Testing and Linkage to Care Outcomes for a Clinician-Initiated Rapid HIV Testing Program in an Urban Emergency Department

Abstract

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.

Full text

Testing and Linkage to Care Outcomes
for a Clinician-Initiated Rapid HIV Testing Program
in an Urban Emergency Department
Katerina A. Christopoulos, M.D., M.P.H.,
1
Beth Kaplan, M.D.,
2
David Dowdy, M.D., Ph.D.,
3
Barbara Haller, M.D., Ph.D.,
4
Patricia Nassos, Ph.D.,
4
Marguerite Roemer, B.A.,
4
Teri Dowling, M.A., M.P.H.,
5
Diane Jones, R.N.,
1
and C. Bradley Hare, M.D.
1
Abstract
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 retro-
spective 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.
Introduction
The urban emergency department is a key site for the
detection of undiagnosed HIV infection. Marginalized
and vulnerable populations (e.g., racial/ethnic minorities, the
socioeconomically disadvantaged) at higher risk for HIV
frequently use the emergency department as their primary or
only source of care.
1
In addition, studies have found that some
patients diagnosed with HIV have visited the emergency
department on prior occasions.
2,3
Finally, the yield of HIV
testing in the emergency department may be greater relative
to other medical testing sites.
4
For these reasons, emergency
departments have played a prominent role in the im-
plementation of the 2006 Centers for Disease Control and
Prevention (CDC) guidelines recommending routine HIV
screening for all persons aged 13–64 years in areas where the
HIV prevalence is above 0.1%.
5
As more emergency departments undertake rapid HIV
testing efforts, they have used different strategies with regard
to patient selection. The 2007 National Emergency Depart-
ment HIV Testing consortium noted that the word ‘‘routine’’
as used in the CDC guidelines could refer either to choosing
patients for testing without regard to risk factors or to less
exceptional testing practices, such as opt-out consent.
6
Thus,
the consortium made explicit the following patient selection
strategies: diagnostic testing, which is based on clinical signs
or symptoms, targeted screening, which focuses on a defined
subpopulation thought to have a higher risk of infection than
1
HIV/AIDS Division,
2
Department of Emergency Medicine, San Francisco General Hospital, University of California San Francisco, San
Francisco, California.
3
Department of Internal Medicine,
4
Department of Laboratory Medicine, University of California San Francisco, San Francisco, California.
5
HIV Prevention Section, San Francisco Department of Public Health, San Francisco, California.
AIDS PATIENT CARE and STDs
Volume 25, Number 7, 2011
ªMary Ann Liebert, Inc.
DOI: 10.1089/apc.2011.0041
439

the general population, and nontargeted screening, in which
any patient within the available population may be tested. In
addition, emergency department HIV testing programs have
used different staffing strategies,
7
ranging from the exclusive
use of ancillary staff to offer and perform testing to incorpo-
rating testing fully into the duties of existing staff.
4,8–10
The optimal emergency department testing strategy in
terms of staffing and patient selection remains unknown, but
studies suggest that the colocation of HIV care in the same
hospital as the emergency department may facilitate linkage
to care.
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-ini-
tiated 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 in-
crease 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.
Methods
Study design
Using retrospective chart and database review, we evalu-
ated test outcomes, population characteristics, and linkage to
care outcomes for an emergency department rapid HIV test-
ing program that was funded in part by a CDC demonstration
project designed to increase testing among groups dispro-
portionately affected by HIV. The dates of analysis were June
1, 2008, through March 31, 2010.
Setting and program development
San Francisco General Hospital (SFGH) is a 300-bed public
safety net hospital for the city and county of San Francisco that
provides care to an urban, underserved population. The
emergency department is a level I trauma center with ap-
proximately 55,000 annual patient visits.
In May 2006, SFGH eliminated the requirement for written
consent for HIV testing and added HIV antibody testing to the
routine laboratory order form.
