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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.
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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 patientsperceived
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 knowones 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 checktheir bodies and ensure good health.
Well, Im in here getting tested. Im 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
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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 its 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 Id never had one and it was free... I would
havenotsoughtoutattestjustonmyown.I
wouldnt have made a doctors appointment. So it
was a good thing that the hospital offered it. I went,
Well, why not?But I wouldnt have thought to go,
cause it wasntaconcerninmymind,whether
thats right or wrong smart or ignorant. I think itsa
good thing because everybody should know and its
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 wasntofferedatthishospital.
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
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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
didnt 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 didnt
express any interest in counseling. I think had they
gone that route I probably wouldnt have wanted to
take it because Im not here for that so it was sort of
like, Oh well, while youre here...And the fact that
they presented it as while youre here, by the way...
I actually thought was pretty good. Because it made
me feel comfortable. It wasntlike,Oh, my God,
you have to make sure everybody who comes
through here doesnthaveAIDS.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 Im monogamous and I didnt
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 dontgotit.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 Ive been home Ive been using
straight condoms and I dont 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 didntwantto
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, its 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 hasntchangedsinceIve 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 Ive 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 Dont 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 dont know, actually.
Ijustdontwanttotakeone.IguessIdontwantto
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 Im not having any outside
sex so I just - theres really no privacy once you get
that information out there... I dontcaretoknow
onewayortheother...Ithinkmyriskislow,I
mean Im trusting him not to be having any outside
sex and I know that Im not and like I said weve
been in a monogamous relationship for more than
twenty years now so I dontthinkthatImatrisk,
no... Should I start a medical record somewhere I
dont want that I was even tested because really sup-
posed confidentiality is not reality. Everythingson
computer. I just dontwantthatinformationout
there. Um, well I would have to be tested so there
my confidentiality is violated cause if its positive
thats everybody. Public health, the lab, everybody
would know. And I dont want to know. Like I said -
well I guess that would ruin whatever trust, cause Id
knowwhereIgotitfromifIgotit.LikeIsaidI
havent 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 layeredstigma around homosexuality
and intravenous drug use [19]. One participant who
declined HIV testing and had never tested for HIV
infection described a familysresponsetoacousinwho
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 peoples
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
cant bring him. They fixed him a plate and told him
to take it with him. Dontworryaboutbringingit
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.
Its kind of like a rush here, so they dont 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 dont
becausetheybesobackeduptothepointwhere
they cant talk to you and they just be like, Okay,
well here go the test. Your doctors 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
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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 knowand fear of confidentiality viola-
tions. The role of patientsperception 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 patients 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.
Authorscontributions
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
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... Based on the type of study pursuant to the MMAT tool [16], the selected sample was composed of 2 qualitative studies [17,18], 9 randomised clinical trials [3,4,[19][20][21][22][23][24][25], 3 non-randomised quantitative studies [7,9,26], and 15 descriptive quantitative studies [2,5,6,8,[27][28][29][30][31][32][33][34][35][36][37]. ...
... The main reasons given by patients for accepting the performance of the test include that they think it is good to know the result and be aware of their current HIV status, it has been more than a year since the last HIV test or they have never been tested, and that the test is quick and for free [3,8,17]. ...
... Pursuant to the consulted studies, most of the population offered a screening rejected it, some of the reasons being the low risk perception, having had a test performed previously, focusing on the reason for consultation with the emergency service and/or not wanting to know the result because of fear or shame [3,8,17,18,25,34,36]. It is worth noting the variability between genders; in a study performed in Tanzania, 100% of women accepted getting tested, as opposed to 69% of men [7]. ...
Article
Full-text available
Aim: To evaluate HIV screening of people attending emergency services. Design: Systematic review. Data sources: CINAHL Complete, Cochrane Library, Cuiden Plus, PubMed, PsycINFO, SCOPUS and Web of Science. Review methods: The search was carried out between December 2020 and March 2021 following the recommendations set forth in the PRISMA declaration. The Mixed Methods Appraisal Tool (MMAT) was used to evaluate the methodological quality of studies. For data extraction, a protocol was prepared. A qualitative synthesis of the main findings was carried out. Results: The final sample consisted of 29 articles. There are several aspects that influence the performance of HIV screening in the emergency department, such as: adequacy of place, attitude towards screening, sociodemo-graphic characteristics, risky sexual behaviour, incidence of area, and detection tools or method employed, in addition to other factors such as the stigma associated with the disease. Conclusions: Emergency services are relevant in screening the human immunodeficiency virus. Further research aimed at creating new interventions allowing early detection and adherence to treatment in this population is still a need, particularly in a first-line service like emergency services.
