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RESEARCH ARTICLE Open Access
Understanding patient acceptance and refusal of
HIV testing in the emergency department
Katerina A Christopoulos
1,2*
, Sheri D Weiser
1,2
, Kimberly A Koester
2
, Janet J Myers
2
, Douglas AE White
3
,
Beth Kaplan
4
and Stephen F Morin
2
ABSTRACT
Background: 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.
Methods: 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.
Results: 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.
Conclusions: 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.
Keywords: Emergency department, HIV testing, HIV test refusal, HIV test acceptance
Background
To facilitate earlier detection of HIV infection, the Cen-
ters for Disease Control and Prevention (CDC) issued
guidelines in 2006 recommending routine HIV screen-
ing 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 [2-5].
Patient satisfaction rates with ED HIV testing range
from 80-90% [6-11].
Despite these favorable attitudes, the proportion of
patients who accept ED HIV testing varies widely, ran-
ging from 24%-91% [8,12]. Demographic factors asso-
ciated with refusal of HIV testing are older age, white
race, female sex, higher income, and being married
[12,13]. Common reasons for refusal are having been
tested recently, feeling sick, and the perception of being
at low risk for HIV infection [5,7].
A current focus of research is how patients’perceived
and actual HIV risk influences decisions around HIV test-
ing, as it is thought that patients who decline ED HIV test-
ing may be at greater risk for HIV infection. A study in a
Boston ED found that 15% of subjects who perceived a
need for testing based on their risk for HIV infection ulti-
mately refused testing [13]. In Washington D.C., research-
ers tested de-identified blood samples from decliners and
* Correspondence: christopoulosk@php.ucsf.edu
1
San Francisco General Hospital HIV/AIDS Division, University of California
San Francisco, San Francisco, CA, USA
Full list of author information is available at the end of the article
Christopoulos et al.BMC Public Health 2012, 12:3
http://www.biomedcentral.com/1471-2458/12/3
© 2012 Christop oulos et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attri bution License (http://creativecommons.org /licenses/by/2.0), which permits unrestricte d use, distribution, and
reproductio n in any medium, provided the original work is properly cited.
found nearly three times the risk of HIV infection com-
pared to patients who accepted testing [14].
The potential importance of testing individuals who
decline ED HIV testing calls for more insight into how
patients make decisions around testing. There are many
quantitative assessments of ED HIV testing uptake, but
to date there has been no detailed exploration of why
people accept or decline HIV testing in the ED. Thus,
the objective of this study was to use in-depth inter-
views to develop a better understanding of acceptance
and refusal of ED HIV testing.
Methods
We conducted in-depth interviews with in fifty patients
(28 who accepted HIV testing and 22 who declined HIV
testing) three northern California EDs. The ED settings
have been described in detail elsewhere [15]. All sites were
recipients of CDC funding to increase HIV testing among
disadvantaged urban populations. As previously described,
[15] two sites in Oakland offered non-targeted oral swab
screening at registration or triage while a third site in San
Francisco utilized clinician-initiated diagnostic venipunc-
ture testing and targeted testing of admitted patients [16].
All patients offered an HIV test in the ED were eligi-
ble to participate in this study, although recruitment of
patients was limited to those who had already received
their test results. Patients with reactive test results were
excluded from recruitment given the sensitive nature of
these test results and the need for immediate follow-up
counseling. In addition, to gain a range of perspectives,
study investigators decided a priori to attempt to sample
ten accepters and ten decliners at each site. Emergency
department staff helped identify patients for recruit-
ment, and flyers advertising the study were posted
throughout the EDs. Once patients were recruited,
researchers explained the goals of the study and
obtained verbal consent for an interview. Interviews
were conducted in a private setting in the ED and lasted
approximately twenty to thirty minutes. Information on
demographics and health care utilization, including age,
gender, race/ethnicity, insurance/care status, and reason
for ED visit, was collected at the beginning of each
interview. Participants were each reimbursed thirty dol-
lars for their participation. Study data were collected
from April to June 2009. The institutional review boards
of the University of California San Francisco and all par-
ticipating sites approved this study.