14
In response to the CDC
guidelines issued in September 2006 on routinizing HIV
testing in medical settings,
5
the SFGH HIV clinic convened
meetings with key stakeholders, including hospital adminis-
tration, the hospital laboratory, the emergency department,
and the San Francisco Department of Public Health on how to
expand hospital capacity for HIV testing. In February 2007 the
hospital switched its entire HIV testing platform to central
laboratory-based rapid testing on venipuncture specimens.
This service was made available 24 h per day, 7 days per
week, with results reported in the electronic medical record
(EMR) within 1–2 h after specimen receipt in the laboratory.
Prior to the new testing platform rollout, the HIV clinic
committed to expanding an existing linkage to care team to
the emergency department and other hospital testing sites in
order to assist with disclosure of positive results, handle all
follow-up appointments, and conduct medical and social
work intakes. This team consisted of a registered nurse, a
social work associate, and a nurse practitioner.
Testing protocol
From February 2007 through November 2008, clinicians
could initiate HIV testing for patients they suspected of hav-
ing signs or symptoms of HIV infection, i.e., diagnostic test-
ing. In June 2008, the CDC awarded the emergency
department HIV testing program a grant to increase the
number of patients tested. This funding was used to hire a
testing program coordinator, who facilitated a series of in-
services among emergency department physicians and staff
to raise awareness of the availability of HIV testing, and to
support the linkage to care team. Working together, the
emergency department and the HIV clinic launched an ex-
panded testing effort with revised criteria for testing on De-
cember 1, 2008 (World AIDS Day). Clinical presentations
consistent with HIV infection were listed and systematically
disseminated to emergency department clinicians on a lami-
nated pocket card. In addition, clinicians were encouraged to
undertake targeted testing of two groups of patients: (a) pa-
tients with HIV risk factors and (b) patients slated for inpa-
tient admission, regardless of their presenting complaints. If
concern existed for acute HIV infection and a rapid test was
negative, quantitative HIV viral load testing was available.
All patients age 13 and over were potentially eligible for HIV
testing in the emergency department.
Nurses drew blood and the hospital laboratory performed
rapid HIV antibody testing (Uni-Gold Recombigen HIV Test,
Trinity Biotech, Bray, Ireland) on plasma or heparin speci-
mens. Negative rapid test results were considered negative
and patients were given written materials on HIV testing
and prevention. Positive rapid test results were reported as
‘‘preliminary positive’’ in the EMR and the specimen was
retested with enzyme immunoassay (EIA; Genetic Systems
HIV-1/HIV-2 Plus O EIA, Bio-Rad, Redmond, WA) and
confirmatory immunofluorescence (IFA; Fluorognost HIV-1
IFA, Sanochemia Pharmazeutika, Vienna, Austria) with re-
sults available in 1–3 days. If EIA and IFA were both nega-
tive, the rapid ‘‘preliminary positive’’ test result was deemed
a false-positive, and a final HIV antibody result was reported
as negative. If EIA and IFA were both positive, a final HIV
antibody result was reported as positive. In cases where the
EIA and IFA results were discrepant, specimens were sent to
the San Francisco Department of Public Health laboratory
for repeat EIA/IFA and Western blot testing. Clinicians
disclosed both negative and ‘‘preliminary positive’’ rapid
test results prior to emergency department discharge.
Patients with preliminary positive rapid test results received
packets with resources for follow-up, including drop-in
appointment times in the HIV clinic for confirmatory test
results within 1–3 days. The hospital laboratory also notified
the linkage to care team of all preliminary positive rapid
antibody test results to ensure complete follow-up of all
patients. The linkage team met patients in person if notified
during business hours and otherwise contacted patients
within 1 business day. The testing program coordinator
provided regular feedback to emergency department clini-
cians on outcomes for patients diagnosed in the emergency
department, including clinic attendance and antiretroviral
therapy initiation.