... Patients accepting testing were largely male (672, 52.7%). The top reasons for declining HCT were 'does not want to know status' (53, 37.6%), 'in too much pain' (48, 34%) and 'does not believe they are at risk' (28,19.9%; Figure 1). Patients declining testing were largely female (85, 60.3%). ...
... While it is difficult to generalise individual motivations, factors including lack of social support and fear of stigma or rejection if tested HIV positive, especially in the presence of their partner or family accompanying them to the ED, may otherwise underlie the greater tendency of women to decline HCT. 25 The top reasons reported for declining HCT in our ED, 'does not want to know status' and 'does not believe they are at risk', are interestingly established findings from high-income countries and LMICs, across healthcare settings. 16,20,26,27,28,29 It could be that patients prefer uncertainty rather than facing the psychosocial consequences of an HIV-positive diagnosis, especially considering the imaginable stigma attached to such a diagnosis. 30 This could be tackled through targeted pre-and post-counselling efforts. ...
Article
Full-text available
Background: South Africa faces the highest burden of HIV infection globally. The National Strategic Plan on HIV recommends provider-initiated HIV counselling and testing (HCT) in all healthcare facilities. However, HIV continues to overwhelm the healthcare system. Emergency department (ED)-based HCT could address unmet testing needs. Objectives: This study examines the reasons for accepting or declining HCT in South African EDs to inform the development of HCT implementation strategies. Method: We conducted a prospective observational study in two rural EDs, from June to September 2017. Patients presenting to the ED were systematically approached and offered a point-of-care test in accordance with national guidelines. Patients demographics, presenting compaint, medical history and reasons for accepting/declining testing, were recorded. A pooled analysis is presented. Results: Across sites, 2074 adult, non-critical patients in the ED were approached; 1880 were enrolled in the study. Of those enrolled, 19.7% had a previously known positive diagnosis, and 80.3% were unaware of their HIV status. Of those unaware, 90% patients accepted and 10% declined testing. The primary reasons for declining testing were ‘does not want to know status’ (37.6%), ‘in too much pain’ (34%) and ‘does not believe they are at risk’ (19.9%). Conclusions: Despite national guidelines, a high proportion of individuals remain undiagnosed, of which a majority are young men. Our study demonstrated high patient acceptance of ED-based HCT. There is a need for investment and innovation regarding effective pain management and confidential service delivery to address patient barriers. Findings support a routine, non-targeted HCT strategy in EDs.
... Patient attitudes found that reasons for not accepting a test included having a recent test [62,65], not perceiving themselves to be at risk [34,62,65,69,[90][91][92], not wanting to know their status [46,62,93] or stating that they did not care [69], concerns about anonymity and confidentiality [ feeling well [59], not wanting additional needles [59] or a finger prick [62,69], inappropriate time for testing as the ED was for emergencies [62], concern about other medical problems [59], or concern it would delay their emergency care [69], with some patients offended at being offered the test [90]. for returning results and linking patients to care are described in Table 3. Overall the proportion of patients who received their test result ranged from 13% to 100% [28,30,32,36,37,39,41,50,55,56,77,95]. ...