A semi-structured interview guide was developed to
cover participant experiences with HIV testing in the ED,
reasons to accept or decline HIV testing, prior HIV test-
ing history, relationship status and perceptions of HIV
risk behavior, and participant attitudes towards HIV
infection. Interviews were transcribed verbatim and
entered into Atlas.ti [17] for organization and easy
retrieval of text elements. Three analysts employed a fra-
mework analysis approach to the data, which included
two distinct analytic tasks: managing and interpreting the
data [18]. The analysts began managing the data by read-
ing a subset of the interviews to gain an initial familiarity
with the dataset and to produce a preliminary list of cod-
ing categories. Subsequent steps included refinement of
codes, as well as sharpening the shared understanding of
how to apply codes. Each interview was coded by a pri-
mary analyst and reviewed by a secondary analyst. The
analytic team then selected text associated with key
codes across cases to be read and summarized as a group
in six three-hour interpretative analysis sessions. The
goal during the interpretative phase was to produce an
exploratory analysis to uncover overarching attitudes
towards HIV testing in the context of a visit to the ED.
Results
Respondent Characteristics
Participants represented a diverse range of ages and
were evenly divided between men and women (Table 1).
Reflecting the demographics of the communities these
EDs serve, half of the participants in this study were
African-American. While we purposively sampled to
obtain an equal number of accepters and decliners of
HIV testing, it was more difficult to recruit decliners at
Site 1, which used clinician-initiated testing, than at
sites 2 and 3, where testing was offered at a central loca-
tion (e.g. registration, triage). It is not clear whether this
was because fewer patients declined clinician-initiated
testing or because ED clinicians were simply too busy to
refer decliners to the study. Thus, the research team
stopped recruitment at site 1 once the quota of accep-
ters and decliners was reached at the other sites (Table
2). About half of participants had insurance and a regu-
lar source of medical care. The majority of patients (44/
50, 88%) had previously tested for HIV infection, includ-
ing 18 (82%) of the 22 decliners sampled. Of the 6 parti-
cipants who had never tested for HIV infection, 2
decided to accept testing in the ED that day.
Reasons for Acceptance
The most common reasons for accepting HIV testing in
the ED were because participants “just wanted to know”
and that it was “good to know”one’s HIV status (Table
3). Participants viewed the test as a form of assurance of
negative status. Some participants saw HIV testing as a
way to “check”their bodies and ensure good health.
Well, I’m in here getting tested. I’m getting my liver
tested, my kidneys tested. I had an ultrasound on
the veins in my leg, so why not get an HIV test.
They already have the blood, so why not?
-51-year-old African-American man
Christopoulos et al.BMC Public Health 2012, 12:3
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One participant described how an HIV test in a medi-
cal setting could help her health:
The hospital ask you anything about your health that
they damn well want to. If it’s helping, ask me.
-42-year-old African-American woman
Participants emphasized HIV testing in the ED as an
opportunity they might not have otherwise encountered
or sought out, and they perceived their acceptance of
testing as taking advantage of that opportunity. Conve-
nience and the fact that tests were free were also cited
as reasons to accept testing.
Because I’d never had one and it was free... I would
havenotsoughtoutattestjustonmyown.I
wouldn’t have made a doctor’s appointment. So it
was a good thing that the hospital offered it. I went,
“Well, why not?”But I wouldn’t have thought to go,
‘cause it wasn’taconcerninmymind,whether
that’s right or wrong smart or ignorant. I think it’sa
good thing because everybody should know and it’s
one less thing you have to worry about.
-52-year-old White woman
One participant who had never taken an HIV test
liked having the test as part of her medical care in the
ED. She acknowledged that stigma played a role in her
decision to test in the ED as opposed to a dedicated
testing center.
Actually - to be honest - I think that I would never
have taken a test if it wasn’tofferedatthishospital.
Because for me to go to a clinic that does HIV
testing - it would make me really uncomfortable.
