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Development and Implementation of a Model to Improve Identification of Patients Infected with HIV Using Diagnostic Rapid Testing in the Emergency Department
Abstract
Objectives:
Infection with the human immunodeficiency virus (HIV) continues to expand in nontraditional risk groups, and the prevalence of undiagnosed infection remains relatively high in the patient populations of urban emergency departments (EDs). Unfortunately, HIV testing in this setting remains uncommon. The objectives of this study were 1) to develop a physician-based diagnostic rapid HIV testing model, 2) to implement this model in a high-volume urban ED, and 3) to prospectively characterize the patients who were targeted by physicians for testing and determine the proportions who completed rapid HIV counseling, testing, and referral; tested positive for HIV infection; and were successfully linked into medical and preventative care.
Methods:
An interdisciplinary group of investigators developed a model for performing physician-based diagnostic rapid HIV testing in the ED. This model was then evaluated using a prospective cohort study design. Emergency physicians identified patients at risk for undiagnosed HIV infection using clinical judgment and consensus guidelines. Testing was performed by the hospital's central laboratory, and clinical social workers performed pretest and posttest counseling and provided appropriate medical and preventative care referrals, as defined by the model.
Results:
Over the 30-month study period, 105,856 patients were evaluated in the ED. Of these, 681 (0.64%; 95% confidence interval [CI] = 0.60% to 0.69%) were identified by physicians and completed rapid HIV counseling, testing, and referral. Of the 681 patients, 15 (2.2%; 95% CI = 1.2% to 3.6%) patients tested positive for HIV infection and 12 (80%; 95% CI = 52% to 96%) were successfully linked into care.
Conclusions:
A physician-based diagnostic HIV testing model was developed, successfully implemented, and sustained in a high-volume, urban ED setting. While the use of this model successfully identified patients with undiagnosed HIV infection in the ED, the overall level of testing remained low. Innovative testing programs, such as nontargeted screening, more specific targeted screening, or alternative hybrid methods, are needed to more effectively identify undiagnosed HIV infection in the ED patient population.
... All papers were published between 2005 and 2019 and study periods varied from 4 months to 6 years. Most studies were from the United States (n = 8) [60,61,[63][64][65][66][67] and from areas of high-HIV prevalence (n = 11) [60-62, 64-69, 79]. Those based in Europe (France, Spain, and Switzerland) were more recent (2018-2019). ...
... Study design varied between prospective and retrospective studies, with one-third of evidence arising from RCTs. 3 studies were prospective studies (2 evaluated targeted HIV screening versus diagnostic screening and one compared targeted HIV screening to nontargeted HIV screening) [60,66,79]. There were four retrospective studies [61,63,65], one cost-utility study [67], and one post-analysis study [69]. All studies were government funded, but two were also supported by commercial funding. ...
... The rate of new HIV cases was the most investigated measure of impact and varied widely (0.03 -2.2%), mainly due to heterogeneity in methodology and definitions. In the two studies reporting the highest rate of new HIV diagnoses, the number of new diagnoses was compared to the number of patients tested and not to the total population included [63,64]. In both studies, the number of patients refusing the test was not reported. ...
Despite considerable improvement in human immunodeficiency virus (HIV) knowledge and treatment in the last 3 decades, the overall number of people living with HIV (PLHIV) is still rising with up to one quarter being unaware of their HIV status. Early HIV diagnosis and treatment prolongs life, reduces transmission, improves quality of life, and is a cost-effective public health intervention. The emergency department (ED) sees a large number of patients from marginalized and traditionally underserved populations in whom HIV is known to be more prevalent and who may not attend traditional services because of either cultural reasons or because of a chaotic lifestyle. This article discusses the two main approaches to screening; 'Opt-out' screening offers testing routinely in all clinical settings, and 'Targeted' screening offers testing to individuals presenting with indicator conditions. There are many studies of 'Opt-out' ED HIV screening in urban areas of high-HIV prevalence. However, little is known about the effectiveness of 'targeted' HIV screening, especially in areas of low prevalence. This review discusses the background to HIV screening in the ED and reviews the evidence around 'targeted' HIV screening in adult EDs in different HIV prevalence settings, concluding that targeted HIV screening at the ED can be impactful, cost-effective, and well accepted in the ED population, but its long-term implementation requires extra funding and increased staffing resource limiting its application in low resource setting. Despite most evidence being from areas of high-HIV prevalence, targeted screening might also be appropriate in low-HIV prevalence areas.
... Length of ED stay was 1.7 hours longer for patients who were tested in the Denver trial. 7 However, the authors point out that the decision to test for HIV was often made late in the patient's ED stay. Testing at triage might eliminate this delay and, because the rapid tests can be performed on saliva or fingerstick blood, should be feasible. ...
... Some programs incorporate HIV screening into ED triage; others are dependent on additional personnel dedicated solely to HIV screening and counseling. 7,8,10,11,17 The American College of Emergency Physicians' policy statement is presented below 18 can prolong life, reduce transmission, and has been demonstrated to be a cost-effective public health intervention. HIV testing in the evaluation for acute care conditions in the emergency department (ED) should be available in an expeditious and efficient fashion similar to testing and results for other conditions. ...
... Reimbursement for HIV testing in the ED is a potential barrier to instituting universal opt-out screening. 7 In many published ED HIV screening studies, the study's financial sponsor absorbed the cost of testing. With a unit cost for rapid HIV testing of $14 to $25, EDs will need to be reimbursed if programs are to be financially feasible. ...
... Several models of delivering ED physician-initiated rapid HIV testing have already been described, including point-of-care testing by native nursing staff, 1 point-of-care testing by exogenous testing staff, 3 and laboratory testing. 4 A presumed advantage of point-ofcare testing is faster turnaround times, although this may be offset by testing falling to either the native ED staff or adjunctive exogenous staff. In a laboratory model, incorporation of testing into standard laboratory procedures minimizes the workload on ED staff and eliminates the need for additional personnel. ...
... However, laboratory testing may result in longer turnaround times to results and increased ED patient length of stay. 4 Accordingly, physicians may be less likely to order laboratory versus point-of-care testing, especially for patients who have no need for other tests. ...
... Although ED HIV screening is recommended by the Centers for Disease Control and Prevention and its benefits are well described, implementation of screening may not be possible in many facilities. 1,4,[7][8][9][10] In this study, we implemented and compared 2 models for integrating physician-initiated rapid HIV testing into ED operations: rapid HIV testing on oral fluid specimens, performed point-of-care by nursing staff, and rapid testing on whole-blood specimens, performed by the hospital's main laboratory. These models were chosen because they require relatively few resources to implement and sustain, do not require the hiring of exogenous staff, and use available "inkind" hospital resources. ...
We compare the outcomes of 2 models of physician-initiated rapid HIV testing in an emergency department (ED).
One-year retrospective cohort comparing 2 6-month models of physician-initiated rapid HIV testing, point-of-care versus laboratory. Patients aged 12 years or older and able to give verbal consent were eligible for physician-initiated rapid HIV testing if their treating physician believed testing was clinically indicated. During the point-of-care phase, nursing staff performed oral fluid testing. During the laboratory phase, the laboratory performed whole-blood testing. The proportion of potentially eligible patients who had physician-initiated rapid HIV testing ordered (order rate), proportion of ordered tests completed (test completion rate), and proportion of potentially eligible patients who completed testing (overall testing rate) during each phase were assessed. ED length of stay and testing times were also compared.
For the point-of-care versus laboratory phase, respectively, there were 24,345 potentially eligible patients versus 26,363; order rate was 3.3% versus 2.4% (P<.001); test completion rate was 75.3% versus 86.8% (P<.001); overall testing rate was 2.5% versus 2.1% (P=.009). Eighteen (3.0%) of the point-of-care-tested patients and 15 (2.7%) of the laboratory-tested patients had reactive tests (P=0.02). The total testing time was greater in the laboratory phase (88 versus 66 minutes; P<.001); however, there was no significant difference in the length of stay between phases (6.2 versus 6.9 hours; P=.15).
Relatively few ED patients undergo physician-initiated rapid HIV testing regardless of whether a point-of-care or laboratory approach is used. Differences exist in most outcome measures when point-of-care and laboratory models are compared, which should be considered when testing is implemented.
... 6,7 Unfortunately, relatively limited research has been performed to define the most effective approach to performing HIV testing in EDs. Past efforts have centered primarily on the feasibility and yield of conducting HIV testing in this specific clinical environment, [8][9][10][11][12][13][14][15][16][17][18][19] and several ED-based rapid testing strategies have attempted to increase the yield of patients diagnosed with HIV infection. 8,9,[12][13][14][15][16][17][18]20 In recent years, rapid HIV testing methods have been proposed and evaluated in a growing but still limited fashion. ...
... Past efforts have centered primarily on the feasibility and yield of conducting HIV testing in this specific clinical environment, [8][9][10][11][12][13][14][15][16][17][18][19] and several ED-based rapid testing strategies have attempted to increase the yield of patients diagnosed with HIV infection. 8,9,[12][13][14][15][16][17][18]20 In recent years, rapid HIV testing methods have been proposed and evaluated in a growing but still limited fashion. A recently published paradigm categorized ED-based rapid HIV testing into diagnostic testing (i.e., testing based on clinical signs or symptoms), targeted testing or screening (i.e., testing a population based on specific risk characteristics), or nontargeted screening (i.e., testing a population regardless of risk). ...
... 21 Over 70% of the patients served by DHMC are racial or ethnic minorities, 40% are uninsured, and the estimates of the undiagnosed HIV seroprevalence in the ED population range from 0.7% to 2.2%. 8,16 STUDY DESIGN ...
In 2006, the Centers for Disease Control and Prevention (CDC) released revised recommendations for performing human immunodeficiency virus (HIV) testing in health care settings, including implementing routine rapid HIV screening, the use of an integrated opt-out consent, and limited prevention counseling. Emergency departments (EDs) have been a primary focus of these efforts. These revised CDC recommendations were primarily based on feasibility studies and have not been evaluated through the application of rigorous research methods. This article describes the design and implementation of a large prospective controlled clinical trial to evaluate the CDC's recommendations in an ED setting. From April 15, 2007, through April 15, 2009, a prospective quasi-experimental equivalent time-samples clinical trial was performed to compare the clinical effectiveness and efficiency of routine (nontargeted) opt-out rapid HIV screening (intervention) to physician-directed diagnostic rapid HIV testing (control) in a high-volume urban ED. In addition, three nested observational studies were performed to evaluate the cost-effectiveness and patient and staff acceptance of the two rapid HIV testing methods. This article describes the rationale, methodologies, and study design features of this program evaluation clinical trial. It also provides details regarding the integration of the principal clinical trial and its nested observational studies. Such ED-based trials are rare, but serve to provide valid comparisons between testing approaches. Investigators should consider similar methodology when performing future ED-based health services research.
... HIV is also increasing in nontraditional risk groups without traditional risk factors [13]. It has been found that nontraditional risk groups are more likely to decline routine HIV testing, mainly because they feel they are not at risk [16]. Another barrier to broad HIV testing has been the Informed Consent process that required pretest counseling prior to testing. ...
... One study group states "nontargeted opt out rapid HIV screening in conjunction with diagnostic testing was associated with approximately 30 times the number of rapid HIV tests performed, yet only a few more patients were newly identified with HIV infection when compared to diagnostic testing alone" [17]. Targeted testing, previously the only testing strategy, has been shown to increase the rate of newly diagnosed HIV infections by two to three times over nontargeted testing at a much lower cost [16]. Targeted testing is defined as performing an HIV test for subpopulations of persons at higher risk, typically defined on the basis of clinical, behavior, or demographic characteristics [3]. ...
Recent data from the USA and elsewhere indicating that the number of new HIV/ AIDS cases continues to rise has stimulated state and national efforts to identify patients with undetected HIV infection. Although the use of Emergency Departments (EDs) as a venue for screening remains controversial, the ED has become a major focus of this effort with more than a dozen studies of ED screening for HIV reported in recent years. This review of ED studies published since 2005 summarizes these findings: selection bias in these programs appears common, acceptance of testing varies widely, positivity rates are usually less than 1% and the cost per case found is approximated to be between 10,000.
... 3 In these trials, 9,365 ED patients were screened, 97 new cases were identified (1.0%), and 88% of those who were newly identified were linked to HIV health care services. The Centers for Disease Control and Prevention (CDC) for many years has recognized the missed opportunity provided by the ED in reaching patients who utilize health care episodically and in 2006 recommended that HIV screening become a routine part of ED medical services, using a nontargeted, voluntary, opt-out approach for all patients aged 13 to 64 years old in settings with prevalence of undiagnosed HIV of ‡0.1%. 4 Several recent reports have focused on issues related to the feasibility of ED screening and linkage to HIV treatment, 3,[5][6][7][8][9][10][11][12][13][14] and there have been reports of increased condom use after multisession, intensive intervention with patients in drug treatment programs. 15 However, to the best of our knowledge there have been no reports to date following changes over time in risky sexual behaviors among ED patients at high risk for HIV and sexually transmitted infections (STIs), after receipt of voluntary HIV testing and brief counseling (VT ⁄ C) and referral to drug treatment in the ED. ...
... 29 A 2009 consensus conference on research priorities related to STI and HIV screening, surveillance, and intervention in the ED identified the need for ''comparative assessment of methods for incorporation of ED HIV and STI testing into a broader public health approach in the ED.'' 10 In the study that we report here, we demonstrate the feasibility of 1) collaboration between research staff designated to perform VT ⁄ C, substance abuse referral experts assigned to the ED, 18 and infectious disease specialists; and 2) the integration of testing and brief counseling into a busy ED. Thus far, the CDC's ED HIV screening and testing program 3,9,10,30 and the Substance Abuse and Mental Health Administration (SAMHSA) Alcohol and Drug Screening Brief Intervention and Referral to Treatment (SBIRT) initiative have represented separate public health policies, strategies, and funding streams. [31][32][33] The current study is significant in that it is the first ED study to combine these two approaches and apply them to a high HIV risk population. ...
Public health initiatives have lowered human immunodeficiency virus (HIV) transmission risk associated with injection drug use in the United States, making sexual risk behaviors a greater source of transmission. Strategies are therefore needed to reduce these risk behaviors among all emergency department (ED) patients who use drugs, regardless of route of administration. Although recent articles have focused on the opportunity for early HIV detection and treatment through an array of ED screening and testing strategies, the effect of voluntary HIV testing and brief counseling (VT/C) on the sexual behaviors of out-of-treatment drug users over time has not yet been reported.
