Monitoring HIV Testing at Visits to Emergency Departments in the United States: Very-Low Rate of HIV Testing
BACKGROUND:: Early diagnosis and treatment of HIV infection results in improved clinical outcomes and decreased transmission, yet many infected persons are unaware of their infection or diagnosed late. The Centers for Disease Control and Prevention (CDC) recommends routine opt-out testing of all persons aged 13-64 in high prevalence settings. STUDY OBJECTIVE:: To describe methods to estimate HIV testing rates at visits to emergency departments (EDs) for monitoring adherence to recommendations for opt-out testing. METHODS:: We analyzed data from the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS). In 2009, two questions were added to the survey about HIV status and testing. We estimated the frequency of HIV testing at ED visits made by persons aged 13-64 years not known to be HIV infected. RESULTS:: In 2009, 90.5 million visits were made to EDs, including 60.0% by whites, 24.5% by blacks, and 12.1% by Hispanics; and 38.4% by privately insured, 25.7% by Medicaid insured, and 21.4% by uninsured persons. Among 89.9 million visits by patients not known to be HIV infected, HIV testing was performed at only 0.2% of visits. Among 3.4 million visits made by persons in whom targeted testing is recommended-those with increased risk for HIV and other sexually transmitted diseases, or pregnancy-only 2.3% were tested for HIV. CONCLUSIONS:: NHAMCS can be a useful tool to monitor trends in HIV testing in U.S. emergency departments. A high proportion of visits to EDs in the United States were made by persons in historically medically underserved populations and routine HIV testing was a rare event during ED visits.
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- "These results and those from other studies conducted in France, in the United States and the United Kingdom showed that non-targeted screening was feasible in health care settings and that it provided a means to reach a large number of patients181920. Nevertheless, the corresponding effectiveness in diagnosing HIV is subject to debate [15, 18,212223. Studies evaluating nurse-driven HIV screening, compared to screening performed by other health care staff, showed a trend in higher test offering, better acceptance and higher delivery rates with the implementation of nurse-driven HIV screening . However, a progressive decrease in test offering rates from nurses and other staff over time has been observed, most likely resulting from of a loss of motivation related to the small number of new diagnoses, which were concentrated in patients at high risk of HIV exposure [20, 25, 26]. "
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ABSTRACT: Background In 2010, to reduce late HIV diagnosis, the French national health agency endorsed non-targeted HIV screening in health care settings. Despite these recommendations, non-targeted screening has not been implemented and only physician-directed diagnostic testing is currently performed. A survey conducted in 2010 in 29 French Emergency Departments (EDs) showed that non-targeted nurse-driven screening was feasible though only a few new HIV diagnoses were identified, predominantly among high-risk groups. A strategy targeting high-risk groups combined with current practice could be shown to be feasible, more efficient and cost-effective than current practice alone. Methods/Design DICI-VIH (acronym for nurse-driven targeted HIV screening) is a multicentre, cluster-randomized, two-period crossover trial. The primary objective is to compare the effectiveness of 2 strategies for diagnosing HIV among adult patients visiting EDs: nurse-driven targeted HIV screening combined with current practice (physician-directed diagnostic testing) versus current practice alone. Main secondary objectives are to compare access to specialist consultation and how early HIV diagnosis occurs in the course of the disease between the 2 groups, and to evaluate the implementation, acceptability and cost-effectiveness of nurse-driven targeted screening. The 2 strategies take place during 2 randomly assigned periods in 8 EDs of metropolitan Paris, where 42 % of France’s new HIV patients are diagnosed every year. All patients aged 18 to 64, not presenting secondary to HIV exposure are included. During the intervention period, patients are invited to fill a 7-item questionnaire (country of birth, sexual partners and injection drug use) in order to select individuals who are offered a rapid test. If the rapid test is reactive, a follow-up visit with an infectious disease specialist is scheduled within 72 h. Assuming an 80 % statistical power and a 5 % type 1 error, with 1.04 and 3.38 new diagnoses per 10,000 patients in the control and targeted groups respectively, a sample size of 140,000 patients was estimated corresponding to 8,750 patients per ED and per period. Inclusions started in June 2014. Results are expected by mid-2016. Discussion The DICI-VIH study is the first large randomized controlled trial designed to assess nurse-driven targeted HIV screening. This study can provide valuable information on HIV screening in health care settings. Trial registration ClinicalTrials.gov: NCT02127424 (29 April 2014).
