-Hispanic white patients. There
appear to be no considerable differences in acceptance rates by
sex or age. Of the 1,583 (52.2%) patients who refused an HIV
test, 46.5% reported having been tested recently, and 37.4%
did not perceive themselves to be at risk for HIV.
Blood samples were obtained from 1,428 (98.7%) of 1,447
patients who accepted HIV testing; 10 tested positive, and 8
(During Study Period)
(During Study Hours)
HIV Screening Eligibility
STD Screening Eligibility
Figure. Eligibility and acceptance rates among patients approached for HIV/sexually transmitted disease screening. STD,
Sexually transmiitted disease.
Silva et al Screening Programs in the Emergency Department
Volume , . : May
Annals of Emergency Medicine 567
(0.6%; 95% confidence interval [CI] 0.3% to 1.1%) had
confirmed positive results by Western blot (Table 1). HIV
positivity rates ranged from 0.0% to 1.0% among the various
demographic groups and were highest among men (1.0%),
non-Hispanic black patients (0.6%), and those aged 30 to 39
years (0.8%). There were no notable differences in HIV
positivity by sex, race/ethnicity, or age.
Of the 8 HIV-infected patients, 3 (37.5%) made at least 1
visit to the infectious diseases clinic and received treatment
according to clinical guidelines. Among the 5 patients who did
not attend the infectious diseases clinic appointment, 1 outright
refused linkage to care, 1 provided erroneous contact
information, 1 moved out of state, and 1 left the ED against
medical advice. These 5 patients were referred to the local health
department for field investigation; however, the investigations
were closed because of inability to contact the patients.
Among the 11,716 patients who visited the ED, sexually
transmitted disease screening eligibility was determined for
11,081 (94.6%), of whom 791 (7.1%) were eligible (Figure).
The primary reason for ineligibility was age (95.2%).
Among the 791 patients who were eligible for sexually
transmitted disease testing, 386 (48.8%) accepted. Men
(54.6%) were more likely to consent than women (46.3%), and
non-Hispanic black patients (54.6%) were more likely to
consent than Hispanic patients (40.6%). There appear to be no
real differences in acceptance rates by age (Table 2). The
primary reasons for refusal among the 405 (51.2%) patients
who declined testing were recent testing (47.0%) and lack of
perceived risk (37.0%).
Of 386 patients who accepted sexually transmitted disease
testing, 320 (82.9%) patients were tested; most (60) were not
tested because they were unable to provide a urine sample. In
all, 48 (15.0%; 95% CI 11.5% to 19.3%) patients tested
positive for a sexually transmitted disease: 16 (5.0%) for
gonorrhea, 38 (11.0%) for chlamydia, and 6 (1.9%) for both.
Sexually transmitted disease positivity rates ranged from 0.0%
to 28.6% among demographic groups (Table 2). Women
(17.8%) had a higher rate than men (9.8%), and non-Hispanic
black patients (19.5%) had a higher rate than Hispanic patients
(5.0%). Also, the rate among those aged 15 to 19 years (20.4%)
was higher than among those aged 20 to 25 years (12.3%).
Sexually transmitted disease treatment was confirmed for 42
(87.5%) of the 48 sexually transmitted disease–infected patients.
Nine patients were empirically treated by ED providers for
sexually transmitted disease symptoms, 7 were treated during
their hospital admission, 11 went to a hospital-affiliated clinic,
5 went to the local health department, 5 went to their primary
care provider, and 5 went elsewhere.
Program costs were estimated to be $72,928 (Table 3). The
cost per person tested was $42 (when counting persons who
tested for HIV or sexually transmitted disease), the cost per
HIV-infected person identified was $9,116, the cost per
HIV-infected person linked to care was $24,309, and the cost
per sexually transmitted disease–infected person treated was
$1,736. The program cost for HIV/sexually transmitted disease
screening was only $14,340 more than if we screened only for
HIV (data not shown); if screening were limited to HIV only,
the cost per HIV-infected person tested and cost per
HIV-infected person linked to care would decrease to $7,276
and $19,403, respectively.