From November 2004 to May 2008, the study screened 46,208 urban ED patients aged 18 to 54 years; 2,148 (4.6%) reported cocaine or heroin use within 30 days, 1,538 met eligibility criteria (Drug Abuse Severity Test [DAST] scores ≥3 and were either English- or Spanish-speaking), and 1,030 were enrolled. These data were obtained in the course of a randomized, controlled trial (Project SAFE) of a brief motivational intervention focused on reducing risky sexual behaviors. Although the intervention itself did not demonstrate any differential effect on the number or percentage of unprotected sexual acts, both control and intervention group participants received baseline VT/C and referral for drug treatment as part of the study protocol. This study is a report of a secondary analysis of cohort data to describe changes in sexual behaviors over time among drug users after the VT/C and referral.
The mean (±SD) age of enrollees was 35.8 (±8.4) years; 67% were male, 39% were non-Hispanic black or African American, 41% were white non-Hispanic, and 19% were Hispanic. Half injected drugs, and 53% met criteria for posttraumatic stress disorder (PTSD). At baseline testing, 8.8% were HIV-positive on enzyme-linked immunosorbent assay. Follow-ups were conducted at 6 and 12 months, with an attrition rate of 22%. Known HIV-positive patients accounted for 84 of 1,030 cases (8.1%), and 13 new cases were discovered: 7 of 946 at were discovered at the baseline contact (0.74%), 2 of 655 were discovered at 6 months (0.3%), and 4 of 706 (0.57%) were discovered at the 12-month contact. Twelve of the 13 returned for confirmatory testing and were actively enrolled in our infectious disease clinic. For all partners, there was a reduction in the percentage of unprotected sex acts over time (p < 0.0001), with decreases at 6 months versus baseline (odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.60 to 0.83), sustained at 12 months versus baseline (OR = 0.69, 95% CI = 0.58 to 0.82). For the outcome of percentage of sex acts while high, there was also a significant reduction over time (p < 0.0001), with a drop-off at 6 months versus baseline (OR = 0.31, 95% CI = 0.25 to 0.37) that was sustained at 12 months (OR vs. baseline 0.25, 95% CI = 0.20 to 0.30). In an adjusted model, male sex, older age, and HIV positivity predicted significant declines over time in the likelihood of unprotected sexual acts. Older age and higher baseline drug severity predicted significant decreases over time in the likelihood of sex acts while high.
Voluntary testing and counseling for HIV or sexually transmitted infections, accompanied by referral to drug treatment, for this population of ED cocaine and heroin users was associated with reduction in unprotected sex acts and fewer sex acts while high.
... 12,22 Diagnostic testing should be uniformly available to all practicing emergency physicians. Unfortunately, even when such testing is available, many physicians do not maintain a high degree of suspicion for HIV infection among their patients, 23 which dramatically limits the effectiveness of this approach in the ED. 23,24 Targeted screening is defined as the selection of a defined subpopulation for testing compared with a base population. ...
... Unfortunately, even when such testing is available, many physicians do not maintain a high degree of suspicion for HIV infection among their patients, 23 which dramatically limits the effectiveness of this approach in the ED. 23,24 Targeted screening is defined as the selection of a defined subpopulation for testing compared with a base population. 21 Although targeted screening allows for "risk-based" testing of patients, something most would consider intuitive and a theoretically broader means of patient selection, this testing approach relies on the assumption that the epidemic functions similarly across settings, that we fully appreciate the characteristics of the epidemic in the targeted population, and that we are capable of identifying patients who are at risk. ...
... Emergency departments (EDs) may offer ready access to a population at high risk for HIV infection, 1 but the feasibility of universal screening of all eligible patients has been questioned and no ED has yet achieved this goal. [2][3][4][5][6][7] Several EDs have partially succeeded at offering nontargeted screening to patients for a sizeable proportion of ED visits, 8,9 but the sustainability and the ability to generalize such experiences to other EDs remains unclear. ...
... If a policy recommendation is judged unfeasible, it might be discarded entirely rather than adopted incrementally as resources allow. [2][3][4][5][8][9][10][11] Thus, the inability to test all eligible patients might inadvertently result in a failure to expand testing to the degree that it is feasible. Because many patients present to EDs repeatedly, the cumulative effect of modest testing efforts could result in more complete screening levels over time than might be assumed according to a single cross-sectional sample and motivate adoption of screening to the extent possible. ...
The lack of well-described population-level outcome measures for emergency department (ED) HIV testing is one barrier to translation of screening into practice. We demonstrate the impact of an ED diagnostic testing and targeted screening program on the proportion of ED patients ever tested for HIV and explore cumulative effects on testing rates over time.
Data were extracted from electronic HIV testing program records and administrative hospital databases for January 2003 to December 2008 to obtain the monthly number of ED visits and HIV tests. We calculated the proportions of (1) patients tested in the program who reported a previous HIV test or had been previously tested in the program, and (2) the cumulative number of unique ED patients who were tested in our program.
During the study period, 165,665 unique patients made 491,552 ED visits and the program provided 13,509 tests to 11,503 unique patients. From 2003 to 2008, tested patients who reported a history of an HIV test increased by 0.085% per month (95% confidence interval [CI] 0.037% to 0.133%), from 67.7% to 74.4%; the percentage of tested patients who had previous testing in the program increased by 0.277% per month (95% CI 0.245% to 0.308%), from 3.2% to 21.2%; and the percentage of unique ED patients previously tested in the program increased by 0.100% per month (95% CI 0.096% to 0.105%), reaching a cumulative proportion of 6.9%.
Our HIV testing program increased the proportion of ED patients who have been tested for HIV at least once and repeatedly tested a subset of individuals. HIV screening, even during a minority of ED visits, can have important cumulative effects over time.
... Emerging data suggest that HIV screening in the ED would identify numerous HIV-infected individuals who commonly use the ED as their sole source of medical care. 2,3 Importance In recognition of the expanding role of ED personnel in the provision of community preventive health care, recent literature has emphasized the critical role EDs could play as HIV testing sites. 1 Although such data have motivated EDs nationwide to establish HIV testing programs, [3][4][5][6][7] expansion of other public health efforts in this setting has stressed the already overworked staff and resources. [8][9][10][11] The numerous HIV screening strategies in the ED setting previously published are ultimately incomparable because of differences in eligibility, data collection and reporting. ...
... Emerging data suggest that HIV screening in the ED would identify numerous HIV-infected individuals who commonly use the ED as their sole source of medical care. 2,3 Importance In recognition of the expanding role of ED personnel in the provision of community preventive health care, recent literature has emphasized the critical role EDs could play as HIV testing sites. 1 Although such data have motivated EDs nationwide to establish HIV testing programs, [3][4][5][6][7] expansion of other public health efforts in this setting has stressed the already overworked staff and resources. [8][9][10][11] The numerous HIV screening strategies in the ED setting previously published are ultimately incomparable because of differences in eligibility, data collection and reporting. ...
We compare rates of rapid HIV testing, test offer, and acceptance in an urban emergency department (ED) when conducted by dedicated HIV counselors versus current members of the ED staff.
The Universal Screening for HIV Infection in the Emergency Room [USHER] trial is a prospective randomized controlled trial that implemented an HIV screening program in the ED of an urban tertiary medical center. ED patients were screened and consented for trial enrollment by an USHER research assistant. Eligible subjects were randomized to rapid HIV testing (oral OraQuick) offered by a dedicated counselor (counselor arm) or by an ED provider (provider arm). In the counselor arm, counselors-without other clinical responsibilities-assumed nearly all testing-related activities (consent, counseling, delivery of test results). In the provider arm, trained ED emergency service assistants (nursing assistants) consented and tested the participant in the context of other ED-related responsibilities. In this arm, ED house officers, physician assistants, or attending physicians provided HIV test results to trial participants. Outcome measures were rates of HIV testing and test offer among individuals consenting for study participation. Among individuals offered the test, test acceptance was also measured.
From February 2007 through July 2008, 8,187 eligible patients were approached in the ED, and 4,855 (59%) consented and were randomized to trial participation. The mean age was 37 years, 65% were women, and 42% were white. The overall testing rate favored the counselor arm (57% versus 27%; P<.001); 80% (1,959/2,446) of subjects in the counselor arm were offered an HIV test compared with 36% (861/2,409) in the provider arm (P<.001). HIV test acceptance was slightly higher in the provider arm (counselor arm 71% versus provider arm 75%; P = .025).
Routine rapid HIV testing in the ED was accomplished more frequently by dedicated HIV counselors than by ED staff in the course of routine clinical work. Without dedicated staff, HIV testing in this setting may not be truly routine.
... 11 To our knowledge, this is the first study to assess the effectiveness of a linkage to care team based in a hospital HIV clinic, as opposed to the emergency department social workers, HIV counselor/testers, or public health staff used by many emergency department HIV testing programs. 12,13 In addition, programs that have chosen to rely on clinician-initiated testing may seek strategies for increasing the number of tests performed. Thus, the objectives of this study were to: (1) describe and evaluate the addition of targeted testing to a model of clinician-initiated diagnostic testing in order to increase the number of HIV tests performed; (2) characterize new diagnoses of HIV infection with regard to demographics and CD4 cell count, and (3) assess linkage to care outcomes for newly diagnosed as well as out-of-care HIV-infected patients. ...
... A clinician-initiated diagnostic testing model utilizing the hospital laboratory and dedicated linkage to care staff has been described as a successful way to implement and sustain HIV testing in the emergency department. 13 We present data to support this claim. In addition, we are the first to describe a successful linkage mechanism based in the hospital HIV clinic, rather than the emergency department. ...
The urban emergency department is an important site for the detection of HIV infection. Current research has focused on strategies to increase HIV testing in the emergency department. As more emergency department HIV cases are identified, there need to be well-defined systems for linkage to care. We conducted a retrospective study of rapid HIV testing in an urban public emergency department and level I trauma center from June 1, 2008, to March 31, 2010. The objectives of this study were to evaluate the increase in the number of tests and new HIV diagnoses resulting from the addition of targeted testing to clinician-initiated diagnostic testing, describe the demographic and clinical characteristics of patients with newly diagnosed HIV infection, and assess the effectiveness of an HIV clinic based linkage to care team. Of 96,711 emergency department visits, there were 5340 (5.5%) rapid HIV tests performed, representing 4827 (91.3%) unique testers, of whom 62.4% were male and 60.8% were from racial/ethnic minority groups. After the change in testing strategy, the median number of tests per month increased from 114 to 273 (p=0.004), and the median number of new diagnoses per month increased from 1.5 to 4 (p=0.01). From all tests conducted, there were 65 new diagnoses of HIV infection (1.2%, 95% confidence interval [CI] 0.9%, 1.5%). The linkage team connected over 90% of newly diagnosed and out-of-care HIV-infected patients to care. In summary, the addition of targeted testing to diagnostic testing increased new HIV case identification, and an HIV clinic-based team was effective at linkage to care.
... All retrospective data collection will use structured methods. In prior HIV studies, we have consistently obtained longitudinal follow-up for > 90% of HIV-diagnosed patients from the ED thus we anticipate collecting similarly high HCV follow-up data [26,27]. ...
Background
Hepatitis C (HCV) poses a major public health problem in the USA. While early identification is a critical priority, subsequent linkage to a treatment specialist is a crucial step that bridges diagnosed patients to treatment, cure, and prevention of ongoing transmission. Emergency departments (EDs) serve as an important clinical setting for HCV screening, although optimal methods of linkage-to-care for HCV-diagnosed individuals remain unknown. In this article, we describe the rationale and design of The D etermining E ffective T esting in E mergency Departments and C are Coordination on T reatment Outcomes (DETECT) for Hep atitis C (Hep C) Linkage-to-Care Trial.
Methods
The DETECT Hep C Linkage-to-Care Trial will be a single-center prospective comparative effectiveness randomized two-arm parallel-group superiority trial to test the effectiveness of linkage navigation and clinician referral among ED patients identified with untreated HCV with a primary hypothesis that linkage navigation plus clinician referral is superior to clinician referral alone when using treatment initiation as the primary outcome. Participants will be enrolled in the ED at Denver Health Medical Center (Denver, CO), an urban, safety-net hospital with approximately 75,000 annual adult ED visits. This trial was designed to enroll a maximum of 280 HCV RNA-positive participants with one planned interim analysis based on methods by O’Brien and Fleming. This trial will further inform the evaluation of cost effectiveness, disparities, and social determinants of health in linkage-to-care, treatment, and disease progression.
Discussion
When complete, the DETECT Hep C Linkage-to-Care Trial will significantly inform how best to perform linkage-to-care among ED patients identified with HCV.
Trial registration
ClinicalTrials.gov
ID: NCT04026867
Original date: July 1, 2019
URL: https://clinicaltrials.gov/ct2/show/NCT04026867
... This could also be due to the transient nature of conditions and acute care needed in the emergency department, where the focus is on the patient's current issue and less on peripheral issues like HIV testing. Furthermore, HIV testing uptake could be higher when a physician offers the test [26][27][28] which may not always be the case in a busy emergency department. Nevertheless, an ED-based HIV screening program remains an integral component of the overall HIV screening strategy to reduce the current HIV testing gap and complement existing community-based HIV screening programs. ...
Purpose of Review
Improving HIV testing uptake is essential to ending the HIV pandemic. HIV testing approaches can be opt-in, opt-out or risk-based. This systematic review examines and compares the uptake of HIV testing in opt-in, opt-out and risk-based testing approaches.
Recent Findings
There remain missed opportunities for HIV testing in a variety of settings using different approaches: opt-in (a person actively accepts to be tested for HIV), opt-out (a person is informed that HIV testing is routine/standard of care, and they actively decline if they do not wish to be tested for HIV) or risk-based (using risk-based screening tools to focus testing on certain individuals or sub-populations at greater risk of HIV). It is not clear how the approach could impact HIV test uptake when adjusted for other factors (e.g. rapid testing, country-income level, test setting and population tested).