Because just the idea of having it stated boldly and
well known as an HIV testing center - for me to
show my face in an area like that - I would feel a
little uncomfortable and just in case I might see
someone I know I would feel as if “Well, this per-
son might think I have something and they might
go around spreading rumors and say, ‘Hey I saw
her at the HIV testing center. She might have
something.’” So it would make me uncomfortable
but I actually took a test here because it was very
convenient. I was like, “Waitaminute-maybeI
do want to know.”AndIguessitisalittlemore
discreet so I kind of like that better than having to
go to a clinic that everyone knows is testing for
HIV.
-25-year-old Asian woman
Table 1 Respondent Characteristics (n = 50)
Age Category
18-29 years 17 (34%)
30-49 years 19 (38%)
> = 50 years 14 (28%)
Gender
Male 26 (52%)
Female 24 (48%)
Race/Ethnicity
African-American 26 (52%)
White 11 (22%)
Latino 3 (6%)
Asian 3 (6%)
Mixed Race 5 (10%)
Other/Unknown 2 (4%)
Accepters of HIV Testing
Yes 28 (56%)
No 22 (44%)
Prior HIV Testing
Yes 43 (86%)
No 6 (12%)
Not Sure/Unknown 1 (2%)
Have Insurance
Yes 26 (52%)
No 20 (40%)
Not Sure/Unknown 4 (8%)
Have Regular Source of Care
Yes 22 (44%)
No 27 (54%)
Not Sure/Unknown 1 (2%)
Reason for ED Visit (as reported to interviewer)
Pain 15 (30%)
Trauma 14 (28%)
Infection/Cough/Fever 7 (14%)
Dermatologic 5 (10%)
Possible HIV Exposure 4 (8%)
Hyperglycemia 3 (6%)
Out of Medication 1 (2%)
Ear Irrigation 1 (2%)
Table 2 Acceptance and Refusal by Site
Site Accepted Refused Total
Site 1: Clinician-Initiated Diagnostic/Targeted Testing Using Venipuncture Specimens 8 1 9
Site 2: Opt-in Non-Targeted Oral Swab Testing Offered at Triage 10 11 21
Site 3: Opt-out Non-Targeted Oral Swab Testing at Registration 10 10 20
Total 28 22 50
Christopoulos et al.BMC Public Health 2012, 12:3
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Similarly, another participant appreciated the absence
of a traditional counseling approach.
I had no intention of getting an HIV test when I
came in here so it was just added on to what my
purpose was being here. I felt pretty confident I
didn’t have HIV. I felt pretty confident the first time
around too but the first time around (testing) was
done with a lot more intention on my part and
there was counseling involved, so it was a much
more elaborate experience that this was. I didn’t
express any interest in counseling. I think had they
gone that route I probably wouldn’t have wanted to
take it because I’m not here for that so it was sort of
like, “Oh well, while you’re here...”And the fact that
they presented it as “while you’re here, by the way...”
I actually thought was pretty good. Because it made
me feel comfortable. It wasn’tlike,“Oh, my God,
you have to make sure everybody who comes
through here doesn’thaveAIDS.”Their casual atti-
tude for me was fine. It worked out very well.
-55-year-old White woman
Finally, other reasons for acceptance were that some
participants felt they had engaged in behavior that put
them at risk for acquiring HIV infection, they had part-
ners who encouraged them to test, and they wanted to
ensure the safety of others as they entered new
relationships.
Reasons for Refusal
Many participants declined HIV testing because they had
tested recently, often in the same ED testing program
(Table 3). In addition, individuals did not perceive them-
selves to be at risk for HIV infection, usually because
they were in long-term monogamous relationships and
had been tested prior to or during these relationships.
I took one during my last pregnancy; I just have a 4-
month-old at home so I’m monogamous and I didn’t
see any need to waste the tester.
-30-year-old mixed-race woman
Other individuals who did not perceive themselves at
risk for HIV infection stated that they had been absti-
nent or used protection consistently since their last HIV
test.
Cause I don’tgotit.ItestedandIhadabloodtest
and a swab test and it was in ‘06 and this is ‘09. But
since I was safe, I was in custody when they did it,
tested it and since I’ve been home I’ve been using
straight condoms and I don’t kiss nobody with sores
in their mouths, stuff like that.