Article
Full-text available
Background Blood‐borne viruses (BBVs) cause significant morbidity and mortality worldwide. Emergency departments (EDs) offer a point of contact for groups at increased risk of BBVs who may be less likely to engage with primary care. We reviewed the literature to evaluate whether BBV testing in this setting might be a viable option to increase case finding and linkage to care. Methods We searched PubMed database for English language articles published until June 2019 on BBV testing in EDs. Studies reporting seroprevalence surveys, feasibility, linkage to care, enablers and barriers to testing were included. Additional searches for grey literature were performed. Results Eight‐nine articles met inclusion criteria, of which 14 reported BBV seroprevalence surveys in EDs, 54 investigated feasibility and acceptability, and 36 investigated linkage to care. Most studies were HIV‐focused and conducted in the USA. Seroprevalence rates were in the range 1.5–17% for HCV, 0.7–1.6% for HBV, and 0.8–13% for HIV. For studies that used an opt‐in study design, testing uptake ranged from 2% to 98% and for opt‐out it ranged from 16% to 91%. There was a wide range of yield: 13–100% of patients received their test result, 21–100% were linked to care, and 50–91% were retained in care. Compared with individuals diagnosed with HIV, linkage to and retention in care were lower for those diagnosed with hepatitis C. Predictors of linkage to care was associated with certain patient characteristics. Conclusions Universal opt‐out BBV testing in EDs may be feasible and acceptable, but linkage to care needs to be improved by optimizing implementation. Further economic evaluations of hepatitis testing in EDs are needed.
... In our research studies, 35% to 62% of adult ED patients declined HIV/HCV screening (Merchant et al., 2009(Merchant et al., , 2011(Merchant et al., , 2014(Merchant et al., , 2015. In US EDs, patients commonly decline HIV screening out of a belief that they are not at risk (Brown et al., 2008;Christopoulos et al., 2012;Jain et al., 2012;Merchant et al., 2008;Pisculli et al., 2011;Schechter-Perkins et al., 2014;Ubhayakar et al., 2011). However, self-perceived and actual risk about HIV are frequently incongruent among ED patients (Pringle et al., 2013;Ubhayakar et al., 2011) which can contribute to losing an opportunity to identify an infection through screening. ...
Article
Full-text available
Screening for HIV and hepatitis C (HCV) in emergency departments (EDs) allows patients to benefit from life-saving treatment; however, some patients at risk for these infections decline to be tested. Interventions that overcome patient reluctance to be screened are needed so that infected patients can be linked with care. In this project, we developed a very brief, theory-based, persuasive health communication intervention (PHCI) drawn from our previous research that can be integrated into usual clinical practice. The intervention was revised with the assistance of stakeholders who would likely either deliver the intervention (ED medical staff or HIV/HCV counselors) and those who would receive it (adult ED patients). The final version of the intervention was rated as both persuasive and respectful of ED patients who initially declined HIV/HCV testing.
... Dangerous gaps in HIV-related health literacy have also been documented among adolescents, including a lack of understanding that people who test negative may need to re-test if they have been recently exposed to HIV [12] and that many HIV positive youth do not know their status [13]. Similar literacy deficits may potentially lead youth to incorrectly believe they do not require testing because they are not at risk [14], and therefore to decline testing when offered. ...
Article
Full-text available
Because adolescents and emerging adults are frequently not offered HIV testing, and often decline tests when offered, we developed and tested a tablet-based intervention to increase HIV test rates among emergency department (ED) patients aged 13-24 years. Pediatric and adult ED patients in a high volume New York City hospital (N = 295) were randomized to receive a face-to-face HIV test offer, or to complete a tablet-based intervention that contained an HIV test offer delivered via computer. Test rates in both conditions were then compared to historic test rates in the same ED during the previous six months. Among participants aged 19 years and younger who were offered HIV testing and declined before enrollment in the study, participants in the tablet-based condition were 1.7 times more likely to test for HIV compared to participants in the face-to-face condition. Participants aged 19 years and younger were three times as likely to test for HIV compared to patients the same age who were treated in the previous six months (26.39%, n = 71 study participants vs. 10.29%, n = 189 prior patients, OR = 3.13, [Formula: see text]2 = 54.76, p < 0.001). Protocols designed to offer HIV testing to all eligible patients can significantly increase adolescent test rates compared to standard practice. Because tablets are equally effective compared to face-to-face offers, and in some cases more so, EDs may consider tablet-based interventions that require fewer staff resources and may integrate more easily into high-volume workflows.