Summary
We searched four databases for studies reporting on HIV test uptake. In total, 18,238 records were screened, and 150 studies were included in the review. Most studies described an opt-in approach (87 estimates), followed by opt-out (76) and risk-based (19). Opt-out testing was associated with 64.3% test uptake ( I ² = 99.9%), opt-in testing with 59.8% ( I ² = 99.9%) and risk-based testing with 54.4% ( I ² = 99.9%). When adjusted for settings that offered rapid testing, country income level, setting and population tested, opt-out testing had a significantly higher uptake (+ 12% (95% confidence intervals: 3–21), p = 0.007) than opt-in testing. We also found that emergency department patients and hospital outpatients had significantly lower HIV test uptake than other populations.
... During both the nurse-order HIV/ hepatitis C virus screening algorithm and the automatedlaboratory-order HIV/hepatitis C virus screening algorithm, physicians also tested patients for HIV or hepatitis C virus at their discretion, using a diagnostic and targeted approach. 14 No sample size calculations were performed because this was a retrospective comparison of 2 clinical screening programs. ...
Study objective:
We compare the effectiveness of 2 nontargeted HIV and hepatitis C virus screening protocols integrated consecutively into care in an urban emergency department: a nurse-order HIV/hepatitis C virus screening algorithm followed by an automated-laboratory-order HIV/hepatitis C virus screening algorithm programmed into the electronic health record.
Methods:
This was a before-after comparative effectiveness cohort study. All patients aged 18 to 75 years who received treatment during 5-month periods were eligible for participation. The main outcome measures were the number of patients screened and the number with newly diagnosed HIV and hepatitis C virus infection.
Results:
Of the eligible patients, 6,736 (33.9%) completed HIV screening during the automated-laboratory-order HIV/hepatitis C virus screening algorithm, whereas 4,121 (19.6%) completed HIV screening during the nurse-order HIV/hepatitis C virus screening algorithm (difference 14.3%; 95% confidence interval 13.4% to 15.1%); and 6,972 (35.1%) completed hepatitis C virus screening during the automated-laboratory-order HIV/hepatitis C virus screening algorithm, whereas 2,968 (14.2%) completed hepatitis C virus screening during the nurse-order HIV/hepatitis C virus screening algorithm (difference 20.9%; 95% confidence interval 20.1% to 21.7%). More patients had newly diagnosed HIV (23 versus 17) and hepatitis C virus infection (101 versus 29) during the automated-laboratory-order HIV/hepatitis C virus screening algorithm than the nurse-order HIV/hepatitis C virus screening algorithm. Results were more often available before discharge (HIV 87.2% versus 65.1%; hepatitis C virus 90.0% versus 65.4%) and fewer patients underwent repeated screening (HIV 1.6% versus 5.8%; hepatitis C virus 1.3% versus 4.5%) during the automated-laboratory-order HIV/hepatitis C virus screening algorithm than the nurse-order HIV/hepatitis C virus screening algorithm.
Conclusion:
An electronic health record algorithm that automatically links HIV/hepatitis C virus screening to laboratory ordering for adult patients is more effective than a nurse-driven protocol. With widespread use of electronic health record systems, this model can be easily replicated and should be considered the standard for future programs.
... Despite the FOPH recommendations, the HIV testing rate in the ED at our centre is around 1% of all patients seen [7]. Indeed, even in EDs in the United States (US), where the Centers for Disease Control and Prevention (CDC) recommend non-targeted, opt-out testing [8], physician-initiated testing has resulted in low (<1%) HIV testing rates [9]. Several barriers to HIV testing in the US ED setting have been reported. ...
Background
The emergency department (ED) is mentioned specifically in the Swiss HIV testing recommendations as a site at which patients can benefit from expanded HIV testing to optimise early HIV diagnosis. At our centre, where local HIV seroprevalence is 0.2–0.4%, 1% of all patients presenting to the ED are tested for HIV. Barriers to HIV testing, from the patient and doctor perspective, and patient acceptability of rapid HIV testing were examined in this study.
Methods
Between October 2014 and May 2015, 100 discrete patient-doctor encounter pairs undertook a survey in the ED of Lausanne University Hospital, Switzerland. Patients completed a questionnaire on HIV risk factors and were offered free rapid HIV testing (INSTI™). For every patient included, the treating doctor was asked if HIV testing had 1) been indicated according to the national testing recommendations, 2) mentioned, and 3) offered during the consultation.
Results
Of 100 patients, 30 had indications for HIV testing through risk factors or a suggestive presenting complaint (PC). Fifty patients accepted rapid testing; no test was reactive. Of 50 patients declining testing, 82% considered themselves not at risk or had recently tested negative and 16% wished to focus on their PC. ED doctors identified 20 patients with testing indications, mentioned testing to nine and offered testing to six. The main reason for doctors not mentioning or not offering testing was the wish to focus on the PC.
Discussion
Patients and doctors at our ED share the testing barrier of wishing to focus on the PC. Rapid HIV testing offered in parallel to the patient-doctor consultation increased the testing rate from 6% (offered by doctors) to 50%. Introducing this service would enable testing of patients not offered tests by their doctors and reduce missed opportunities for early HIV diagnosis.
... Expecting EPs to screen greater numbers of patients, however, may be unrealistic. Haukoos et al [11] reported the results of an EP-initiated HIV screening program using existing ED resources, and they were able to test 0.64% of their total patient census over a 30-month period. ...
... 13 Since then, work in this field has focused on various models of screening in an effort to decrease barriers to testing, minimize effects on ED flow, assess the cost-effectiveness of programs, and examine how to best connect patients to regular outpatient care. [14][15][16][17][18][19][20][21][22] Computer modeling of enhanced HIV screening in the highly active antiretroviral era suggests that, especially among high-risk populations, there may be improved survival with population-based screening. 14 Mr. Henry, as a former user of injection drugs, would have fallen into such a high-risk group. ...
... The control phase consisted of three four-month periods during which physician-directed diagnostic rapid opt-in HIV testing was performed 24-hours per day using only existing ED and hospital staff [23]. Consent was obtained directly by physicians and documented in the patient's medical record. ...
The Centers for Disease Control and Prevention recommends nontargeted opt-out HIV screening in healthcare settings. Cost effectiveness is critical when considering potential screening methods. Our goal was to compare programmatic costs of nontargeted opt-out rapid HIV screening with physician-directed diagnostic rapid HIV testing in an urban emergency department (ED) as part of the Denver ED HIV Opt-Out Trial.
This was a prospective cohort study nested in a larger quasi-experiment. Over 16 months, nontargeted rapid HIV screening (intervention) and diagnostic rapid HIV testing (control) were alternated in 4-month time blocks. During the intervention phase, patients were offered HIV testing using an opt-out approach during registration; during the control phase, physicians used a diagnostic approach to offer HIV testing to patients. Each method was fully integrated into ED operations. Direct program costs were determined using the perspective of the ED. Time-motion methodology was used to estimate personnel activity costs. Costs per patient newly-diagnosed with HIV infection by intervention phase, and incremental cost effectiveness ratios were calculated.
During the intervention phase, 28,043 eligible patients were included, 6,933 (25%) completed testing, and 15 (0.2%, 95% CI: 0.1%-0.4%) were newly-diagnosed with HIV infection. During the control phase, 29,925 eligible patients were included, 243 (0.8%) completed testing, and 4 (1.7%, 95% CI: 0.4%-4.2%) were newly-diagnosed with HIV infection. Total annualized costs for nontargeted screening were 31,355. The average costs per HIV diagnosis were 7,839, respectively. Nontargeted HIV screening identified 11 more HIV infections at an incremental cost of $10,693 per additional infection.
Compared to diagnostic testing, nontargeted HIV screening was more costly but identified more HIV infections. More effective and less costly testing strategies may be required to improve the identification of patients with undiagnosed HIV infection in the ED.
... To facilitate earlier detection of HIV infection, the Centers for Disease Control and Prevention (CDC) issued guidelines in 2006 recommending routine HIV screening of all adults ages 13-64 in all health care settings, including the emergency department (ED) [1]. Since the release of these guidelines, ED HIV testing has been shown to be feasible and acceptable across a spectrum of consent, testing, and patient selection strategies [2][3][4][5]. Patient satisfaction rates with ED HIV testing range from 80-90% [6][7][8][9][10][11]. ...
Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing.
In-depth interviews with fifty ED patients (28 accepters and 22 decliners of HIV testing) in three ED HIV testing programs that serve vulnerable urban populations in northern California.
Many factors influenced the decision to accept ED HIV testing, including curiosity, reassurance of negative status, convenience, and opportunity. Similarly, a number of factors influenced the decision to decline HIV testing, including having been tested recently, the perception of being at low risk for HIV infection due to monogamy, abstinence or condom use, and wanting to focus on the medical reason for the ED visit. Both accepters and decliners viewed ED HIV testing favorably and nearly all participants felt comfortable with the testing experience, including the absence of counseling. While many participants who declined an ED HIV test had logical reasons, some participants also made clear that they would prefer not to know their HIV status rather than face psychosocial consequences such as loss of trust in a relationship or disclosure of status in hospital or public health records.
Testing for HIV in the ED as for any other health problem reduces barriers to testing for some but not all patients. Patients who decline ED HIV testing may have rational reasons, but there are some patients who avoid HIV testing because of psychosocial ramifications. While ED HIV testing is generally acceptable, more targeted approaches to testing are necessary for this subgroup.
... More patients are newly diagnosed with HIV in the ED than in any other clinical setting, 11 and a substantial fraction of patients diagnosed with late-stage HIV visit the ED in preceding years. 12 As opposed to routine opt-out testing of all patients, 13 limited or ''targeted'' screening of high-risk patients, regardless of presenting symptoms, [14][15][16][17] may be even more cost-effective. Nevertheless, even targeted ED-based HIV screening programs have not been widely scaled up in the United States, partially because their long-term maintenance requires substantial resources. ...
Although targeted screening of patients at high risk for human immunodeficiency virus (HIV) infection in the emergency department (ED) improves patient outcomes and may prevent HIV transmission, ED-based screening programs incur additional costs and have thus not been widely scaled up. The objective of this study was to evaluate the cost-effectiveness of ED-based targeted HIV screening as implemented in actual practice.
This was a cost-utility analysis of a rapid HIV screening program in an urban ED. Physicians were encouraged to screen patients undergoing inpatient admission or who had HIV risk factors. The authors measured costs directly and estimated quality-adjusted life expectancy using chart review, literature assumptions, and mathematical modeling. Incremental cost utility was evaluated from a societal perspective using a lifetime time horizon.
From June 2008 through September 2009, a total of 3,766 HIV tests were ordered (235 tests per month), of which an estimated 2,406 (64%) represented screening in patients without HIV-related signs or symptoms. Nineteen (0.8%) patients were newly diagnosed through screening during the study period, of whom nine (47%) were eligible for antiretroviral therapy (ART) and maintained consistent outpatient follow-up. Estimated screening costs were 45.53 per screening test, of which 112 (95% uncertainty range [UR] = 225) and resulted in 2.71 quality-adjusted life-days gained (95% UR = 1.71 to 4.01). Cost-utility was most sensitive to the prevalence of undiagnosed HIV in the screened population.
Targeted HIV screening, as implemented in an urban ED, is cost saving and increases quality-adjusted life expectancy.
... It has been demonstrated that acceptance rates are greatest when HIV tests are offered by physicians, suggesting that acceptance rates may depend on who is offering screening. 2,13,14 In our study, optout screening was offered by registration staff and opt-in screening was offered by HIV testers. Patients may find it easier to decline screening offered by nonclinical registration staff than that offered by dedicated HIV testers. ...
We compare outcomes of opt-in and opt-out HIV screening approaches in an urban emergency department.
This was a 1-year prospective observational study comparing 2 6-month screening approaches. Eligibility for opt-in and opt-out screening was identical: aged 15 years or older, medically stable, and able to complete general consent. During the opt-in phase, triage nurses referred patients to HIV testers stationed at triage, who obtained separate opt-in written consent and performed rapid oral fluid tests. During the opt-out phase, registration staff conducted integrated opt-out consent and then referred patients to HIV testers. We assessed the proportion of potentially eligible patients who were offered screening (screening offer rate), the proportion offered screening who accepted (screening acceptance rate), the proportion who accepted screening and subsequently completed testing (test completion rate), and the proportion of potentially eligible patients who completed testing (overall screening rate) during each phase.
For the opt-in versus the opt-out phases, respectively, there were 23,236 potentially eligible patients versus 26,757, screening offer rate was 27.9% versus 75.8% (P<.001), screening acceptance rate was 62.7% versus 30.9% (P<.001), test completion rate was 99.8% versus 74.6% (P<.001), and overall screening rate was 17.4% versus 17.5% (P = .90).
A significantly higher proportion of patients were offered HIV screening with an opt-out approach at registration. However, this was offset by much higher screening acceptance and test completion rates with the opt-in approach at triage. Overall screening rates with the 2 approaches were nearly identical.
... Several emergency departments (EDs) have instituted risktargeted HIV testing (ie, testing is offered on the basis of behavioral risk factors or clinical symptoms). [1][2][3][4] Only 1 ED testing program has published data specific to individuals aged 18 years and younger. 5 Most of the EDs that offer routine HIV screening are in large urban areas that do not serve large rural catchment areas. ...
We determine the feasibility and yield of universal opt-out HIV screening among adolescents and adults in a southeastern emergency department (ED) serving a semiurban-semirural population.
Individuals aged 13 to 64 years who visited the ED during specified hours received the OraQuick rapid HIV test (administered by trained counselors) if they did not opt out. Western blot was used to confirm reactive results. Patients were excluded if they had a history of HIV, had been tested within the past year, were physically or mentally incapacitated, did not understand their right to opt out, or did not speak English or Spanish. Basic demographic information was analyzed by using standard descriptive statistics. Measures of diagnostic test performance were calculated for all valid tests.
From March 2008 through August 2009, 91% (n=8,493) of eligible patients accepted testing, and results were valid. Of 41 reactive results, 35 were confirmed HIV positive, 2 were indeterminate by Western blot, and 4 were false positive. Blacks accounted for the largest percentage (0.65%) of newly detected infections, and the percentage among black men (1%) was more than twice the percentage among black women (0.42%). Rapid-test specificity was estimated at 99.95% (95% confidence interval 99.88% to 99.98%). Nearly 75% of patients confirmed as HIV positive kept their first HIV clinic appointment.