-38-year-old African-American man
In addition, a few participants alluded to wanting to
focus on the medical issue that brought them to the ED,
even though they may have tested for HIV in the past.
’Cause I just came here for my toe. I didn’twantto
do nothing else.
-27-year-old Hispanic woman
While nearly all participants had favorable views on
testing for HIV infection in the ED, there was case
where a participant expressed a desire for a more
nuanced conversation within the bounds of an estab-
lished patient-provider relationship. She described her
rationale for declining the test as follows:
One, it’s because this is the county hospital. The
approach of the person who asked me was a little
raunchy, like, “Hey, you want to take an HIV?”No
information or nothing like that. I feel like I have
the right to know. I think I know my status and I
pray it hasn’tchangedsinceI’ve known it and I
would just feel more comfortable at my regular phy-
sician, you know what mean, far as if there was
something I needed to consult them about or some-
thing of that nature; just the confinements of the
relationship that I’ve already established with my
current provider. I would just feel more comfortable
and for them having a record or whatever.
-25-year-old African-American woman
Table 3 Reasons for Acceptance or Refusal of HIV Testing in the ED
Reasons for Acceptance Reasons for Refusal
Curiosity/Assurance Recent Negative Test
Convenience/Opportunity Perception of Being at Low Risk
Perception of Being at Risk Feel Sick/Only Want to Address Reason for ED Visit
Perception of Being at Low Risk Don’t Want to Know
Encouraged by Partner Confidentiality Concern
Ensure Safety of Others Potential Strain on Relationship
Testing for HIV As Any Other Health Problem Free Prefer to Test with Primary Care Physician
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Of the four participants who declined HIV testing and
had never previously tested for HIV infection, two parti-
cipants stated that they felt at low risk for HIV infection
because of being in long-term monogamous relation-
ships. Another participant stated, “I don’t know, actually.
Ijustdon’twanttotakeone.IguessIdon’twantto
know anything.”While this participant did not feel that
HIV testing was necessary for him at the moment
because he had not had sex in eighteen months, he did
go on to endorse HIV testing as important in general.
Another patient gave a layered response, explaining that
she perceived herself at low risk because of being in a
monogamous relationship, but she also voiced concerns
about the potential disruption of trust in that relation-
ship and the confidentiality of test results if she was
found to be HIV-infected. She also expressed not want-
ing to know her HIV status.
Um, because I have been with the same guy for
more than 20 years and I’m not having any outside
sex so I just - there’s really no privacy once you get
that information out there... I don’tcaretoknow
onewayortheother...Ithinkmyriskislow,I
mean I’m trusting him not to be having any outside
sex and I know that I’m not and like I said we’ve
been in a monogamous relationship for more than
twenty years now so I don’tthinkthatI’matrisk,
no... Should I start a medical record somewhere I
don’t want that I was even tested because really sup-
posed confidentiality is not reality. Everything’son
computer. I just don’twantthatinformationout
there. Um, well I would have to be tested so there
my confidentiality is violated cause if it’s positive
that’s everybody. Public health, the lab, everybody
would know. And I don’t want to know. Like I said -
well I guess that would ruin whatever trust, cause I’d
knowwhereIgotitfromifIgotit.LikeIsaidI
haven’t had sex with anybody but him so I just pre-
fer not to know.
-50-year-old African-American woman
Overall, many of the decliners had personal experi-
ences with HIV, including family members and friends
who died of AIDS. Decliners were more likely to discuss
HIV stigma compared to the accepters, including
descriptions of “layered”stigma around homosexuality
and intravenous drug use [19]. One participant who
declined HIV testing and had never tested for HIV
infection described a family’sresponsetoacousinwho
died of AIDS.
And I remember one year Christmas dinner,
Thanksgiving dinner, we used to get together to
have a kind of potluck thing at different people’s
houses-mygrandmotheroroneofmyaunts.And
he wanted to come to dinner. That was fine, but he
wanted to bring his partner and like hell no. No, you
can’t bring him. They fixed him a plate and told him
to take it with him. Don’tworryaboutbringingit
back.