... Dental patients 18 years and older who visited the sample practices from August to September were invited to participate in the survey. The proportion of participants who were willing to receive ORHT ranged from 24% to 91% [36]. If we take 24% as the expected proportion of our survey, α = 0.01 and the allowable error d = 0.15P, according to the formula 2 , which is commonly used to estimate the sample size of cross sectional study, then the approximately sample size would be 934. ...
Article
Full-text available
Introduction HIV testing is an important strategy for controlling and ultimately ending the global pandemic. Oral rapid HIV testing (ORHT) is an evidence-based strategy and the evidence-based shows is favored over traditional blood tests in many key populations. The dental setting has been found to be a trusted, convenient, and yet untapped venue to conduct ORHT. This study assessed the HIV testing behaviors and willingness to receive ORHT among dental patients in Xi’an, China. Methods A cross-sectional survey of dental patients from Xi’an was conducted from August to September 2017. Dental patients were recruited using a stratified cluster sampling. A 44-item survey was used to measure HIV/AIDS knowledge, HIV testing behaviors, and willingness to receive ORHT. Results Nine hundred and nine dental patients completed the survey with a mean HIV/AIDS knowledge score of 10.7/15 (SD 2.8). Eighty-four participants (9.2%) had previously received an HIV test. Participants would have a high rate of HIV testing if they had higher monthly income (OR = 1.982, 95% CI: 1.251–3.140) and a higher HIV/AIDS knowledge score (OR = 1.137, 95% CI: 1.032–1.252). Five hundred and eighty-two participants (64.0%) were willing to receive ORHT before a dental treatment, 198 (21.8%) were not sure, and 129 (14.2%) were unwilling. Logistic regression showed that age (OR = 0.970, 95% CI: 0.959–0.982), HIV/AIDS knowledge score (OR = 1.087, 95% CI: 1.031–1.145), previous HIV test (OR = 2.057, 95% CI: 1.136–3.723), having advanced HIV testing knowledge (OR = 1.570, 95% CI: 1.158–2.128), and having advanced ORHT knowledge (OR = 2.074, 95%: CI 1.469–2.928) were the factors affecting the willingness to receive ORHT. Conclusions The majority of dental patients had not previously received an HIV test, although many were receptive to being tested in the dental setting. The dental setting as a venue to screen people for HIV needs further exploration, particularly because many people do not associate dentistry with chairside screenings. Increasing awareness of ORHT and reducing testing price can further improve the patient’s willingness to receive ORHT.
... Some of the reasons why pregnant women do not test for HIV in SSA include inaccessibility of healthcare facility [20], perceived lack of confidentiality, stigma, and discrimination [21,22], cost, illiteracy, and inability to secure husband's permission, attitude, and skills of health workers and inadequate resources [23,24]. Health behavioural theories such as the Health belief model (HBM) [25] and Capability, Opportunity, and Motivation Model of Behaviour (COM-B) model [26] have also highlighted barriers and enablers of uptake of health behaviours and behavioural change among individuals, including deciding to test for HIV during pregnancy. ...
Article
Full-text available
Background Prenatal screening of pregnant women for HIV is central to eliminating mother-to-child-transmission (MTCT) of HIV. While some countries in sub-Saharan Africa (SSA) have scaled up their prevention of MTCT programmes, ensuring a near-universal prenatal care HIV testing, and recording a significant reduction in new infection among children, several others have poor outcomes due to inadequate testing. We conducted a multi-country analysis of demographic and health surveys (DHS) to assess the coverage of HIV testing during pregnancy and also examine the factors associated with uptake. Methods We analysed data of 64,933 women from 16 SSA countries with recent DHS datasets (2015–2018) using Stata version 16. Adjusted and unadjusted logistic regression models were used to examine correlates of prenatal care uptake of HIV testing. Statistical significance was set at p<0.05. Results Progress in scaling up of prenatal care HIV testing was uneven across SSA, with only 6.1% of pregnant women tested in Chad compared to 98.1% in Rwanda. While inequality in access to HIV testing among pregnant women is pervasive in most SSA countries and particularly in West and Central Africa sub-regions, a few countries, including Rwanda, South Africa, Zimbabwe, Malawi and Zambia have managed to eliminate wealth and rural-urban inequalities in access to prenatal care HIV testing. Conclusion Our findings highlight the between countries and sub-regional disparities in prenatal care uptake of HIV testing in SSA. Even though no country has universal coverage of prenatal care HIV testing, East and Southern African regions have made remarkable progress towards ensuring no pregnant woman is left untested. However, the West and Central Africa regions had low coverage of prenatal care testing, with the rich and well educated having better access to testing, while the poor rarely tested. Addressing the inequitable access and coverage of HIV testing among pregnant women is vital in these sub-regions.