High rates of acceptance of testing in an ED and linkage to HIV care for adolescents and adults with newly detected infection can be achieved by using opt-out testing and trained HIV counselors.
... Most HIV screening in EDs to date has been in higher-prevalence, urban, academic centers serving disadvantaged patient populations. 15,[17][18][19][20][21][22][23][24][25][26][27] Because HIV epidemiology mirrors typical patterns of health disparity, [28][29][30] undiagnosed HIV might be less common in EDs serving more affluent populations. Whether such settings have sufficient prevalence of undiagnosed HIV to warrant expanded screening is unknown. ...
Differences in the prevalence of undiagnosed HIV between different types of emergency departments (EDs) are not well understood. We seek to define missed opportunities for HIV diagnosis within 3 geographically proximate EDs serving different patient populations in a single metropolitan area.
For an urban academic, an urban community, and a suburban community ED located within 10 miles of one another, we reviewed visit records for a cohort of patients who received a new diagnosis of HIV between July 1999 and June 2003. Missed opportunities for earlier HIV diagnosis were defined as ED visits in the year before diagnosis, during which there was no documented ED HIV testing offer or test. Outcomes were the number of missed opportunity visits and the number of patients with a missed opportunity for each ED. We secondarily reviewed medical records for missed opportunity encounters, using an extensive list of indications that might conceivably trigger testing.
Among 276 patients with a new HIV diagnosis, 123 (44.5%) visited an ED in the year before diagnosis or received a diagnosis in the ED. The urban academic ED HIV testing program diagnosed 23 (8.3%) cases and offered testing to 24 (8.7%) patients who declined. Missed opportunities occurred during 187 visits made by 76 (27.5%) patients. These included 70 patients with 157 visits at the urban academic ED, 9 patients with 24 visits at the urban community ED, and 4 patients with 6 visits at the suburban community ED. Medical records were available for 172 of the 187 missed opportunity visits. Visits were characterized by the following potential testing indicators: HIV risk factors (58; 34%), related diagnosis indicating risk (7; 4%), AIDS-defining illness (8; 5%), physician suspicion of HIV (29; 17%), and nonspecific signs or symptoms of illness potentially consistent with HIV (126; 73%).
Geographically proximate EDs differ in their opportunities for earlier HIV diagnosis, but all 3 sites had missed opportunities. Many ED patients with undiagnosed HIV have potential indications for testing documented even in the absence of a dedicated risk assessment, although most of these are nonspecific signs or symptoms of illness that may not be clinically useful selection criteria.
... Linkage to care models have been mostly homegrown, small single-site efforts at large medical centers closely co-located with HIV testing facilities. Some of these models from large medical centers with emergency room testing and a nearby HIV clinic have shown impressive rates of linkage to care within a few months, often exceeding 85%7891011. However, there is still an urgent need to evaluate linkage models that connect clients to HIV care from testing locations outside of HIV medical care settings. ...
Implementation of linkage to HIV care programs in the U.S. is poorly described in the literature despite the central role of these programs in delivering clients from HIV testing facilities to clinical care sites. Models demonstrating success in linking clients to HIV care from testing locations that do not have co-located medical care are especially needed.
Data from the Antiretroviral Treatment Access Studies-II project ('ARTAS-II') as well as site visit and project director reports were used to describe structural factors and best practices found in successful linkage to care programs. Successful programs were able to identify recently diagnosed HIV-positive persons and ensure that a high percentage of persons attended an initial HIV primary care provider visit within six months of enrolling in the linkage program.
Eight categories of best practices are described, supplemented by examples from 5 of 10 ARTAS-II sites. These five sites highlighted in the best practices enrolled a total of 352 HIV+ clients and averaged 85% linked to care after six months. The other five grantees enrolled 274 clients and averaged 72% linked to care after six months. Sites with co-located HIV primary medical care services had higher linkage to care rates than non-co-located sites (87% vs. 73%). Five grantees continued linkage to care activities in some capacity after project funding ended.
With the push to expand HIV testing in all U.S. communities, implementation and evaluation of linkage to care programs is needed to maximize the benefits of expanded HIV testing efforts.
... Such findings are informative for HIV testing initiatives, and alternative means of minimizing these barriers have been explored both in our program 33,34 and others. 10,[35][36][37][38] Alternative models for delivering HIV testing in EDs that have been explored recently include provision of dedicated HIV testing facilitators, which would essentially eliminate ED providers' concern over time, paper work, manpower, and testing procedures. [13][14][15][16]39 Drawbacks of that approach, however, are the requirement for dedicated sustainable funding from the public or private sector to hire additional staff and the need for a separate parallel operational program. ...
The objectives were to determine attitudes and perceptions (A&P) of emergency medicine (EM) residents toward emergency department (ED) routine provider-driven rapid HIV testing services and the impact of both a focused training program (FTP) and implementation of HIV testing on A&P.
A three-phase, consecutive, anonymous, identity-unlinked survey was conducted pre-FTP, post-FTP, and 6 months postimplementation. The survey was designed to assess residents' A&P using a five-point Likert scale. A preimplementation FTP provided both the rationale for the HIV testing program and the planned operational details of the intervention. The HIV testing program used only indigenous ED staff to deliver HIV testing as part of standard-of-care in an academic ED. The impact of the FTP and implementation on A&P were analyzed by multivariate regression analysis using generalized estimating equations to control for repeated measurements in the same individuals. A "favorable" A&P was operationally defined as a mean score of >3.5, "neutral" as mean score of 2.5 to 3.5, and "unfavorable" as mean score of <2.5.
Thirty of 36 residents (83.3%) participated in all three phases. Areas of favorable A&P found in phase I and sustained through phases II and III included "ED serving as a testing venue" (score range = 3.7-4.1) and "emergency medicine physicians offering the test" (score range = 3.9-4.1). Areas of unfavorable and neutral A&P identified in phase I were all operational barriers and included required paperwork (score = 3.2), inadequate staff support (score = 2.2), counseling and referral requirements (score range = 2.2-3.1), and time requirements (score = 2.9). Following the FTP, significant increases in favorable A&P were observed with regard to impact of the intervention on modification of patient risk behaviors, decrease in rates of HIV transmission, availability of support staff, and self-confidence in counseling and referral (p < 0.05). At 6 months postimplementation, all A&P except for time requirements and lack of support staff scored favorably or neutral. During the study period, 388 patients were consented for and received HIV testing; six (1.5%) were newly confirmed HIV positive.
Emergency medicine residents conceptually supported HIV testing services. Most A&P were favorably influenced by both the FTP and the implementation. All areas of negative A&P involved operational requirements, which may have influenced the low overall uptake of HIV testing during the study period.
... Only 73 patients were tested by ED staff outside of routine testing hours, which supports other findings illustrating that reliance on existing ED staff may result in low levels of testing. 8 Furthermore, studies using existing staff to perform testing have lower percentages of persons accepting testing actually tested due to the time constraints, limited staff, and other priorities. 13,19 Of those completing the risk assessment, few (2%-3%) were considered at high risk for infection. ...
The objective was to assess the acceptance of an emergency department (ED) human immunodeficiency virus (HIV) screening program based on the Centers for Disease Control and Prevention (CDC) recommendations for routine HIV screening in health care settings.
Rapid HIV screening was offered on an opt-out basis to patients aged 13 to 64 years presenting to the ED by trained HIV counselors. Patients were excluded if they had a history of HIV, were physically or mentally incapacitated, did not understand their right to opt-out, or did not speak English or Spanish. Statistical analyses, including logistic regression, were performed to assess the associations between the demographics of patients offered testing and their test acceptance or refusal.
From March 2008 to January 2009, a total of 5,080 (91%) of the 5,585 patients offered the HIV test accepted, and 506 (9%) refused. White and married patients were less likely to accept testing than those who were African American and unmarried (p < 0.001). Adult patients were almost twice as likely to accept testing as pediatric patients (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.50 to 2.53). As age increased among pediatric patients, testing refusal decreased (OR = 0.71; 95% CI = 0.59 to 0.85), and as age increased among adult patients, testing refusal increased (OR = 1.17; 95% CI = 1.12 to 1.22). Two percent of persons accepting the test were considered high risk. Males were more likely to report high-risk behavior than females (OR = 1.83; 95% CI = 1.23 to 2.72).
The opt-out approach results in high acceptance of routine HIV screening. Widespread adoption of the CDC's recommendations, although feasible, will require significant increases in resources.
Objective
To identify innovation and implementation determinants of HIV testing, diagnosis, and linkage-to-care in the U.S.
Data sources and study setting
Between November 2020 and January 2022, a broad search strategy was employed in three literature databases: Ovid MEDLINE, PsycINFO, and Web of Science.
Study design
A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.
Data collection/extraction methods
A team of master’s and Ph.D.-level researchers screened eligible studies against the inclusion criteria and extracted the data using COVIDENCE software in pairs with consensus performed by a senior member of the team. Barriers and facilitators were extracted and analyzed according to the Consolidated Framework for Implementation Research (CFIR). Frequency of determinants across studies was mapped according to CFIR, valence, study design, delivery setting, unit of analysis, population of interest, region of the U.S., and year.
Results
We identified 1,739 implementation and innovation determinants from 186 articles. Most determinants were for HIV testing rather than linkage-to-care. Most determinants were identified in the inner setting and individuals domains of CFIR, with the fewest identified in the process and innovations domains. Determinants of providers were only slightly more frequently identified than determinants of recipients. However, determinants of organizations and systems were rarely identified.
Conclusion
This review provides a synthesis of innovation and implementation determinants of HIV testing and linkage-to-care using the most-cited implementation science (IS) framework, CFIR. This synthesis enables the larger field of HIV science to utilize IS in efforts to end the HIV epidemic and positions IS to consider the application of IS frameworks to fields like HIV.
Purpose of review
Improving HIV testing uptake is essential to ending the HIV pandemic. HIV testing approaches can be opt-in, opt-out or risk-based. This systematic review examines and compares the uptake of HIV testing in opt-in, opt-out and risk-based testing approaches.
Recent findings
There remains missed opportunities for HIV testing in a variety of settings using different approaches: opt-in (a person actively accepts to be tested for HIV), opt-out (a person is informed that HIV testing is routine/standard of care, and they actively decline if they do not wish to be tested for HIV) or risk-based (using risk-based screening tools to focus testing on certain individuals or sub-populations at greater risk of HIV). It is not clear how the approach could impact HIV test uptake when adjusted for other factors (e.g. rapid testing, country-income level, test setting and population tested).
Summary
We searched four databases for studies reporting on HIV test uptake. In total, 18,238 records were screened, and 150 studies were included in the review. Most studies described an opt-in approach (87 estimates), followed by opt-out (76) and risk-based (19). Opt-out testing was associated with 64.3% test uptake ( I 2 =99.9%), opt-in testing with 59.8% ( I 2 =99.9%), and risk-based testing with 54.4% ( I 2 =99.9%). When adjusted for settings that offered rapid testing, country income level, setting and population tested, opt-out testing had a significantly higher uptake (+12% (95% confidence intervals: 3-21), p =0.007) than opt-in testing. We also found that emergency department patients and hospital outpatients had significantly lower HIV test uptake than other populations.
Background: Human immunodeficiency virus (HIV) infection continues to expand worldwide and a significant proportion of infection is still undiagnosed. Recent studies have addressed the impact and feasibility of 'opt-out' HIV screening in Emergency Departments (EDs) in urban settings at high HIV prevalence, whereas little is known about the yield of implementing 'targeted' HIV testing especially in low-prevalence areas.
Objective: The present study undertakes a scoping review of research carried out on the implementation of targeted HIV screening in adult EDs to determine the impact, feasibility and acceptability of HIV testing in different HIV prevalence settings.
Design: Online databases (EMBASE, MEDLINE) were used to identify papers published between 2000 to 2020. A threeconcept search was employed with HIV (HIV, Human immunodeficiency virus infection, HIV infections), targeted testing (Target, screening or testing) and emergency medicine (Emergency Service, emergency ward, A&E, accident and emergency or Emergency Department) (28th February 2020). Only full-text articles written in English, French, Spanish or Italian and using impact and/or feasibility and/or acceptability of the program as primary or secondary outcomes were analysed.
Results: The search returned 416 articles. Of these, 12 met inclusion criteria and were included in the final review. Most of the included studies were carried out in the United States (n=8; 67%) and in areas of high HIV prevalence (n=11; 92%). Three (20%) were randomized control studies. While the rate of newly diagnosed HIV cases varied widely (0.03-2.2%), likely due to methodological heterogeneity between studies, the linkage of new HIV diagnosis was often high (80-100%) and median CD4+ cell count was always greater than 200 cells per microliter. Targeted HIV screening was found to be cost-effective (out of 2 studies) and well accepted by participants (out 2 studies).
Conclusions: Targeted HIV screening at the ED can be impactful, feasible and well accepted, but often requires extra funding and staff. Most previous work has focused on areas of high disease prevalence.
Keywords: HIV; early diagnosis; emergency department; low-prevalence areas; public health; targeted screening.
One of the four national HIV prevention goals is to incorporate combinations of effective, evidence-based approaches to prevent HIV infection. In fields of public health, techniques that alter environment and affect choice options are effective. Structural approaches may be effective in preventing HIV infection. Existing frameworks for structural interventions were lacking in breadth and/or depth. We conducted a systematic review and searched CDC’s HIV/AIDS Prevention Research Synthesis Project’s database for relevant interventions during 1988–2013. We used an iterative process to develop the taxonomy. We identified 213 structural interventions: Access (65%), Policy/Procedure (32%), Mass Media (29%), Physical Structure (27%), Capacity Building (24%), Community Mobilization (9%), and Social Determinants of Health (8%). Forty percent targeted high-risk populations (e.g., people who inject drugs [12%]). This paper describes a comprehensive, well-defined taxonomy of structural interventions with 7 categories and 20 subcategories. The taxonomy accommodated all interventions identified.
Background:
An increasing number of U.S. emergency departments (EDs) have implemented ED-based HIV testing programs since the Centers for Disease Control and Prevention issued revised HIV testing recommendations for clinical settings in 2006. In 2010, the National HIV/AIDS Strategy (NHAS) set an linkage-to-care (LTC) rate goal of 85% within 90 days of HIV diagnosis. LTC rates for newly diagnosed HIV-infected patients vary markedly by site, and many are suboptimal. The optimal approach for LTC in the ED setting remains unknown.