440 CHRISTOPOULOS ET AL.

Data collection and analysis
Data were obtained from the hospital laboratory on all
emergency department rapid HIV antibody tests from June 1,
2008 to March 31, 2010. Descriptive statistics were used to cal-
culate proportions with confidence intervals. The Wilcoxon
rank sum test was used to compare the median number of tests
and new HIV diagnoses per month before and after the ex-
panded program launch. Demographic data on patients un-
dergoing testing was obtained from the EMR. The v
2
test was
used to assess associations between demographic characteristics
and a positive rapid test result. The emergency department HIV
testing program database was queried for additional informa-
tion on subjects with positive rapid tests results, including rapid
test disclosure, prior HIV diagnosis, confirmatory test results,
sexual orientation, housing status, CD4cell count, and time to
linkage to care for new diagnoses. Linkage to care was defined
as one HIV-related outpatient visit. All analyses were con-
ducted in Stata SE/10. The Committee on Human Research at
the University of California San Francisco approved this study.
Results
There were 96,711 emergency department visits during the
observation period, during which 5340 (5.5%) rapid HIV an-
tibody tests were performed, representing 4827 (91.3%) un-
ique patients. There were 16,662 inpatient admissions (17.2%
of emergency department visits), with a median of 738 ad-
missions per month. Of the HIV antibody tests performed,
2430 (45.5%) were on patients who were admitted to the
hospital. After the expanded testing launch on December 1,
2008, the number of tests increased from a median of 114 tests
per month to 273 tests per month, p=0.004 (Fig. 1).
The first rapid test result for each patient is shown in Table
1. Rapid test results were positive for 126 testers (2.6%, 95%
confidence interval [CI] 2.2%, 3.1%), of which 10 were false-
positive, resulting in 116 confirmed cases of HIV infection.
The median age of testers was 44 years, (interquartile range
[IQR] 31–55 years). Women accounted for nearly 40% of tes-
ters but individuals with positive rapid test results were more
likely to be male ( p<0.001).
Of the 116 confirmed cases of HIV infection, 55 individuals
had known HIV infection, 58 patients had newly diagnosed
HIV infection, and 3 patients were suspected new HIV diag-
noses, as they had no record of a previous positive test (2
patients left the emergency department prior to disclosure
and 1 was intubated in the emergency department and died
during hospitalization). In addition to the 61 patients without
a prior known HIV diagnosis, 3 patients presented with
symptoms consistent with acute retroviral syndrome and
were diagnosed with acute HIV infection based on negative
rapid HIV antibody test results and HIV RNA levels higher
than 500,000 copies per milliliter. Furthermore, 1 patient with
a negative HIV test tested HIV positive on a repeat emergency
department visit, for a total of 65 new emergency department
HIV diagnoses out of the 5340 tests (1.22%: 95% CI, 0.94%–
1.55%). The median number of new HIV diagnoses increased
from 1.5 per month to 4 per month during the study period
p=0.01 (Fig. 1). Patients with newly diagnosed HIV infection
were 76.9% male and 37% white (Table 1). The median CD4
cell count was 268 cells per microliter, with 40% of patients
having CD4 cell counts under 200 cells per microliter.
Of the 65 patients with newly diagnosed HIV infection, 58
patients received results at the time of testing and 49 patients
were eligible for linkage to outpatient care. Reasons for inel-
igibility were discharge to a skilled nursing facility after in-
patient admission (n=3), incarceration at time of testing
(n=2), private insurance incompatible with the publicly fun-
ded SFGH HIV clinic (n=2), death during inpatient admission
FIG. 1. Number of rapid
HIV tests and new HIV diag-
noses by month, June 2008 to
March 2010.
EMERGENCY DEPARTMENT HIV TESTING 441

(n=1), and out-of-county residence (n=1). Forty-six patients
(93.9%, 95% CI: 83.1, 98.7%) were successfully linked to care,
with 73% linked by 7 days, 84% linked by 30 days, and 90% by
90 days. Of the 7 patients whose results were not disclosed at
the time of the test, 4 were able to be contacted with results
after discharge and 1 presented to the emergency department
at a later date; 4 of these patients were also linked to care. Of
the 55 patients with known HIV infection, the majority
identified as in care (n=39), while a few had out-of-county
residence (n=2) or were incarcerated (n=1). Two patients had
unknown care status. Of the remaining 11 patients, 10 (90.9%,
95% CI: 58.7%, 99.8%) were successfully relinked to care.