Our study has certain limitations. First, we could not
completely differentiate screening costs as HIV- or sexually
transmitted disease–specific because some costs applied to both
(eg, screening and approaching patients); thus, we may have
slightly overestimated costs if the program were limited to HIV
Second, we do not know how well the prevalence of
undiagnosed HIV or sexually transmitted disease infection
among patients who were tested during the study can be
generalized to the respective populations of eligible patients who
were not tested (because they refused or were never
approached). The prevalence of undiagnosed HIV or sexually
Table 1. HIV screening acceptance, testing, and positivity
rates among eligible patients.
1447 (47.7)1428 (98.7)8 (0.6)
Table 2. Sexually transmitted disease screening acceptance,
testing, and positivity rates among eligible patients.
386 (48.8)320 (82.9) 48 (15.0)
Screening Programs in the Emergency DepartmentSilva et al
568 Annals of Emergency MedicineVolume , . : May
transmitted disease infection may have differed between those
who were tested and those who were not.
Third, for this analysis we treated each patient visit as a
unique patient. Some patients were probably screened or refused
testing more than once. Hence, the actual consent rate is
probably higher than the one we calculated. However, because
patients were ineligible if they were recently tested, we have few
repeated testers. For instance, only 39 patients were tested twice
for HIV during the study period, and they all had negative
test results, so this would not significantly affect the HIV
Finally, our patient population may not be representative of
other ED populations. In fact, institution-specific factors, such
as the proportion of infected patients who are aware of their
infection and linkages to HIV care and sexually transmitted
disease treatment, may influence the effectiveness of screening
at individual sites.
Although other studies have shown the feasibility of
implementing ED-based HIV22-28 or sexually transmitted
disease29,30 screening, our study demonstrates that a combined
HIV and sexually transmitted disease screening program is also
feasible and can be conducted at a slightly higher cost than HIV
screening only. However, through screening, we identified only
a small number of patients with undiagnosed HIV infection
and linked even fewer to care.
Implementing this screening program was feasible for several
reasons. First, hiring additional staff to conduct the screening,
testing, and referrals prevented overburdening the ED medical
staff or hindering the fast pace of the ED. Second, the screening
program was well accepted by ED patients. Our HIV (47.7%)
and sexually transmitted disease (48.8%) consent rates were
comparable to those of other ED-based HIV22,24,26,27 or
sexually transmitted disease screening projects.29,30 Using
simple and noninvasive HIV and sexually transmitted disease
tests may have contributed to their acceptability. Finally, the
local health department helped subsidize the cost of HIV and
sexually transmitted disease testing and assisted with follow-up
efforts. In all, we attempted to remove the most common
barriers (ie, time, cost, follow-up) to implementing an
ED-based HIV/sexually transmitted disease screening program.
Unfortunately, we could not routinely offer testing to all
eligible patients. ED patients were not screened during
nonstudy hours or when study staff was unavailable. Increasing
the number of patients screened may be possible by hiring
additional staff to offer screening during more hours of the day
or by encouraging existing ED staff to offer screening as a
routine part of patient care. The latter may not be feasible, given
the time currently required for screening, counseling,
consenting, and testing (Table 3). However, eliminating
requirements for separate, HIV-specific written consent and
pretest counseling, as recommended by some clinicians and
public health professionals,37-39 would make HIV screening and
testing easier for ED staff.
Although we anticipated identifying a lower proportion
(0.6%) of HIV-infected patients through routine screening than
what we found through our previous targeted (high-risk or
symptomatic patients)25 screening approach, the positivity rate
was lower than expected, given the high AIDS incidence and
prevalence rates in the communities surrounding the ED.31,40
In contrast, through sexually transmitted disease screening
we identified a significant number (48) and proportion (15.2%)
of infected patients and successfully linked most of them to
treatment (87.5%). The positivity rates for chlamydia and
gonorrhea in this ED were comparable to or slightly higher
than those found among patients of similar ages in other
Our cost analysis results can be compared with those of other
HIV screening studies in similar settings. Walensky et al27
calculated a cost per test, cost per infected patient tested, and
cost per person linked to care of $103, $5,266, and $6,026
Table 3. Cost analysis results: combined HIV and sexually
transmitted disease screening.