Objective:
The objective was to perform a brief descriptive analysis of the LTC methods practiced in EDs across the United States to determine the overall linkage rate of ED-based HIV testing programs.
Methods:
We conducted a systematic review of literature related to U.S. ED HIV testing in the adult population using PubMed, Embase, Web of Science, Scopus, and Cochrane. There were 333 articles were identified; 31 articles were selected after a multiphasic screening process. We analyzed data from the 31 articles to assess LTC methods and rates. LTC methods that involved physical escort of the newly diagnosed patient to an HIV/infectious disease (ID) clinic or interaction with a specialist health care provider at the ED were operationally defined as "intensive" LTC protocol. "Mixed" LTC protocol was defined as a program that employed intensive linkage only part of the coverage hours. All other forms of linkage was defined as "nonintensive" LTC protocol. An LTC rate of ≥85% was used to identify characteristics of ED-based HIV testing program associated with a higher LTC rate.
Results:
There were 37 ED-based HIV testing programs in the 31 articles. The overall LTC rate was 74.4%. Regarding type of protocol, nine (24.3%) employed intensive LTC protocols, 25 (67.6%) nonintensive, two (5.4%) mixed, and one (2.7%) with unclear protocols. LTC rates for programs with intensive and nonintensive LTC protocols were 80.0 and 72.7%, respectively. Four (44.4%) with intensive protocols and nine (36.0%) with the nonintensive protocols had LTC rates > 85%. The linkage staff employed was different between ED programs. Among them, 25 (67.6%) programs used exogenous staff, 10 (27.0%) used the ED staff, and two had no information. All the programs in the nonintensive group utilized drop-in HIV/ID clinic or medical appointments while seven of nine of the programs in the intensive group physically escorted the patients to the initial medical intake appointment. There were no significant differences in characteristics of ED-based HIV testing programs between those with ≥85% LTC rate versus those with <85% within the intensive or nonintensive group.
Conclusion:
Intensive LTC protocols had a higher LTC rate and a higher proportion of programs that surpassed the >85% NHAS goal compared to nonintensive methods, suggesting that, when possible, ED-based HIV testing programs should adopt intensive LTC strategies to improve LTC outcomes. However, intensive LTC protocols most often required involvement of multidisciplinary non-ED professionals and external research funding. Our findings provide a foundation for developing best practices for ED-based HIV LTC programs.
How you ask is a critical part of the process
Worldwide, approximately 37 million people are infected with HIV and approximately 46% of infections remain undiagnosed.1 The proportion of undiagnosed cases is lower in industrialized countries, although the burden of people living with undiagnosed infection remains substantial. For example, approximately 13% of the 1.2 million people living with HIV in the United States do not have a diagnosis.2 Moreover, people without a diagnosis contribute disproportionately to transmission of the virus, accounting for about 30% of HIV transmissions.3
Testing for HIV infection remains a critical first step in a series of interventions aimed at controlling the epidemic.4 People who test positive for HIV can then engage in care and attain viral suppression, which dramatically limits the possibility of forward transmission.5 Besides knowing who should be offered HIV testing, maximizing acceptance when HIV testing is offered is a vital piece of the process and may significantly …
HIV-testing algorithms for preexposure prophylaxis (PrEP) should be optimized to minimize the risk of drug resistance, the
time off PrEP required to evaluate false-positive screening results, and costs and to expedite the start of therapy for those
confirmed to be infected. HIV rapid tests (RTs) for anti-HIV antibodies provide results in less than 1 h and can be conducted
by nonlicensed staff at the point of care. In many regions, Western blot (WB) testing is required to confirm reactive RT results.
WB testing, however, causes delays in diagnosis and adds expense. The iPrEx study evaluated the safety and efficacy of daily
oral emtricitabine-tenofovir disoproxil fumarate among HIV-seronegative men and transgender women who have sex with men: HIV
infection was assessed with two RTs plus WB confirmation, followed by HIV-1 plasma viral load testing. During the iPrEx study,
there were 51,260 HIV status evaluations among 2,499 volunteers using RTs: 142 (0.28%) had concordant positive results (100%
were eventually confirmed) and 19 (0.04%) had discordant results among 14 participants; 11 were eventually determined to be
HIV infected. A streamlined approach using only one RT to screen and a second RT to confirm (without WB) would have had nearly
the same accuracy. Discrepant RT results are best evaluated with nucleic acid testing, which would also increase sensitivity.
Study objective:
A clinical prediction tool, the Denver HIV Risk Score, was recently developed to help identify patients with increased probability of undiagnosed HIV infection. Our goal was to compare targeted rapid HIV screening using the Denver HIV Risk Score to nontargeted rapid HIV screening in an urban emergency department (ED) and urgent care.
Methods:
We used a prospective, before-after design at an urban medical center with an approximate annual census of 110,000 visits. Patients aged 13 years or older were eligible for screening. Targeted HIV screening of patients identified as high-risk by nurses using the Denver HIV Risk Score during medical screening was compared to nontargeted HIV screening offered by medical screening nurses during 2 separate 4-month time periods. The primary outcome was newly diagnosed HIV-infected patients.
Results:
28,506 patients presented during the targeted phase, 1,718 were identified as high-risk, and 551 completed HIV testing. Of these, 7 (1.3%, 95% confidence interval [CI] 0.5% to 2.6%) were newly diagnosed with HIV infection. 29,510 patients presented during the nontargeted phase and 3,591 completed HIV testing. Of these, 7 (0.2%, 95% CI 0.1% to 0.4%) were newly diagnosed with HIV infection. Targeted HIV screening was significantly associated with identification of newly diagnosed HIV infection when compared to nontargeted screening, adjusting for patient demographics and payer status (relative risk [RR] 10.4, 95% CI 3.4 to 32.0).
Conclusion:
Targeted HIV screening using the Denver HIV Risk Score was strongly associated with new HIV diagnoses when compared to nontargeted screening. Although both HIV screening methods identified the same absolute number of newly diagnosed patients, significantly fewer tests were required during the targeted phase to achieve the same effect.
Casual review of existing literature reveals a multitude of individualized approaches to emergency department (ED) HIV testing. Cataloging the operational options of each approach could assist translation by disseminating existing knowledge, endorsing variability as a means to address testing barriers, and laying a foundation for future work in the area of operational models and outcomes investigation. The objective of this study is to provide a detailed account of the various models and operational constructs that have been described for performing HIV testing in EDs.
Systematic review of PUBMED, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Web of Science through February 6, 2009 was performed. Three investigators independently reviewed all potential abstracts and identified all studies that met the following criteria for inclusion: original research, performance of HIV testing in an ED in the United States, description of operational methods, and reporting of specific testing outcomes. Each study was independently assessed and data from each were abstracted with standardized instruments. Summary and pooled descriptive statistics were reported by using recently published nomenclature and definitions for ED HIV testing.
The primary search yielded 947 potential studies, of which 25 (3%) were included in the final analysis. Of the 25 included studies, 13 (52%) reported results using nontargeted screening as the only patient selection method. Most programs reported using voluntary, opt-in consent and separate, signed consent forms. A variety of assays and communication methods were used, but relatively limited outcomes data were reported.
Currently, limited evidence exists to inform HIV testing practices in EDs. There appears to be recent progression toward the use of rapid assays and nontargeted patient selection methods, with the rate at which reports are published in the peer-reviewed literature increasing. Additional research will be required, including controlled clinical trials, more structured program evaluation, and a focus on an expanded profile of outcome measures, to further improve our understanding of which HIV testing methods are most effective in the ED.
Various HIV testing models have been described, but widespread implementation has lagged. We describe a clinical HIV testing program notable for its use of conventional (nonrapid) assays, native hospital personnel, and an electronic system to aid targeted patient selection.
Clinical HIV testing program records and hospital emergency department (ED) and laboratory records were reviewed and linked for the period from January 2007 until November 5, 2008.
There were 103,475 visits to the ED, for which 1,258 (1.2%) resulted in HIV testing, and 54 (4.3%) were positive for HIV antibody. Result notification was successful for 52 (96%) individuals with positive test results. After reporting to the health department, it was determined that 28 (2.2%) individuals had received a new diagnosis, of whom 89% were linked with care. Mean baseline CD4 counts for new diagnoses for periods 1 through 3, respectively, were (1) unavailable, (2) 138 cells/μL (95% confidence interval [CI] 34 to 242 cells/μL), and (3) 222 cells/μL (95% CI 119 to 325 cells/μL). Overall, mean calculated to be 180 cells/μL (95% CI 16 to 345 cells/μL).
This ED HIV testing model successfully expanded new patient identification, result notification, and linkage to care. Although this effort falls short of Centers for Disease Control and Prevention recommendations, the model can be implemented widely without external funding for parallel staffing or rapid assays.
We implement an opt-out routine screening program in a high-volume, urban emergency department (ED), using conventional (nonrapid) technology as an alternative to rapid HIV tests.
We performed a retrospective cohort study. Since October 2008, all patients who visited Ben Taub General Hospital ED and had blood drawn were considered eligible for routine opt-out HIV screening. The hospital is a large, publicly funded, urban, academic hospital in Houston, TX. The ED treats approximately 8,000 patients monthly. Screening was performed with standard chemiluminescence technology, batched hourly. Patients with positive screening test results were informed of their likely status, counseled by a service linkage worker, and offered follow-up care at an HIV primary care clinic. Confirmatory Western blot assays were automatically performed on all new HIV-positive samples.
Between October 1, 2008, and April 30, 2009, 14,093 HIV tests were performed and 39 patients (0.3%) opted out. Two hundred sixty-two (1.9%) HIV test results were positive and 80 new diagnoses were made, for an incidence of new diagnoses of 0.6%. There were 22 false-positive chemiluminescence results and 7 indeterminate Western blot results. Nearly half the patients who received a new diagnosis were not successfully linked to HIV care in our system.
Opt-out screening using standard nonrapid technology, rather than rapid testing, is feasible in a busy urban ED. This method of HIV screening has cost benefits and a low false-positivity rate, but aggressive follow-up and referral of patients with new diagnoses for linkage to care is required.
We describe electronic medical record use in automated eligibility determination for an emergency department (ED)-based nontargeted HIV screening program.
We reviewed the electronic medical record system at an urban, inner-city ED from March 17 to April 14, 2008. During that period, patient eligibility for HIV screening was electronically determined according to preprogrammed criteria: (1) age between 18 and 64 years; (2) no known history of HIV disease; and (3) no known HIV screening in the previous year. This populated an electronic work list used by HIV testing counselors.
Of 8,489 ED patients during the study period, the electronic medical record system determined 5,794 (68.3%) as eligible. Of 1,484 (25.6%) patients approached for screening, 1,121 (75.5%) consented, and 5 received confirmed positive results (0.4%). Reasons for ineligibility, as determined by the electronic medical record system, were previous screening 1,125 (41.7%), age 890 (33.0%), known HIV 111 (4.1%), and reason unknown 569 (21.1%).
Clinical informatics solutions can provide automated delineation of ED subpopulations eligible for HIV screening, according to predetermined criteria, which could increase program efficiency and might accelerate integration of HIV screening into clinical practice.
We compare the outcomes and costs of alternative staffing models for an emergency department (ED) rapid HIV testing program.
A rapid oral-fluid HIV testing program was instituted in an inner-city ED in 2005. Three staffing models were compared during 24.5 months: indigenous medical staff only, exogenous staff only, or exogenous staff plus medical staff (hybrid). Personnel obtained written consent and provided brief pretest counseling, obtained kits, collected specimens, returned specimens to the ED satellite laboratory, and performed posttest counseling and referral to care. Cost analysis was performed to estimate cost per patient tested and cost per patient linked to care.
Overall, 44 of 2,958 (1.5%) patients tested received confirmed positive results and 30 (68%) were linked to care. The exogenous staff only model yielded the highest number tested per month (587), and indigenous medical staff only yielded the lowest (57). Significantly higher positivity rates were found in both indigenous medical staff only (2.2%) and hybrid (2.0%) models versus the exogenous staff only model (0.6%) (prevalence rate ratio: 3.7 [95% confidence interval {CI}1.5 to 9.3] versus 3.4 [95% CI 1.5 to 7.8], respectively). All patients with confirmed positive results were linked to care in the indigenous medical staff only model but only approximately 60% were linked to care in the 2 other models (linked to care rate ratio versus exogenous staff only: 1.8 [95% CI 1.1 to 4.4]; versus hybrid: 1.7 [95% CI 1.2 to 2.5]). The indigenous medical staff only model had the highest cost (87) and the exogenous staff only (4,937) per patient linked to care, followed by the hybrid (11,454).
The exogenous staff only model tested the most patients at the least cost per patient tested. The indigenous medical staff only model identified the fewest patients with unrecognized HIV infection and had the highest cost per patient tested but the lowest cost per patient linked to care.
We present findings from a multisite evaluation that systematically compares HIV screening programs in 6 emergency departments (EDs).
From 2007 to 2008, we collected previous-year data on structural factors, process attributes, testing outcomes, and cost-effectiveness from 6 ED HIV testing programs operating for 6 months or longer. We administered questionnaires to program directors, conducted site visits, and interviewed key informants.
HIV care providers (n=3 sites), emergency physicians (n=2), or health departments (n=1) initiated the testing programs. ED leadership and providers helped design and implement the programs (n=5), and emergency physicians or administrators provided daily oversight (n=5). Testing strategies included targeted (patients selected from at-risk populations; n=2), nontargeted (patients selected without regard to risk or intention of testing all; n=3), and universal (all patients selected; n=1) screening. Testing was conducted by supplemental staff (n=4) and existing hospital staff (n=2). ED testing programs were funded by grants (n=3), city HIV prevention/care budgets (n=2), or the hospital (n=1). The median percentage of census tested was 4.7% (range 2.1% to 8.4%). The median rate of preliminary positive test results was 1.2% (range 1.0% to 7.3%). The median confirmed new HIV diagnosis rate was 0.9% (range 0.8% to 6.4%). The median linkage to care rate was 92.0% (range 50% to 100%). The median cost per patient receiving a new diagnosis and linked to care was 3,400 to $12,300).