-50-year-old African-American woman
It is worth noting that no participant invoked test type
(oral swab vs. venipuncture) as a reason for declining
the test.
The Experience of Testing for HIV in the ED
All participants described being given the opportunity to
decline HIV testing in the ED, and nearly all partici-
pants were satisfied with the offer of HIV testing. As
most of the people who accepted testing had tested for
HIV infection previously, they acknowledged having
familiarity with HIV testing. Only one person expressed
a desire for more counseling.
It’s kind of like a rush here, so they don’t really sit
down and really talk to you about that test and they
just want to test you for when you do come back
and you already been on record as negative or posi-
tive or whatever... I wish they could talk to me about
the test and everything like that but they don’t
becausetheybesobackeduptothepointwhere
they can’t talk to you and they just be like, “Okay,
well here go the test. Your doctor’s going to tell you
the results.”Butitwouldbeniceyouknowifthey
would give a little background and tell them how
the test is and how you can just get it far as even
having sex transmitted, just being sexual with your
partneroryoucangetitfromkissingorwhatever
like somebody bleed or somebody get cut and you
try to help them clean up and they might be having
it and your blood touch their blood and damn you
got it.
-19-year-old African-American woman
In contrast to most participants, this respondent felt
she was at high risk for HIV infection because in the
past she had an HIV-infected partner. She wanted the
opportunity to speak with someone about her situation
and also wanted more information on risks of HIV
transmission. Her story was the exception in this data-
set, but it demonstrates that those at increased risk of
HIV infection may continue to benefit from counseling
at the time of testing.
Discussion
Participants described a number of factors that influ-
enced their decision to accept testing, including
Christopoulos et al.BMC Public Health 2012, 12:3
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curiosity, reassurance of negative status, convenience,
and opportunity. Bringing the test to patients in the ED
removed logistical and psychological barriers that are
known to prevent people from seeking out testing in
traditional venues [20]. In addition, treating HIV like
any other health problem helped patients feel comforta-
ble about the HIV testing process. With regard to refu-
sal of HIV testing in the ED, we found that reasons
were having been tested recently and wanting to focus
on the medical issue that brought the patient to the ED,
consistent with other studies [5,7]. Other reasons were
“not wanting to know”and fear of confidentiality viola-
tions. The role of patients’perception of HIV risk in
testing decisions was more complex. The perception of
being at risk for HIV infection was certainly a motiva-
tion to accept testing, as at voluntary and counseling
testing sites [21], however, we found that the perception
of being at low risk for HIV infection was a reason for
both refusal and acceptance, as it allowed individuals to
feel comfortable accepting a test that they may not have
sought elsewhere.
We discovered that many decliners provided logical
reasons for refusing the test. Even so, decliners viewed
HIV testing in general as important and interpreted the
offer to test as an expression of concern on the part of
the medical establishment. However, our data suggest
that even patients who support HIV testing and are
aware of its benefits may choose not to test because
they prefer to live in uncertainty rather than face psy-
cho-social consequences such as partner discord or dis-
crimination based on HIV status. Indeed, the decliners
in our study were more likely to describe instances of
HIV stigma, even though there was no conscious
acknowledgment of HIV stigma in the decision-making
process.
There are several limitations to this study. This qua-
litative data is hypothesis-generating rather than defini-
tive, and it may not be generalizable to other ED HIV
testing programs. In addition, the interviews were done
in busy EDs with patients who had pressing medical
issues, thus participants may not have been as reflec-
tive as they would have been in other settings. Since
the goal of this investigation was to look across rather
than within programs, we did not assess how opera-
tional aspects of the three different models of ED HIV
testing may have affected acceptance or refusal of test-
ing. We were only able to recruit one decliner from
the site that used clinician-initiated testing, as referrals
of decliners at that site had to come directly from ED
clinicians who had multiple competing priorities and
may have been too busy to refer patients to the study.
Finally, we did not systematically ascertain when
patients last tested, since at the time of this study,
these programs did not have policies on repeat testing.