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- "In the more anonymous and accessible emergency department (ED) setting, adoption of non-targeted screening policies has been limited by time, concerns about follow up of test results, and competing priorities. Previous studies have demonstrated significant increases in detecting undiagnosed HIV with non-targeted, rapid HIV tests in the ED setting [5,6], yet only about 25% of eligible patients complete testing in these studies [3,7-9]. In settings without explicit opt-out screening protocols, there were far lower rates of screening, such as the 1.5% overall screening rate observed within the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS) data . "
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Despite recommendations by the Centers for Disease Control (CDC) that all adults be offered non-targeted HIV screening in all care settings, screening in acute-care settings remains unacceptably low. We performed an observational study to evaluate an HIV screening pilot in an academic-community partnership health center urgent care clinic.
We collected visit data via encounter forms and demographic and laboratory data from electronic medical records. A post-pilot survey of perceptions of HIV screening was administered to providers and nurses. Multivariable analysis was used to identify factors associated with completion of testing.
Visit provider and triage nurse were highly associated with both acceptance of screening and completion of testing, as were younger age, male gender, and race/ethnicity. 23.5% of patients completed tests, although 36.0% requested screening; time constraints as well as risk perceptions by both the provider and patient were cited as limiting completion of screening. Post-pilot surveys showed mixed support for ongoing HIV screening in this setting by providers and little support by nurses.
Visit provider and triage nurse were strongly associated with acceptance of testing, which may reflect variable opinions of HIV screening in this setting by clinical staff. Among patients accepting screening, visit provider remained strongly associated with completion of testing. Despite longstanding recommendations for non-targeted HIV screening, further changes to improve the testing and results process, as well as provider education and buy-in, are needed to improve screening rates.
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- "This survey demonstrated that nationwide, overall HIV testing rates in the ED for patients aged 13–64 was only 0.2%. Among patients with increased risk for HIV and other sexually transmitted diseases or pregnancy, only 2.3% were tested for HIV  . Since the HIV testing rates in the pre-intervention group were already higher than the national testing rates, an electronic order set without an electronic alert may be more appropriate, targeted and cost-effective than an electronic alert at detecting new cases of HIV in the ED. "
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ABSTRACT: Based on US. Centers for Disease Control and Prevention recommendations, New York State enacted legislation in 2010 requiring healthcare providers to offer non-targeted human immunodeficiency virus (HIV) testing to all patients aged 13-64. Three New York City adult emergency departments implemented an electronic alert that required clinicians to document whether an HIV test was offered before discharging a patient. The purpose of this study was to assess the impact of the electronic alert on HIV testing rates and diagnosis of HIV positive individuals.
During the pre-intervention period (2.5-4 months), an electronic "HIV Testing" order set was available for clinicians to order a test or document a reason for not offering the test (e.g., patient is not conscious). An electronic alert was then added to enforce completion of the order set, effectively preventing ED discharge until an HIV test was offered to the patient. We analyzed data from 79,786 visits, measuring HIV testing and detection rates during the pre-intervention period and during the six months following the implementation of the alert.
The percentage of visits where an HIV test was performed increased from 5.4% in the preintervention period to 8.7% (p<0.001) after the electronic alert. After the implementation of the electronic alert, there was a 61% increase in HIV tests performed per visit. However, the percentage of patients testing positive per total patients-tested was slightly lower in the post-intervention group than the pre-intervention group (0.48% vs. 0.55%), but this was not significant. The number of patients-testing positive per total-patient visit was higher in the post-intervention group (0.04% vs. 0.03%).
An electronic alert which enforced non-targeted screening was effective at increasing HIV testing rates but did not significantly increase the detection of persons living with HIV. The impact of this electronic alert on healthcare costs and quality of care merits further examination.
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