Although structure and process of screening programs varied across EDs, outcomes were similar, which suggests that with current ED environments, testing methods, and resources available, the capacity and structure to increase testing in EDs has limits. These ED HIV screening programs were cost-effective according to standard thresholds.
A 'test and treat' strategy to reduce HIV transmission hinges on linking and retaining HIV patients in care to achieve the full benefit of antiretroviral therapy. We integrated empirical findings and estimated the percentage of HIV-positive persons in the United States who entered HIV medical care soon after their diagnosis; and were retained in care during specified assessment intervals.
We comprehensively searched databases and bibliographic lists to identify studies that collected data from May 1995 through 2009. Separate meta-analyses were conducted for entry into care and retention in care (having multiple HIV medical visits during specified assessment intervals) stratified by methodological variables. All analyses used random-effects models.
Overall, 69% [95% confidence interval (CI) 66-71%, N = 53 323, 28 findings] of HIV-diagnosed persons in the United States entered HIV medical care averaged across time intervals in the studies. Seventy-two percent (95% CI 67-77%, N = 6586, 12 findings) entered care within 4 months of diagnosis. Seventy-six percent (95% CI 66-84%, N = 561, 15 findings) entered care after testing HIV-positive in emergency/urgent care departments and 67% (95% CI 64-70%, N = 52 762, 13 findings) entered care when testing was done in community locations. With respect to retention in care, 59% (95% CI 53-65%, N = 75 655, 28 findings) had multiple HIV medical care visits averaged across assessment intervals of 6 months to 3-5 years. Retention was lower during longer assessment intervals.
Entry and retention in HIV medical care in the United States are moderately high. Improvement in both outcomes will increase the success of a test and treat strategy.
The Centers for Disease Control and Prevention recommends routine HIV screening for adults.
Community-based participatory research incorporates subjects in the design and conduct of research. We included nurses and physicians in the implementation of HIV rapid test use in the emergency department (ED). We explored the process, facilitators, and barriers.
We identified clinical champions and trained staff. Physicians obtained consent and ordered HIV testing; nurses performed rapid testing. Testing rates were tracked by electronic medical record. We conducted regular meetings between staff and researchers. Semistructured qualitative interviews with providers were conducted at 3 months.
By week 15, we administered 121 tests. After the eligibility protocol evolved to incorporate ED nursing concerns regarding staffing limitations from a random sampling model to one focused on testing during nonpeak hours, the weekly number of tests increased. Eighteen percent of providers favored nontargeted HIV screening, 27% favored the current model of testing at nonpeak hours, 32% supported diagnostic testing, and 18% favored no testing or "other." Barriers include written consent, electronic documentation, time constraints, and belief that screening is not a core ED duty. Facilitators include ease of test administration, belief that ED patients are at higher risk, and flexibility to tailor screening efforts according to patient volume.
The ED-based HIV testing is feasible within a Veterans Hospital Administration setting. Involvement of nursing in a community-based participatory research implementation model may facilitate staff acceptance of nontargeted HIV screening and be a mechanism to initiate administration of clinical preventive services to ED patients with limited primary care contact.
The Centers for Disease Control and Prevention (CDC) recommends routine (nontargeted) opt-out HIV screening in health care settings, including emergency departments (EDs), where the prevalence of undiagnosed infection is 0.1% or greater. The utility of this approach in EDs remains unknown.
To determine whether nontargeted opt-out rapid HIV screening in the ED was associated with identification of more patients with newly diagnosed HIV infection than physician-directed diagnostic rapid HIV testing.
Quasi-experimental equivalent time-samples design in an urban public safety-net hospital with an approximate annual ED census of 55,000 patient visits. Patients were 16 years or older and capable of providing consent for rapid HIV testing.
Nontargeted opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing alternated in sequential 4-month time intervals between April 15, 2007, and April 15, 2009.
Number of patients with newly identified HIV infection and the association between nontargeted opt-out rapid HIV screening and identification of HIV infection.
In the opt-out phase, of 28,043 eligible ED patients, 6933 patients (25%) completed HIV testing (6702 patients were screened; 231 patients were diagnostically tested). Ten of 6702 patients (0.15%; 95% CI, 0.07%-0.27%) who did not decline HIV screening in the opt-out phase had new HIV diagnoses, and 5 of 231 patients (2.2%; 95% CI, 0.7%-5.0%) who were diagnostically tested during the opt-out phase had new HIV diagnoses. In the diagnostic phase, of 29,925 eligible patients, 243 (0.8%) completed HIV testing. Of these, 4 patients (1.6%; 95% CI, 0.5%-4.2%) had new diagnoses. The prevalence of new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 15 in 28,043 (0.05%; 95% CI, 0.03%-0.09%) and 4 in 29,925 (0.01%; 95% CI, 0.004%-0.03%), respectively. Nontargeted opt-out HIV screening was independently associated with new HIV diagnoses (risk ratio, 3.6; 95% CI, 1.2-10.8) when adjusting for patient demographics, insurance status, and whether diagnostic testing was performed in the opt-out phase. The median CD4 cell count for those with new HIV diagnoses in the opt-out phase (including those diagnostically tested) and in the diagnostic phase was 69/microL (IQR, 17-430) and 13/microL (IQR, 11-15) , respectively (P = .02).
Nontargeted opt-out rapid HIV screening in the ED, vs diagnostic testing, was associated with identification of a modestly increased number of patients with new HIV diagnoses, most of whom were identified late in the course of disease.
The US Centers for Disease Control and Prevention (CDC) guidelines and the World Health Organization (WHO) both recommend HIV testing in health-care settings. However, neither organization provides prescriptive details regarding how these recommendations should be adapted into clinical practice in an emergency department.
We have implemented an HIV-testing program in the ED of a major academic medical center within the scope of the Universal Screening for HIV Infection in the Emergency Room (USHER) Trial-a randomized clinical trial evaluating the feasibility and cost-effectiveness of HIV screening in this setting.
Drawing on our collective experiences in establishing programs domestically and internationally, we offer a practical framework of lessons learned so that others poised to embark on such HIV testing programs may benefit from our experiences.
In the context of a randomized controlled trial (RCT) on HIV testing in the emergency department (ED) setting, we evaluated preferences for survey modality and data quality arising from each modality.
Enrolled participants were offered the choice of answering a survey via audio computer assisted self-interview (ACASI) or pen and paper self-administered questionnaire (SAQ). We evaluated factors influencing choice of survey modality. We defined unusable data for a particular survey domain as answering fewer than 75% of the questions in the domain. We then compared ACASI and SAQ with respect to unusable data for domains that address sensitive topics.
Of 758 enrolled ED patients, 218 (29%) chose ACASI, 343 chose SAQ (45%) and 197 (26%) opted not to complete either. Results of the log-binomial regression indicated that older (RR = 1.08 per decade) and less educated participants (RR = 1.25) were more likely to choose SAQ over ACASI. ACASI yielded substantially less unusable data than SAQ.
In the ED setting there may be a tradeoff between increased participation with SAQ versus better data quality with ACASI. Future studies of novel approaches to maximize the use of ACASI in the ED setting are needed.
Although whole blood rapid HIV testing has a greater sensitivity and specificity compared with oral fluid (OF) testing, patients prefer HIV testing using OF specimen collection. Whether patient preference for noninvasive collection methods affects acceptance of HIV screening in clinical practice, however, is unknown.
To determine whether patient acceptance of fingerstick whole blood (FWB) and OF rapid HIV screening differs in an emergency department setting.
From May 1 to June 30, 2007, triage-based testers offered rapid HIV screening to patients. OF and FWB tests were available on alternate days. Eligible patients were medically stable, > or =15 years of age, and not known to be HIV infected.
: Two thousand two hundred one patients were referred for HIV screening: 1089 on OF days and 1112 on FWB screening days. Screening rates with OF and FWB were similar (61.9% vs. 59.1%, P = 0.18). Although most reasons why patients declined screening were similar for the groups, the specimen collection method was the primary reason for refusal by 25 patients who declined FWB screening compared with none of the patients who declined OF screening.
Among emergency department patients, the preference for 1 rapid test collection modality over another has a minimal effect on actual screening rates.
Although national guidelines recommend universal human immunodeficiency virus (HIV) testing, emergency departments (EDs) may choose to limit testing to certain patients, such as those triaged to urgent care (UC).
To compare the results of rapid HIV testing in an urban ED with an affiliated UC.
This was a retrospective analysis of an HIV testing program that included screening, which was initiated by triage nurses, and diagnostic testing, which was initiated by clinicians. Eligible patients were ≥ 12 years old and medically stable.
From April 2005 through December 2006, HIV tests were completed in 6196 (8.3%) of the 74,331 ED visits and 3256 (8.8%) of the 37,169 UC visits. Screening accounted for 5009 (80.8%) of the ED tests and 2914 (89.5%) of the UC tests, and diagnostic testing accounted for the remainder. Eighty (1.3%) of the ED tests and 21 (0.6%) of the UC tests were positive (p = 0.0024). Compared with newly diagnosed HIV-positive ED patients, HIV-positive UC patients were less likely to have CD4 counts < 200 cells/μL (adjusted odds ratio 0.19, 95% confidence interval 0.05-0.65).
Although the yield of HIV testing is greater among ED patients, UC patients are diagnosed at a less advanced stage of illness.
We examined the influence of viral load in relation to other risk factors for the heterosexual transmission of human immunodeficiency virus type 1 (HIV-1). In a community-based study of 15,127 persons in a rural district of Uganda, we identified 415 couples in which one partner was HIV-1-positive and one was initially HIV-1-negative and followed them prospectively for up to 30 months. The incidence of HIV-1 infection per 100 person-years among the initially seronegative partners was examined in relation to behavioral and biologic variables.
The male partner was HIV-1-positive in 228 couples, and the female partner was HIV-1-positive in 187 couples. Ninety of the 415 initially HIV-1-negative partners seroconverted (incidence, 11.8 per 100 person-years). The rate of male-to-female transmission was not significantly different from the rate of female-to-male transmission (12.0 per 100 person-years vs. 11.6 per 100 person-years). The incidence of seroconversion was highest among the partners who were 15 to 19 years of age (15.3 per 100 person-years). The incidence was 16.7 per 100 person-years among 137 uncircumcised male partners, whereas there were no seroconversions among the 50 circumcised male partners (P<0.001). The mean serum HIV-1 RNA level was significantly higher among HIV-1-positive subjects whose partners seroconverted than among those whose partners did not seroconvert (90,254 copies per milliliter vs. 38,029 copies per milliliter, P=0.01). There were no instances of transmission among the 51 subjects with serum HIV-1 RNA levels of less than 1500 copies per milliliter; there was a significant dose-response relation of increased transmission with increasing viral load. In multivariate analyses of log-transformed HIV-1 RNA levels, each log increment in the viral load was associated with a rate ratio of 2.45 for seroconversion (95 percent confidence interval, 1.85 to 3.26).
The viral load is the chief predictor of the risk of heterosexual transmission of HIV-1, and transmission is rare among persons with levels of less than 1500 copies of HIV-1 RNA per milliliter.
Many HIV-infected persons learn about their diagnosis years after initial infection. The extent to which missed opportunities for HIV testing occur in medical evaluations prior to one's HIV diagnosis is not known.
We performed a 10-year retrospective chart review of patients seen at an HIV intake clinic between January 1994 and June 2001 who 1). tested positive for HIV during the 12 months prior to their presentation at the intake clinic and 2). had at least one encounter recorded in the medical record prior to their HIV-positive status. Data collection included demographics, clinical presentation, and whether HIV testing was recommended to the patient or addressed in any way in the clinical note. Prespecified triggers for physicians to recommend HIV testing, such as specific patient characteristics, symptoms, and physical findings, were recorded for each visit. Multivariable logistic regression was used to identify factors associated with missed opportunities for discussion of HIV testing. Generalized estimating equations were used to account for multiple visits per subject.
Among the 221 patients meeting eligibility criteria, all had triggers for HIV testing found in an encounter note. Triggers were found in 50% (1702/3424) of these 221 patients' medical visits. The median number of visits per patient prior to HIV diagnosis to this single institution was 5; 40% of these visits were to either the emergency department or urgent care clinic. HIV was addressed in 27% of visits in which triggers were identified. The multivariable regression model indicated that patients were more likely to have testing addressed in urgent care clinic (39%), sexually transmitted disease clinic (78%), primary care clinics (32%), and during hospitalization (47%), compared to the emergency department (11%), obstetrics/gynecology (9%), and other specialty clinics (10%) (P <.0001). More recent clinical visits (1997-2001) were more likely to have HIV addressed than earlier visits (P <.0001). Women were offered testing less often than men (P =.07).
Missed opportunities for addressing HIV testing remain unacceptably high when patients seek medical care in the period before their HIV diagnosis. Despite improvement in recent years, variation by site of care remained important. In particular, the emergency department merits consideration for increased resource commitment to facilitate HIV testing. In order to detect HIV infection prior to advanced immunosuppression, clinicians must become more aware of clinical triggers that suggest a patient's increased risk for this infection and lower the threshold at which HIV testing is recommended.
Although the Centers for Disease Control and Prevention (CDC) recommend routine HIV counseling, testing, and referral (HIVCTR) in settings with at least a 1 percent prevalence of HIV, roughly 280,000 Americans are unaware of their human immunodeficiency virus (HIV) infection. The effect of expanded screening for HIV is unknown in the era of effective antiretroviral therapy.
We developed a computer simulation model of HIV screening and treatment to compare routine, voluntary HIVCTR with current practice in three target populations: "high-risk" (3.0 percent prevalence of undiagnosed HIV infection; 1.2 percent annual incidence); "CDC threshold" (1.0 percent and 0.12 percent, respectively); and "U.S. general" (0.1 percent and 0.01 percent). Input data were derived from clinical trials and observational cohorts. Outcomes included quality-adjusted survival, cost, and cost-effectiveness.
In the high-risk population, the addition of one-time screening for HIV antibodies with an enzyme-linked immunosorbent assay (ELISA) to current practice was associated with earlier diagnosis of HIV (mean CD4 cell count at diagnosis, 210 vs. 154 per cubic millimeter). One-time screening also improved average survival time among HIV-infected patients (quality-adjusted survival, 220.7 months vs. 219.8 months). The incremental cost-effectiveness was 36,000 dollars per quality-adjusted life-year gained. Testing every five years cost 50,000 dollars per quality-adjusted life-year gained, and testing every three years cost 63,000 dollars per quality-adjusted life-year gained. In the CDC threshold population, the cost-effectiveness ratio for one-time screening with ELISA was 38,000 dollars per quality-adjusted life-year gained, whereas testing every five years cost 71,000 dollars per quality-adjusted life-year gained, and testing every three years cost 85,000 dollars per quality-adjusted life-year gained. In the U.S. general population, one-time screening cost 113,000 dollars per quality-adjusted life-year gained.