To our knowledge, there are no published guidelines
on repeat HIV testing in the ED. In general, the 2006
CDC guidelines suggest at least annual testing of high-
risk individuals with repeat testing of other individuals
based on clinical judgment [1]. Thus, it is important to
acknowledge that repeat testing may not have been
necessary for some of the individuals who cited recent
testing as a reason for refusal. Indeed, the optimal
interval for repeating an HIV test in the ED is an
important area of future research.
Conclusions
Participants in this study appreciated HIV testing as part
of their ED care and for the most part did not feel the
need for counseling with testing. Offering testing for
HIV as for any other health problem facilitated accep-
tance for many participants. For several participants,
this type of offer was not compelling enough, and they
did not necessarily perceive HIV testing as normative.
In order to reach this group, some studies have sug-
gested increasing education about the rationale and ben-
efits of testing [13]. However, the results of this study
demonstrate that education alone may not address con-
cerns that are related to potential psychosocial conse-
quences of testing and that these concerns may
supersede a patient’s willingness to receive screening
tests that benefit overall health. While acknowledging
that all patients have the right to refuse testing at any
time and for any reason, further research is needed to
better understand these concerns and develop interven-
tions to address them. It is likely that these interven-
tions will require more counseling than is currently
available in ED HIV testing programs, thus assessment
of feasibility will be a key consideration in moving this
research agenda forward.
Acknowledgements
Funding for this study was provided by the California Department of Public
Health, Office of AIDS, Contract 03-75344. This work was supported in part
by the National Institutes of Health 5P30MH062246, T32 AI60530 and K23
MH092220 (K.A.C), and K23 MH079713 (S.W.). The authors would like to
thank Lisa Georgetti, Scott Milagro-Forte, and Stuart Gaffney for conducting
the interviews used this study.
Author details
1
San Francisco General Hospital HIV/AIDS Division, University of California
San Francisco, San Francisco, CA, USA.
2
Center for AIDS Prevention Studies,
University of California San Francisco, San Francisco, CA, USA.
3
Department
of Emergency Medicine, Alameda County Medical Center, Highland Hospital,
Oakland, CA. USA.
4
Department of Emergency Medicine, San Francisco
General Hospital, University of California San Francisco, San Francisco, CA,
USA.
Authors’contributions
SW, JM, and SM conceived the study and obtained research funding. DW
and BK helped recruit participants. KC, KK, and SW analyzed the data. KC
drafted the manuscript and all authors contributed substantially to its
revision. All authors read and approved the final manuscript.
Christopoulos et al.BMC Public Health 2012, 12:3
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Competing interests
The authors declare that they have no competing interests.
Received: 21 October 2011 Accepted: 3 January 2012
Published: 3 January 2012
References
1. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB,
Clark JE: Revised recommendations for HIV testing of adults, adolescents,
and pregnant women in health-care settings. MMWR Recomm Rep 2006,
55(RR-14):1-17, quiz CE1-4.
2. White DA, Scribner AN, Schulden JD, Branson BM, Heffelfinger JD: Results
of a Rapid HIV Screening and Diagnostic Testing Program in an Urban
Emergency Department. Ann Emerg Med 2008.
3. Brown J, Shesser R, Simon G, Bahn M, Czarnogorski M, Kuo I, Magnus M,
Sikka N: Routine HIV screening in the emergency department using the
new US Centers for Disease Control and Prevention Guidelines: results
from a high-prevalence area. J Acquir Immune Defic Syndr 2007,
46(4):395-401.
4. Haukoos JS, Hopkins E, Eliopoulos VT, Byyny RL, Laperriere KA,
Mendoza MX, Thrun MW: Development and implementation of a model
to improve identification of patients infected with HIV using diagnostic
rapid testing in the emergency department. Acad Emerg Med 2007,
14(12):1149-57.
5. Christopoulos KA, Schackman BR, Lee G, Green RA, Morrison EA: Results
from a New York City emergency department rapid HIV testing
program. J Acquir Immune Defic Syndr 2010, 53(3):420-2.