... negative test, self-perception of low risk, preference to remain unaware of their diagnosis, and concern for confidentiality. 3 Patients with a history or trauma, ID, or sensory integration differences may be fearful of the experience of testing. Some patients may have contraindications to the available test. ...
... Understanding patient refusal is crucial because it has been demonstrated that patients who decline testing in the ED are at a higher risk of infection as compared to those who accept testing [8]. Factors that influence this decision have been studied through the context of patient perception of HIV risk, but there is limited research examining the social influences inherent to testing dynamics [9]. In a study examining why patients refuse HIV rapid testing, 50% of their sample refused testing because of aspects of the testing process [8]. ...
Article
Full-text available
Rapid HIV testing programs in emergency departments (EDs) have been shown to promote early diagnosis and linkage to specialty care. However, sensitivity of the subject-matter and stigmatization of disclosing associated risk factors may make patients reluctant to consent to testing in this setting. This study sought to determine whether men are more likely to refuse rapid HIV testing in the ED as compared to women and to analyze the influence of tester gender on the response. This retroactive study utilized demographic and testing information from a rapid HIV testing program housed within two urban EDs for a 5-month period. Gender and age were collected for both testers and patients, along with patient consent outcome. A total of 5358 patients (males = 2230; females = 3128) were approached and offered an HIV test by one of 19 testers during the study period. From the sample population, male and female patient refusal rates were similar (30.0% vs 29.1%, respectively). Female testers approached 57.8% (n = 3,095) of the patients; however, they had a significantly higher refusal rate compared to male testers (35.6% vs 21.4%; p < 0.001). We found a potential gender effect on HIV test consenting. Such a finding could have important implications on HIV screening program effectiveness and warrants further investigation.
Article
Dental settings are untapped venues to identify patients with undiagnosed HIV who may otherwise lack testing opportunities. Perceived lack of patient acceptance has been a significant barrier limiting dentists' willingness to offer HIV testing. This study implemented rapid HIV testing in dental settings located in an HIV prevalent region to evaluate patient acceptance. Two South Florida community health centers implemented routine oral rapid HIV testing as part of clinical practice, followed by exit interviews with patients immediately after to determine patient acceptance. The binary primary outcome was patient's acceptance of the rapid HIV test. Multivariable logistic regression assessed associations between patient characteristics and acceptance. Overall acceptance by dental patients (N = 600) was 84.5%. Patients who were more likely to participate in other medical screenings in dental settings were more than twice as likely to accept the test compared to those who were neutral/less likely (OR: 2.373; 95% CI: 1.406-4.004). Study findings highlight the high patient acceptance of HIV testing in dental settings. Widespread implementation of such testing will require an expanded societal view of the traditional role of the dentist that will embrace the potentially valuable role of dentistry in preventive health screenings and population health.
Article
Full-text available
The CDC released revised HIV testing guidelines in 2006 recommending routine, opt-out HIV testing in acute care settings including emergency departments (ED). Patient attitudes have been cited as a barrier to implementation of routine HIV testing in the ED. We assessed patients' perceptions of HIV testing in the ED through a contextual qualitative approach. The study was conducted during a 72-h period. All adults presenting to the ED without life-threatening trauma or psychiatric crisis completed a standardized questionnaire. The questionnaire explored HIV testing history, knowledge of testing resources, and qualitative items addressing participant perceptions about advantages and disadvantages to ED testing. After completion of the interview, participants were offered a free, confidential, rapid HIV test. Among 329 eligible individuals approached, 288 (87.5%) completed the initial interview. Participants overwhelmingly (n=247, 85.8%) reported support for testing and identified increased knowledge (41%), prevention (12.5%), convenience (11.8%), and treatment (4.9%) among the advantages. Fear and denial about one's HIV status, reported by <5% of patients, were identified as the most significant barriers to ED testing. Bivariate analysis determined race and ethnicity differences between individuals completing the interview and those who refused (p<0.05). Among individuals consenting for testing (n=186, 64.6%), no positives were detected. Most patients support HIV testing in the ED, noting knowledge of status, prevention, convenience, and linkage to early treatment as distinct advantages. These data are of particular benefit to decision makers considering the addition of routine HIV testing in EDs.