In all but the lowest-risk populations, routine, voluntary screening for HIV once every three to five years is justified on both clinical and cost-effectiveness grounds. One-time screening in the general population may also be cost-effective.
The costs, benefits, and cost-effectiveness of screening for human immunodeficiency virus (HIV) in health care settings during the era of highly active antiretroviral therapy (HAART) have not been determined.
We developed a Markov model of costs, quality of life, and survival associated with an HIV-screening program as compared with current practice. In both strategies, symptomatic patients were identified through symptom-based case finding. Identified patients started treatment when their CD4 count dropped to 350 cells per cubic millimeter. Disease progression was defined on the basis of CD4 levels and viral load. The likelihood of sexual transmission was based on viral load, knowledge of HIV status, and efficacy of counseling.
Given a 1 percent prevalence of unidentified HIV infection, screening increased life expectancy by 5.48 days, or 4.70 quality-adjusted days, at an estimated cost of 194 dollars per screened patient, for a cost-effectiveness ratio of 15,078 dollars per quality-adjusted life-year. Screening cost less than 50,000 dollars per quality-adjusted life-year if the prevalence of unidentified HIV infection exceeded 0.05 percent. Excluding HIV transmission, the cost-effectiveness of screening was 41,736 dollars per quality-adjusted life-year. Screening every five years, as compared with a one-time screening program, cost 57,138 dollars per quality-adjusted life-year, but was more attractive in settings with a high incidence of infection. Our results were sensitive to the efficacy of behavior modification, the benefit of early identification and therapy, and the prevalence and incidence of HIV infection.
The cost-effectiveness of routine HIV screening in health care settings, even in relatively low-prevalence populations, is similar to that of commonly accepted interventions, and such programs should be expanded.
The goals of this study were to quantify delays in diagnosing HIV infection in patients presenting for medical care prior to the identification of their HIV infection, and to determine characteristics of visits preceding the identification of HIV infection. This was a retrospective cohort study of consecutive newly diagnosed HIV infected patients in a large urban setting. Patients were predominantly minorities and identified from all inpatient and outpatient HIV tests performed between December 29, 1998 and December 27, 1999. Data were collected from all emergency department and clinic visits for each patient included in this study for a 3-year period preceding the first diagnosis of HIV infection. Two hundred seventy-eight patients tested positive for HIV during the study period. Of these, 76 (27%) met inclusion criteria. Twenty-three patients made a total of 53 health care visits preceding the diagnosis of their HIV infection. The median delay in diagnosis of HIV infection was 2 days (interquartile range [IQR], 1-22 days; range, 0-1093 days) for all subjects, although 19 (25%; 95% confidence interval [CI]: 16%-36%) patients had a delay in diagnosis of 30 days or more. Among those patients who had made prior health care visits, the median delay in diagnosis was 112 days (IQR, 33-690 days; range, 2-1093 days). No specific risk factor, historical clue, physical examination finding, or laboratory finding reliably identified patients with HIV infection. Documentation in the medical record of specific risk factors and clinical characteristics suggestive of HIV infection was poor. This study documented missed opportunities and delays in diagnosis of patients with unrecognized HIV infection. Clinicians must maintain a high index of suspicion for HIV infection in all patients.
North Carolina has added nucleic acid amplification testing for the human immunodeficiency virus (HIV) to standard HIV antibody tests to detect persons with acute HIV infection who are viremic but antibody-negative.
To determine the effect of nucleic acid amplification testing on the yield and accuracy of HIV detection in public health practice, we conducted a 12-month observational study of methods for state-funded HIV testing. We compared the diagnostic performance of standard HIV antibody tests (i.e., enzyme immunoassay and Western blot analysis) with an algorithm whereby serum samples that yielded negative results on standard antibody tests were tested again with the use of nucleic acid amplification. A surveillance algorithm with repeated sensitive-less-sensitive enzyme immunoassay tests was also evaluated. HIV infection was defined as a confirmed positive result on a nucleic acid amplification test or as HIV antibody seroconversion.
Between November 1, 2002, and October 31, 2003, 109,250 persons at risk for HIV infection who had consented to HIV testing presented at state-funded sites. There were 606 HIV-positive results. Established infection, as identified by standard enzyme immunoassay or Western blot analysis, appeared in 583 participants; of these, 107 were identified, with the use of sensitive-less-sensitive enzyme immunoassay tests, as recent infections. A total of 23 acutely infected persons were identified only with the use of the nucleic acid amplification algorithm. With all detectable infections taken into account, the sensitivity of standard antibody testing was 0.962 (95 percent confidence interval, 0.944 to 0.976). There were two false positive results on nucleic acid amplification tests. The specificity and positive predictive value of the algorithm that included nucleic acid amplification testing were greater than 0.999 (95 percent confidence interval, 0.999 to >0.999) and 0.997 (95 percent confidence interval, 0.988 to >0.999), respectively. Of the 23 acute HIV infections, 16 were detected at sexually transmitted disease clinics. Emergency measures for HIV prevention protected 48 sex partners and one fetus from high-risk exposure to HIV.
The addition of nucleic acid amplification testing to an HIV testing algorithm significantly increases the identification of cases of infection without impairing the performance of diagnostic testing. The detection of highly contagious, acutely infected persons creates new opportunities for HIV surveillance and prevention.
Accessing at-risk and underserved populations for intervention remains a major obstacle for public health programs. Emergency departments (EDs) care for patients not otherwise interacting with the health care system, and represent a venue for such programs. A variety of perceived and actual barriers inhibit widespread implementation of ED-based public health programs. Collaboration between local health departments and EDs may overcome such barriers. The goal of this study was to assess the effectiveness of a health department-funded, ED-based public health program in comparison with other similar community-based programs through analysis of data reported by health department-funded HIV counseling and testing centers in one Ohio county.
Data for HIV counseling and testing at publicly funded sites in southwestern Ohio from January 1999 through December 2002 were obtained from the Ohio Department of Health. Demographic and risk-factor profiles were compared between the counseling and testing program located in the ED of a large, urban teaching hospital and the other publicly funded centers in the same county.
A total of 26,382 patients were counseled and tested; 5,232 were ED patients, and 21,150 were from community sites. HIV positivity was 0.86% (95% confidence interval [CI] 0.64%, 1.15%) in the ED and 0.65% (95% CI 0.55%, 0.77%) elsewhere. The ED program accounted for 19.8% of all tests and 24.7% of all positive results. The ED notified 77.3% of individuals testing positive and 84.4% of individuals testing negative. At community program centers, 88.3% of patients testing positive and 63.8% of patients testing negative were notified of results. All ED patients notified of positive status were successfully referred to infectious disease specialists.
Public health programs can operate effectively in the ED. EDs should have a rapidly expanding role in the national public health system.
These recommendations for human immunodeficiency virus (HIV) testing are intended for all health-care providers in the public and private sectors, including those working in hospital emergency departments, urgent care clinics, inpatient services, substance abuse treatment clinics, public health clinics, community clinics, correctional health-care facilities, and primary care settings. The recommendations address HIV testing in health-care settings only. They do not modify existing guidelines concerning HIV counseling, testing, and referral for persons at high risk for HIV who seek or receive HIV testing in nonclinical settings (e.g., community-based organizations, outreach settings, or mobile vans). The objectives of these recommendations are to increase HIV screening of patients, including pregnant women, in health-care settings; foster earlier detection of HIV infection; identify and counsel persons with unrecognized HIV infection and link them to clinical and prevention services; and further reduce perinatal transmission of HIV in the United States. These revised recommendations update previous recommendations for HIV testing in health-care settings and for screening of pregnant women (CDC. Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. MMWR 1993;42[No. RR-2]:1-10; CDC. Revised guidelines for HIV counseling, testing, and referral. MMWR 2001;50[No. RR-19]:1-62; and CDC. Revised recommendations for HIV screening of pregnant women. MMWR 2001;50[No. RR-19]:63-85). Major revisions from previously published guidelines are as follows: For patients in all health-care settings HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Persons at high risk for HIV infection should be screened for HIV at least annually. Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. For pregnant women HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women. HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.
Design: Cost-effectiveness analysis linking simulation models of HIV screening to published reports of HIV transmission risk, with and without antiretroviral therapy. Data Sources: Published randomized trials, observational cohorts, national cost and service utilization surveys, the Red Book, and previous modeling results. Target Population: U.S. communities with low to moderate HIV prevalence (0.05% to 1.0%) and annual incidence (0.0084% to 0.12%).
In order to determine the sensitivity and specificity of two rapid human immunodeficiency virus (HIV-1) assays compared with enzyme immunoassay and Western blot and to assess their potential use for routine screening in an emergency department (ED), we analyzed sera from 492 consecutive ED patients using an identity-unlinked design. Sera were analyzed for HIV-1 by standard enzyme-linked immunosorbent assay and Western blot and two rapid assays: the Abbott Testpack HIV-1 (Abbott Labs, Inc, Abbott Park, IL) and the HIV-1 Genle, (Genetic Systems, Seattle, WA). Seroprevalence of HIV-1 among 492 samples was 5.1%. Both rapid assays were easy to perform and required approximately 10 minutes per test. Sensitivity and specificity of both rapid assays were 100% and 99.8%, with positive and negative predictive values of 96.2% and 100%, respectively. It was concluded that both rapid assays showed high concordance with standard enzyme-linked immunosorbent assay and Western blot. Since the ED is often the primary care setting for many patients at risk for HIV-1, the ED may be an optimal site for routine HIV-1 screening. Rapid assay screening may provide the opportunity for timely identification of HIV-1-infected patients, allowing earlier treatment and counseling. However, ethical and practical questions regarding appropriate application of rapid HIV-1 testing in EDs still needs resolution.
Studies in a Baltimore emergency room identified the patient with penetrating trauma as having the highest incidence of Human Immunodeficiency Virus Type I (HIV-1) infection. Anonymous testing over a 15-month period of 165 victims of penetrating trauma presenting to the Medical Center Hospital Emergency Center (San Antonio, Texas) revealed a 0% incidence of HIV-1. This data suggests that HIV-1 trauma patient incidence can be expected to vary between specific geographic areas and patient populations served, independent of community-wide AIDS incidence.
To determine the prevalence of antibody to human immunodeficiency virus (HIV) in trauma and nontrauma patients not identified as having known HIV infection in a noninner-city university teaching hospital emergency department, and to determine the frequency with which treating emergency physicians are knowledgeable of patients' risk factors for HIV infection.
ED patients between 18 and 59 years old with injuries that met trauma center triage criteria or with nontrauma-related illness who had blood drawn for physician-requested laboratory tests and for whom an extra aliquot of blood was available for HIV antibody testing.
All serum samples were first tested for antibody to HIV by enzyme-linked immunosorbent assay. If positive, the specimen was retested. All repeatedly reactive specimens were analyzed by Western blot test. The treating physician completed a questionnaire regarding the patient's illness and risk factors for HIV infection after the patient's care was completed.
Two of 100 major trauma patients (confidence interval, 0% to 5%) and seven of 100 nontrauma patients (confidence interval, 2% to 12%) had antibody to HIV. The seropositive rate by age and clinical group varied from 0% to 12.5%, with the highest rates in the 30- to 39-year-old group of nontrauma patients. The difference in proportions of seropositivity between the sexes was not statistically significant. Physicians obtained information regarding homosexual or bisexual behavior, IV drug use, and hemophilia from 52% of the nontrauma patients and only 17% of trauma patients. None of 30 trauma patients for whom data were available and only two of the 100 nontrauma patients gave a history of any high-risk behavior.
Although the sampling technique we used has limitations, the prevalence of HIV infection in our noninner-city ED is similar to that recently reported from inner-city EDs. This is in contrast to previous reports of low rates of HIV infection among ED patients in nonurban settings. Physician assessment of risk factors was incomplete in the majority of our patients. Patients rarely acknowledged any high-risk behavior. It is essential that emergency health care workers take maximum diligence to prevent exposure to blood and other body fluids from all ED patients.
To assess the feasibility and effectiveness of an emergency department-based, risk-targeted voluntary HIV screening program.
We prospectively enrolled consenting adult i.v. drug users (IDUs) not known to have HIV infection in the ED of a large inner-city hospital with a high rate of HIV infection among patients during a 10-week trial. Study patients were given confidential HIV pretest and risk-reduction counseling, with 10- to 14-day on-site ED follow-up. Follow-up included posttest counseling, reinforcement of risk-reduction practices, and a +10 incentive to cover transportation costs. HIV seropositive patients were referred to the hospital HIV clinic for further evaluation and treatment.
Of 200 eligible IDUs, 168 (84%) consented to HIV testing. Of the 104 (62%) who returned for follow-up, 17 (16%) tested positive for HIV. Of these patients, 6 (35%) kept their initial hospital HIV clinic referral appointment, a rate consistent with the experience of the hospital HIV clinic. Of nine patients in whom CD4+ counts were performed at time of the visit, three (33%) had counts less than 200. At 3-month follow-up, 4 of 20 active IDUs (20%) had reportedly ceased drug use because of the program. The complete program costs was an estimated 16,659, 99 per enrolled patient and $521 per HIV-positive patient.
An ED-based, risk-targeted HIV screening program is feasible and over time could detect a significant number of asymptomatic HIV-infected individuals, including those who should receive antiretroviral therapy and prophylaxis for Pneumocystis carinii pneumonia therapy (CD4+ count less than 200). An additional benefit of ED-based HIV screening in high-prevalence EDs is the opportunity to conduct successful risk-reduction counseling in some high-risk individuals.