Discussion
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. We also dem-
onstrate that additional new diagnoses of HIV infection can be
identified through the implementation of strategies other than
hiring ancillary staff to conduct testing, namely by re-em-
phasizing clinical indicators of HIV infection and expanding
testing to admitted and high-risk patients. These efforts
helped create a ‘‘culture change’’ among busy emergency
department clinicians with regard to incorporating HIV test-
ing into their everyday practice. In addition, external funding
was used to support the linkage to care team, as concern about
patient follow-up has been a commonly cited barrier to cli-
nician-initiated emergency department HIV testing.
15
The
effort of the program coordinator and the linkage team cor-
responded to 2 full-time equivalent positions (FTEs). The
program’s cost effectiveness is reported separately.
16
In our study, the linkage to care team achieved rates of
success exceeding 90% for both newly diagnosed and out-of-
Table 1. Characteristics of Patients Undergoing Rapid HIV Testing and Testing Newly HIV Positive
in the San Francisco General Hospital Emergency Department, June 2008–March 2010
Total tested,
n(%)
Positive rapid test,
n(% of total with
a positive rapid test)
v
2
Test, p
Confirmed rapid test,
n(% of total with
a confirmed rapid test)
Confirmed HIV
infection, newly
diagnosed, n(%)
a
Total 4827 (100%) 126 (2.6%) 116 (2.4%) 65 (100%)
Age categories (years)
a
13–24 653 (13.5%) 9 (1.4%) 7 (1.1%) 6 (9.2%)
25–44 1791 (37.1%) 66 (3.7%) p=0.001 61 (3.4%) 33 (50.8%)
45–64 1961 (40.7%) 46 (2.4%) 43 (2.2%) 23 (35.4%)
>65 418 (8.7%) 5 (1.2%) 5 (1.2%) 3 (4.6%)
Gender
Male 3014 (62.4%) 103 (3.4%) p<0.001 96 (3.2%) 50 (76.9%)
Female
b
1813 (37.6%) 23 (1.3%) 20 (1.1%) 15 (23.1%)
Race/ethnicity
White 1692 (35.0%) 24 (37.0%)
Black 1348 (27.9%) 16 (24.6%)
Latino 988 (20.5%) 14 (21.5%)
Asian/Pacific Islander 597 (12.4%) 10 (15.4%)
Other/unknown 202 (4.2%) 1 (1.5%)
Sexual orientation
Gay/bisexual 29 (44.6%)
Heterosexual 23 (35.4%)
Unknown 13 (20.0%)
Housing status
Permanent (own/rent) 32 (49.2%)
Temporary (e.g., SRO) 7 (10.8%)
Homeless/shelter 23 (35.4%)
Unknown 3 (4.6%)
Median CD4 cell count
c,d
268
IQR (65, 472)
CD4 cell count <200
Yes 23 (40.0%)
No 36 (60.0%)
Admitted to hospital
Yes 29 (44.6%)
No 26 (55.4%)
a
New diagnoses include three patients with acute HIV infection (rapid test negative, quantitative viral load >500,000 copies/mL) and one
patient who tested positive on a subsequent emergency department visit.
b
Includes 5 male-to-female transgender patients.
c
CD4 cell counts available for 59/65 patients.
d
CD4 cell counts in cells per microliter.
SRO, single room occupancy; IQR, interquartile range.
442 CHRISTOPOULOS ET AL.

care HIV patients, although studies have shown that con-
nection to care does not necessarily mean patients stay in
care.
17
Although a small number of patients left the emer-
gency department before disclosure of positive rapid test re-
sults, most of these patients were contacted by the linkage
team. Even though the turnaround time of the rapid test was
one to two hours after specimen receipt in the laboratory, the
main barrier to disclosure was discharging patients before test
results were available, either because patients wanted to leave
or because of overcrowding in the emergency department.