CategoryMeasure No.Subtotal, $
Screening for eligibility
Screened for eligibility, but not
Approached and refused testing
Accepted, but not tested
Tested: HIV and STD
Tested: STD only
Tested: HIV only
Posttest HIV-negative patient
Posttest HIV-infected patient
Follow-up on STD-infected
patients for results and
Follow-up on HIV-infected
patients who did not keep
appointment at infectious
HIV test costs for HIV-negative
HIV test costs HIV-infected
HIV test cost HIV-infected:
STD test costs
STD treatment costs (STD-
33% Administrative costs
(clerical, supervision and
Unit cost, $
*Assumes patients testing positive for gonorrhea were treated for both chla-
mydia and gonorrhea; cost includes cost of treatment visit.34,35
†Cost per patient tested for HIV or STD: $42; cost per HIV-positive patient iden-
tified: $9,116; cost per STD-positive patient identified and treated: $1,736; cost
per HIV-positive patient linked to care: $24,309.
Silva et al Screening Programs in the Emergency Department
Volume , . : May
Annals of Emergency Medicine 569
(2004 dollars), respectively, for an HIV testing program that
used oral fluid (nonrapid) testing in urban urgent care centers,
with a 2.0% seropositivity rate. In another study of rapid HIV
testing in an urban ED, the cost per person tested and cost per
positive identified was $51 and $1,581 (adjusted to 2004
dollars), with a 3.2% seropositivity rate.24 Although our cost per
person tested is within or below the range of other studies, our
lower seropositivity rate (0.6%) resulted in a substantially higher
cost per infected person identified. Our substantially higher cost
per HIV-infected person linked to care ($24,309) is due to the
low rate of linkage to care and indicates a key area for
improvement; in fact, in a model-based study, Walensky et al27
demonstrated that limited screening resources should focus on
linkage to care. A limitation of our cost analysis was that it was
conducted from the perspective of the hospital offering testing
rather than the societal perspective. As such, we did not
incorporate certain costs (eg, lifetime treatment costs for HIV)
or benefits (reductions in sequelae of chlamydia and gonorrhea)
of screening. Also, many studies have shown reductions in risk
behavior among persons who learn they are HIV infected,
which we did not assess.42,43 HIV infections averted as a
consequence of disease recognition and subsequent risk
reduction would at least partially offset the net societal cost of
ED screening. An additional limitation is that we based our cost
estimates on the actual time spent on the screening activities.
Depending on patient volume, some EDs might find it difficult
to devote the required time to screening activities without hiring
additional staff. A given ED might find labor costs for testing to
be higher if additional staff were not fully used for other
productive activities when not conducting the screening
Sexually transmitted disease screening can be combined with
HIV screening at a reasonable cost. Considering only the
additional sexually transmitted disease screening–associated
costs ($14,340), the cost per case of chlamydia or gonorrhea
treated ($299) was comparable to or lower than reported for
other similar chlamydia or gonorrhea standalone screening
programs ($300 to $1400); the cost per person screened ($45)
was within the range reported previously ($23 to $53).44-46
Recent studies demonstrated that, in EDs with high sexually
transmitted disease prevalence among young women (7% to
24%), screening all young women was more cost-effective than
other approaches.44-46 Compared to that of those studies, our
results show that adding sexually transmitted disease screening
to HIV screening is less costly compared with sexually
transmitted disease screening alone. Furthermore, sexually
transmitted disease screening and treatment provide health
benefits beyond those of HIV screening, including a reduction
in HIV incidence and transmission.47 However, the cost of
screening for both HIV and sexually transmitted diseases is
influenced by the prevalence rates of the populations screened;
lower prevalence rates increase the cost per case detected.
Future ED-based HIV/sexually transmitted disease screening
programs should consider several factors before implementation.