Personnel of inner-city emergency departments (EDs), which are frequently the only source of medical care for many patients,
may be in a unique position to detect human immunodeficiency virus (HIV) infection earlier than personnel at other recommended
screening sites. To assist development of ED-based screening strategies for HIV infection, we undertook a serosurvey of HIV
infection in adult patients attending an ED during a 6-week period in 1992 using an identity-unlinked technique and compared
our findings with data collected similarly in 1988. Of 1,606 patients, 183 (11.4%) were HIV-positive, compared with 6.0% in
1988. Seroprevalence rates of HIV infection among patients only at risk of heterosexual transmission increased more than fourfold
(7% to 30.3%). CD4+ cell counts were higher in those patients with undiagnosed HIV infection than in those with known HIV infection. Targeting
minority patients aged 25–44 years, intravenous drug users, and those patients at heterosexual risk would have identified
87% of patients with new HIV infection, while requiring screening of 41% of the study sample. Targeted voluntary screening
programs in certain EDs would likely detect significant numbers of new early HIV infections.
We sought to (1) determine whether some emergency departments could play an important role in the national strategy of early HIV detection through the implementation of a voluntary HIV screening program and (2) describe the experience with standard and rapid HIV testing.
Consenting adults were enrolled during 3 distinct phases between 1993 and 1995 for the assessment of routine testing only, routine versus rapid testing, and rapid testing only. Patients administered the rapid test were given information at the time of the visit. We assessed the cost of the program.
Of 3,048 patients approached, 1,448 (48%) consented, 981 to standard and 467 to rapid testing. Of these, 6.4% and 3.2%, respectively, were newly identified as being HIV seropositive. More than twice as many new infections were diagnosed among those discharged from the ED as among those admitted (55 versus 21). Even among those previously tested, 5% proved seropositive. The mean+/-SD time to obtain results for the rapid assay performed in the hospital's main laboratory was 107+/-52 minutes, with 55% leaving the ED before receiving the results. Rapid assays performed in the ED satellite laboratory required 48+/-37 minutes, and only 20% left before getting the results. Follow-up among HIV-seropositive patients was 64% for the standard protocol and 73% for the rapid protocol (P >. 20). The prearranged HIV clinic intake appointment was kept by 62%. Rapid test sensitivity and specificity were 100% and 98.9%, respectively, with 5 initial false-positives and no false-negatives. Cost per patient enrolled and counseled was 601 for the routine test and $1,124 with the rapid test; these prices are competitive with those incurred at other sites.
Emergency department-based HIV testing was well accepted and detected a significant number of new HIV infections earlier than might have otherwise been, particularly among patients sent home. The rapid test is best performed on-site and is very sensitive. Confirmation of initial results is required because of the occurrence of occasional false-positive results. With relatively high HIV detection and return rates, it is evident that some EDs could play a major role in the national strategy of early HIV detection.
The objective of this study was to determine common practices for testing for Human Immunodeficiency Virus (HIV), particularly in patients with other sexually transmitted diseases (STD) in emergency departments (ED) with residency training in Emergency Medicine. Via mail, 112 directors of academic emergency medicine programs in the United States were surveyed. Surveys from 95 academic institutions were completed, returned, and included in the analysis. Three EDs (3%) routinely tested for HIV in patients with suspected STD. HIV testing was performed in the ED in 54% of responding institutions under special circumstances such as employee testing after occupational exposures (54%), cases of rape (46%), and suspicion of HIV infection by clinical manifestations other than suspected STD (36%). Based on the results it was determined that academic EDs do not routinely test for HIV in patients suspected of having a STD and have variable testing practices and policies regarding other possible HIV exposures.
This study was performed to determine the rate of previously undiagnosed HIV infection among patients presenting to an urban emergency department (ED) and to assess the feasibility of routinely offering voluntary HIV testing in this setting. HIV serostatus was determined anonymously among consecutive acute medicine and trauma ED patients (aged 18-55) who had blood drawn as part of their medical care. Excess serum was aliquoted and coded with an anonymous study code. Before performing HIV testing, the number of persons with previously reported HIV infection was determined by linkage with the state HIV/AIDS reporting registry. Concurrent with the blinded HIV serosurvey, ED patients were offered voluntary HIV testing in a pilot program. Overall, 76 of 2,155 (3.5%) adult ED patients in the blinded survey were HIV-seropositive, 15 of whom (0. 7% of those tested, 20% of those HIV-seropositive) had no infection previously reported to the state HIV/AIDS registry. In the pilot program, six of the 156 (3.8%) individuals who underwent voluntary HIV testing were HIV-seropositive, including three of 53 (5.6%) individuals without prior HIV testing. Of the six HIV-seropositive subjects, one was previously diagnosed, while five of the remaining 155 (3.2%) represented previously undiagnosed infections. Overall, 3. 5% of ED patients from whom blood was obtained for other reasons tested positive for HIV antibody, 20% of whom were previously undiagnosed. Implementation of the voluntary testing program uncovered newly diagnosed infection among 3.2% of those tested. An ED may be an important setting for routinely offering HIV testing, especially for patients who have not been previously tested for HIV.
Two major pillars of the United States' safety net system are urban public hospitals and community health centers. Their common mission is to care for the uninsured and other vulnerable populations. However, in most communities these important components of the safety net remain organizationally and functionally separate, which inhibits the continuum of care and creates substantial inefficiencies. Denver Health is a long-standing vertically and horizontally integrated system for vulnerable populations. The integration benefits the patient and the system and serves as a model for the U.S. safety net. This paper outlines the benefits of integration to the patient, provider, and health system, using data from the National Association of Public Hospitals and Health Systems, the Bureau of Primary Health Care, and Denver Health.
Undiagnosed HIV infection is prevalent among patients who present to urban emergency departments (EDs). Providing appropriate counseling, testing, and follow-up in the ED is difficult. The aim of this study was to evaluate the effectiveness of a referral-based outpatient HIV testing system for patients referred from the ED.
This was a prospective cohort study performed at an urban teaching hospital. Consecutive patients referred from the emergency department (ED) for outpatient HIV testing were enrolled. Data were collected from each patient's ED record and HIV clinic record, if applicable.
Of the 586 referrals made from our ED, 494 (84%) met inclusion criteria. Only 56 patients (11%, 95% CI: 9-15%) arrived at the HIV clinic and completed pretest counseling. Of these, 51 (91%, 95% CI: 80-97%) tested negative for HIV, 4 (7%, 95% CI: 2-17%) tested positive for HIV, and 1 (2%, 95% CI: 0-10%) refused the test.
This referral system was ineffective at identifying unrecognized HIV infection due to poor adherence. Changes in the structure of the referral system or the use of point-of-care testing in the ED may improve the ability to detect HIV infection in this setting.
Rapid HIV testing with same-visit results should increase the number of individuals who know they are HIV infected. We assessed the acceptability and feasibility of point-of-care rapid testing in three public venues, a sexually transmitted disease clinic, a county jail, and an emergency department. Over 98% of all participants received their results, and 82% of newly identified HIV-positive participants entered care. Point-of-care rapid testing was feasible, acceptable, and may improve entry into care.
Despite recommendations, emergency department (ED)-based HIV screening is not widespread, and feasibility studies are generally limited to settings with high HIV prevalence (>1%). This investigation was to evaluate an ongoing, publicly funded, ED-based HIV counseling and testing program in a low-prevalence area.
We reviewed a database of patients treated by an ED-based HIV counseling and testing program at a large, urban, teaching hospital for 1998 to 2002. ED patients at risk for HIV were targeted for standard serologic testing and counseling. Data were collected prospectively using standardized forms as part of clinical operations rather than in the context of rigorous research methodology; patient-oriented outcomes were not assessed. Counselors were trained according to Centers for Disease Control and Prevention guidelines, and health department guidelines for counseling and testing centers were followed. The main outcome measure was the number and proportion of patients newly diagnosed with HIV.
Eight thousand five hundred seventy-four patients were approached; 5,504 consented to HIV testing. Mean age was 29 years (SD 9.4 years), 76% were black, and 50% were men. Five thousand three hundred seventy-four (97.6%) patients tested negative and 39 (0.7%) patients tested positive. Seventy-five percent of negative-test patients and 79% of positive-test patients were notified of test results. Information for seropositive patients not notified of results was forwarded to the health department. All notified HIV-positive patients entered treatment. Risk factors included sexually transmitted disease (47%), multiple sexual partners (40%), unprotected sex while using drugs or alcohol (30%), men having sex with men (5%), and intravenous drug use (4%).
Identification of HIV-positive patients is possible in low-prevalence ED settings. In this instance, it was possible to perpetuate an ED-based HIV intervention program during an extended time. Although our work expands the profile of ED-based HIV counseling and testing beyond previous reports, the results should not be overgeneralized.
Undiagnosed human immunodeficiency virus (HIV) infection is not uncommon among patients who seek care in urban inner-city emergency departments (EDs). The optimal method for providing appropriate HIV counseling, testing, and referral in this setting is unclear. A previous evaluation of an outpatient referral system for HIV testing among patients seen in the ED demonstrated that only 11% returned to be tested; of those tested, 7% were seropositive. The purpose of this study was to evaluate the effect of a financial incentive on the proportion of referred ED patients who completed outpatient HIV counseling and testing.
This was a quasi-experiment performed at an urban county teaching hospital. ED patients identified using Centers for Disease Control and Prevention guidelines as being at risk for HIV infection were referred for outpatient HIV counseling and testing at our institution within one week. This study was divided into three study periods. During the first and third periods, no financial incentive was offered for completing HIV counseling and testing. During the second period, a 25 dollars incentive was offered for completing HIV counseling and testing.
During the study, 372 patients were referred for HIV counseling and testing. During the control periods, 20 (8%) of 252 patients completed HIV counseling and testing; during the intervention period, 27 (23%) of 120 patients completed HIV counseling and testing (odds ratio, 3.4; 95% confidence interval = 1.8 to 6.3). Of the 47 patients who completed HIV counseling and testing, none (0%; 95% confidence interval = 0% to 8%) tested positive for HIV infection.
The use of a modest financial incentive increased the proportion of patients who completed HIV counseling and testing after being referred from the ED. It is unclear whether the use of a financial incentive increases the identification of HIV-infected patients unaware of their status or if it is cost-effective.
To evaluate opportunities for earlier human immunodeficiency virus (HIV) diagnosis within a comprehensive public health care system.
Retrospective review of newly diagnosed HIV-infected patients between September 2001 and December 2003.
One hundred twenty of 348 (34%) newly diagnosed HIV-infected patients had medical care within our system in the 3 years before diagnosis. One hundred five of 120 (88%) patients had at least 1 prior encounter in the emergency department or urgent care center, whereas just 12 (10%) HIV diagnoses were made in these 2 sites. Only 33 (28%) patients previously presented with an HIV clinical indicator condition or sexually transmitted infection.
Although one-third of newly diagnosed HIV-infected patients had clinical visits in the 3 years before diagnosis, few presented with clinical conditions typically associated with HIV infection. Targeted testing based on clinical presentations is not likely to result in substantially earlier HIV diagnosis. Routine screening in high prevalence settings could be more effective.
We assess the feasibility, effectiveness, and cost of routinely recommended HIV/sexually transmitted disease screening in an urban emergency department (ED).
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.
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 9,116 and 1,736. The program cost for HIV/sexually transmitted disease screening was only $14,340 more than if we screened only for HIV.
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.
An extensive literature supports expanded HIV screening in the United States. However, the question of whom to test and how frequently remains controversial.
To inform the design of HIV screening programs by identifying combinations of screening frequency and HIV prevalence and incidence at which screening is cost-effective.
Cost-effectiveness analysis linking simulation models of HIV screening to published reports of HIV transmission risk, with and without antiretroviral therapy.
Published randomized trials, observational cohorts, national cost and service utilization surveys, the Red Book, and previous modeling results.
U.S. communities with low to moderate HIV prevalence (0.05% to 1.0%) and annual incidence (0.0084% to 0.12%).
Lifetime.
Societal.
One-time and increasingly frequent voluntary HIV screening of all adults using a same-day rapid test.
HIV infections detected, secondary transmissions averted, quality-adjusted survival, lifetime medical costs, and societal cost-effectiveness, reported in discounted 2004 dollars per quality-adjusted life-year (QALY) gained.
Under moderately favorable assumptions regarding the effect of HIV patient care on secondary transmission, routine HIV screening in a population with HIV prevalence of 1.0% and annual incidence of 0.12% had incremental cost-effectiveness ratios of 30,800 dollars/QALY (one-time screening), 32,300 dollars/QALY (screening every 5 years), and 55,500 dollars/QALY (screening every 3 years). In settings with HIV prevalence of 0.10% and annual incidence of 0.014%, one-time screening produced cost-effectiveness ratios of 60,700 dollars/QALY.
The cost-effectiveness of screening policies varied within a narrow range as assumptions about the effect of screening on secondary transmission varied from favorable to unfavorable. Assuming moderately favorable effects of antiretroviral therapy on transmission, cost-effectiveness ratios remained below 50,000 dollars/QALY in settings with HIV prevalence as low as 0.20% for routine HIV screening on a one-time basis and at prevalences as low as 0.45% and annual incidences as low as 0.0075% for screening every 5 years.
This analysis does not address the difficulty of determining the prevalence and incidence of undetected HIV infection in a given patient population.
Routine, rapid HIV testing is recommended for all adults except in settings where there is evidence that the prevalence of undiagnosed HIV infection is below 0.2%.
To evaluate and compare HIV screening and provider-referred diagnostic testing as strategies for detecting undiagnosed HIV infection in an urban emergency department (ED).
From January 2003 through April 2004, study staff offered HIV screening with rapid tests to ED patients regardless of risks or symptoms. ED providers could also refer patients for diagnostic testing. Patients aged 18 to 54 years without known HIV infection were eligible.
Of 4849 eligible patients approached for screening, 2824 (58%) accepted and were tested; 414 (95%) of 436 provider-referred patients accepted and were tested. Thirty-five (1.2%) screened patients and 48 (11.6%) provider-referred patients were infected with HIV (P < 0.001). Of these, 18 (51%) screened patients and 24 (50%) referred patients reported no traditional risk factors; 27 (77%) screened patients and 38 (79%) referred patients entered HIV care. Of HIV-infected patients with CD4 cell counts available, 14 (45%) of 31 screened patients and 37 (82%) of 45 provider-referred patients had <200 cells/microL (P < 0.001).
ED screening detects HIV infection and links to care patients who may not be tested through risk- or symptom-based strategies. The diagnostic yield was higher among provider-referred patients, but screening detected patients earlier in the course of disease.
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