The high proportion of patients with previously diagnosed
HIV infection in our study is notable, and consistent with
other studies.
9
Reasons for this finding merit further investi-
gation. Most of these patients did not have prior HIV test
results available in the electronic medical record, though a
minority did. It may be that patients do not initially disclose
their HIV status; they do not believe their diagnosis; they lack
documentation of HIV status; or they seek reengagement in
care.
The optimal approach to emergency department-based
HIV testing remains uncertain.
18
A recent study found that
nontargeted testing identified only a modestly increased
number of new HIV diagnoses compared to physician-
initiated diagnostic testing, despite large increases in the
number of patients tested.
19
A previous blinded study in the
SFGH emergency department found that the prevalence of
HIV infection was 8.0%, of whom 0.9% had unknown HIV
infection.
20
While our data indicate that emergency depart-
ment clinicians can identify populations with a prevalence of
undiagnosed HIV infection greater than 1%, the additional
yield of non-targeted screening in this setting is unknown.
Limitations of our data are that we do not know testing rates
by category of clinician (e.g., attending, resident) nor we do
know the rates and yield of diagnostic versus targeted testing,
which in many cases may overlap. However, using the
magnitude of the increase in testing allows us to define a
reasonable ‘‘upper bound’’ of the proportion of patients tested
via targeted criteria: (273–114)/273 =58%.
One important goal of testing in medical settings is to
identify ‘‘hidden’’ populations with HIV infection—those
who would not otherwise be diagnosed in a timely fashion.
The demographic characteristics of patients with newly
identified HIV infection in the SFGH emergency department
differ noticeably from newly identified HIV cases in
San Francisco at large. In 2008, those newly diagnosed with
HIV in San Francisco were nearly 90% male, at least 80% were
men who have sex with men, and half were white.
21
In
contrast, in our study, new HIV diagnoses were nearly one
quarter female or male-to-female transgender, nearly two
thirds were racial/ethnic minorities, and approximately one
third were heterosexual-identified. In addition, the median
CD4 cell count was relatively low at the time of diagnosis.
Given these findings, it is our opinion that public hospital
emergency department-based testing may identify HIV in-
fection that might go undiagnosed by other HIV testing
systems.
Rates of clinician-initiated emergency department rapid
HIV antibody testing and identification of new HIV cases can
be increased by adding a targeted testing component to di-
agnostic testing. The integration of laboratory rapid testing
with a linkage to care team was an effective strategy for
connecting newly diagnosed and out-of-care HIV-infected
patients to care in our study. These programmatic features
should be explored in other settings.
Acknowledgments
The authors would like to thank Clarissa Ospina-Norvell
and Alida Marrero-Calderon for their dedication in linking
HIV-infected patients to care, Maria Bahn-Tigaoan for pro-
gram coordination, Noah Carraher for program monitoring
data, and Margaret Wong for the laboratory data used in this
analysis. The San Francisco General Hospital HIV testing
program was supported by CDC grant PS07-768 ‘‘Expanded
and Integrated Human Immunodeficiency Virus (HIV) Test-
ing for Populations Disproportionately Affected by HIV,
Primarily African-Americans.’’ This publication was made
possible by grant number UL1 RR024131 from the National
Center for Research Resources (NCRR), a component of the
National Institutes of Health (NIH) and the NIH Roadmap for
Medical Research. Its contents are solely the responsibility of
the authors and do not necessarily represent the official view
of NCRR. Information on NCRR is available at www.ncrr
.nih.gov/. Information on Re-engineering the Clinical Re-
search Enterprise can be obtained from http://nihroadmap
.nih.gov/clinicalresearch/overview-translational.asp. This
work was supported by the National Institutes of Health T32
AI60530 and K23 MH092220-01 (KAC).
Author Disclosure Statement
No competing financial interests exist.
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995 Potrero Avenue
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Box 0874
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E-mail: christopoulosk@php.ucsf.edu
444 CHRISTOPOULOS ET AL.