First, although rapid HIV testing increases result notification,
preliminary positive results require a return visit for
confirmatory test results and linkage to care. In our study,
confirmatory test results were provided at the scheduled
infectious diseases clinic appointment. Only 5 (including the 2
false-positive patients) of the 10 patients who received a
preliminary positive test result attended their scheduled
infectious diseases appointment and thus received their Western
blot results. Therefore, only 3 of the 8 confirmed positive
patients were successfully linked to care. There are a number of
ways to increase linkage to care. One strategy would be for
patients with preliminary positive test results to meet with HIV
case managers or social workers before they leave the ED; if
patients receive assistance with some of their social issues (eg,
homelessness, drug use) they may be more inclined to tend to
their health issues.48,49 In one ED-based HIV screening
program, 80% linkage to care was attained by walking patients
directly to the infectious diseases clinic on receipt of their
positive test result.28 Finally, offering a modest financial
incentive to attend a clinic appointment may be effective. For
instance, one study that offered a monetary incentive reported
an increase (from 8% to 23%) in the proportion of ED patients
who completed HIV counseling and testing after being referred
from the ED.50
Second, despite the high sensitivity and specificity rate of the
rapid HIV test, some false-positive results should be anticipated
in low-prevalence settings. Such screening tests must be
followed by further diagnostic testing to confirm the presence of
the disease. Therefore, positive rapid test results were reported
as “preliminary positive” to the patients, and they were told that
a follow-up confirmatory test was needed. The small risk of
giving some patients a “preliminary positive” test result is
outweighed by the public health good in identifying and
treating HIV-infected patients.
Third, collaboration with the local health department in
implementing testing can help sustain an ED-based screening
program. One ED28,39 successfully implemented and sustained
a targeted HIV screening program with the support of local
health department and Ryan White funding. Similarly, our local
health department subsidized all costs related to sexually
transmitted disease and HIV confirmatory testing, assisted with
follow-up, and was a source of free sexually transmitted disease
In conclusion, with appropriate funding and collaboration
with the local health department, HIV/sexually transmitted
disease screening was feasible in this ED. Although routine,
voluntary sexually transmitted disease screening identified and
treated many patients in this ED, screening for HIV was less
successful. According to resources and the results of this project,
we are continuing to screen for sexually transmitted diseases,
with the collaboration of the local health department; we are
also exploring opportunities to implement more targeted HIV
screening. The decision to implement HIV and sexually
transmitted disease screening for any ED should consider the
Screening Programs in the Emergency Department Silva et al
570 Annals of Emergency MedicineVolume , . : May
resources available (from its institution or local health
department), the prevalence of undiagnosed infections in the
population to be screened, and the strategies for linking infected
patients to treatment and care.
We thank David Withum, DrPH, and Thomas Peterman, MD,
MSc, for their assistance with the initial concept and design of the
study and Nan Ruffo, BS, for the creation of the study database that
made data entry and management easy. We are also grateful to
Kristi Allgood for collecting the data necessary for the cost-analysis
piece of the project. Finally, we are especially indebted for the
dedicated work of Dyanna Charles, BA, and Jacqueline Franqui,
who screened patients, tracked patients, and linked them to
treatment or care.
Supervising editor: Arthur L. Kellermann, MD, MPH
Author contributions: AS, NRG, SL, LNP, and DB contributed
significantly to the study concept and design. AS and NRG
drafted the article. AS oversaw data collection and analyzed
the data. ABH and TLG analyzed the time-motion data and
drafted the cost analysis. NRG, SL, LNP, and SW critically
revised the manuscript. AS takes responsibility for the paper
as a whole.
Funding and support: This work was funded through a
Cooperative Agreement (R18/CCR520998-01) with the
National Center for HIV, STD, and TB Prevention, Centers for
Disease Control and Prevention, Atlanta, GA.
Publication dates: Received for publication January 4, 2006.
Revisions received April 6, 2006; August 1, 2006; and
September 22, 2006. Accepted for publication September 29,
2006. Available online November 20, 2006.
Reprints not available from the authors.
Address for correspondence: Abigail Silva, MPH, Sinai Urban
Health Institute, Sinai Health System California at 15thStreet,
K436, Chicago, IL 60608; 773-257-5785, fax 773-257-5680;
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Screening Programs in the Emergency Department Silva et al
572 Annals of Emergency MedicineVolume , . : May