6. Haukoos JS, Hopkins E, Byyny RL: Patient acceptance of rapid HIV testing
practices in an urban emergency department: assessment of the 2006
CDC recommendations for HIV screening in health care settings. Ann
Emerg Med 2008, 51(3):303-9, 9 e1.
7. Brown J, Kuo I, Bellows J, Barry R, Bui P, Wohlgemuth J, Wills E, Parikh N:
Patient perceptions and acceptance of routine emergency department
HIV testing. Public Health Rep 2008, 123(Suppl 3):21-6.
8. Merchant RC, Clark MA, Seage GR, Mayer KH, Degruttola VG, Becker BM:
Emergency department patient perceptions and preferences on opt-in
rapid HIV screening program components. AIDS Care 2009, 21(4):490-500.
9. Donnell-Fink L, Reichmann WM, Arbelaez C, Case AL, Katz JN, Losina E,
Walensky RP: Patient Satisfaction With Rapid HIV Testing in the
Emergency Department. Ann Emerg Med 2011, 58(Suppl 1):S49-52.
10. Hecht CR, Smith MD, Radonich K, Kozlovskaya O, Totten VY: A Comparison
of Patient and Staff Attitudes About Emergency Department-Based HIV
Testing in 2 Urban Hospitals. Ann Emerg Med 2011, 58(Suppl 1):S28-S32
e4.
11. Batey DS, Hogan VL, Cantor R, Hamlin CM, Ross-Davis K, Nevin C,
Zimmerman C, Thomas S, Mugavero MJ, Willig JH: Routine HIV Testing in
the Emergency Department: Assessment of Patient Perceptions. AIDS Res
Hum Retroviruses 2011.
12. Freeman AE, Sattin RW, Miller KM, Dias JK, Wilde JA: Acceptance of rapid
HIV screening in a southeastern emergency department. Acad Emerg
Med 2009, 16(11):1156-64.
13. Pisculli ML, Reichmann WM, Losina E, Donnell-Fink LA, Arbelaez C, Katz JN,
Walensky RP: Factors Associated with Refusal of Rapid HIV Testing in an
Emergency Department. AIDS Behav 2010.
14. Czarnogorski MBJ, Lee V, Oben J, Kuo I, Stern R, Simon G: The prevalence
of undiagnosed HIV infection in those who decline HIV screening in an
urban emergency department. AIDS Research and Treatment 2011, 2011,
Article ID 879065.
15. Christopoulos KA, Koester K, Weiser S, Lane T, Myers JJ, Morin SF: A
comparative evaluation of the process of developing and implementing
an emergency department HIV testing program. Implement Sci 2011, 6:30.
16. Christopoulos KA, Kaplan B, Dowdy D, Haller B, Nassos P, Roemer M,
Dowling T, Jones D, Hare CB: Testing and Linkage to Care Outcomes for
a Clinician-Initiated Rapid HIV Testing Program in an Urban Emergency
Department. AIDS Patient Care STDS 2011.
17. Atlas.ti Qualitative Software, Version 6.2. Berlin, Germany.
18. Ritchie J, Spencer L: Qualitative Data Analysis for Applied Policy Research.
In Analyzing Qualitative Data. Edited by: Bryman A, Burgess RG. London:
Routledge; 1994:173-94.
19. Nyblade LC: Measuring HIV stigma: existing knowledge and gaps. Psychol
Health Med 2006, 11(3):335-45.
20. Myers JJ, Modica C, Dufour MS, Bernstein C, McNamara K: Routine rapid
HIV screening in six community health centers serving populations at
risk. J Gen Intern Med 2009, 24(12):1269-74.
21. Morin SF, Khumalo-Sakutukwa G, Charlebois ED, Routh J, Fritz K, Lane T,
Vaki T, Fiamma A, Coates TJ: Removing barriers to knowing HIV status:
same-day mobile HIV testing in Zimbabwe. J Acquir Immune Defic Syndr
2006, 41(2):218-24.
Pre-publication history
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doi:10.1186/1471-2458-12-3
Cite this article as: Christopoulos et al.: Understanding patient
acceptance and refusal of HIV testing in the emergency department.
BMC Public Health 2012 12:3.
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