Article
Full-text available
Objective. To determine the prevalence of occult HIV infection in patients who decline routine HIV testing in an urban emergency department. Design, Setting, and Patients. Discarded blood samples were obtained from patients who had declined routine ED HIV testing. After insuring that the samples came from patients not known to be HIV positive, they were deidentified, and rapid HIV testing was preformed using 5 μL of whole blood. Main Outcome Measures. The prevalence of occult HIV infection in those who declined testing compared with prevalence in those who accepted testing. Results. 600 consecutive samples of patients who declined routine HIV screening were screened for HIV. Twelve (2%) were reactive. Over the same period of time, 4845 patients accepted routine HIV testing. Of these, 35 (0.7%) were reactive. The difference in the prevalence of HIV infection between those who declined and those who accepted testing was significant (P = .001). The relative risk of undetected HIV infection in the group that declined testing was 2.74 times higher (95% CI 1.44–5.18) compared with those accepted testing. Conclusion. The rate of occult HIV infection is nearly three-times higher in those who decline routine ED HIV testing compared with those who accept such testing. Interventions are urgently needed to decrease the opt-out rate in routine ED HIV testing settings.
Article
Full-text available
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.
Article
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.
Article
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.
Article
Patient satisfaction with HIV screening is crucial for sustainable implementation of the Centers for Disease Control and Prevention (CDC) HIV testing recommendations. This investigation assesses patient satisfaction with rapid HIV testing in the emergency department (ED) of an urban tertiary academic medical center. After receiving HIV test results, participants in the Universal Screening for HIV Infection in the Emergency Room (USHER) randomized controlled trial were offered a patient satisfaction survey. Questions concerned overall satisfaction with ED visit, time spent on primary medical problem, time spent on HIV testing, and test provider's ability to answer HIV-related questions. Responses were reported on a 4-point Likert scale, ranging from very dissatisfied to very satisfied (defined as optimal satisfaction). Of 4,860 USHER participants, 2,025 completed testing and were offered the survey: 1,616 (79.8%) completed the survey. Overall, 1,478 (91.5%) were very satisfied. Satisfaction was less than optimal for 34.5% (10 of 29) of participants with reactive results and for 7.5% (115 of 1,542) with nonreactive results. The independent factors associated with less than optimal satisfaction were reactive test result, aged 60 years or older, black race, Hispanic/Latino ethnicity, and testing by ED provider instead of HIV counselor. Most participants were very satisfied with the ED-based rapid HIV testing program. Identification of independent factors that correlate with patient satisfaction will help guide best practices as EDs implement CDC recommendations. It is critical to better understand whether patients with reactive results were negatively affected by their results or truly had concerns about the testing process.
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This study compares and contrasts emergency department (ED) patient and staff attitudes towards ED-based HIV testing in 2 major hospitals in a single city, with an attempt to answer the following: Should routine ED-based HIV testing be offered? If so, who should be responsible for disclosing HIV test results? And what barriers might prevent ED-based HIV testing? Paper-based surveys were presented to a convenience sample of ED patients and staff at 2 urban, academic, tertiary care hospitals between December 2007 and June 2009. Descriptive statistics were derived with SAS and MicroSoft Excel. Data are reported in percentages, fractions, and graphs. A total of 457 patients and 85 staff completed the surveys. The majority of patients favor ED-based HIV testing. Only a minority of ED staff support ED-based HIV testing. In both hospitals, patients prefer to have HIV test results delivered by a physician. This was true for both positive and negative results. However, only about one third of attending physicians feel comfortable disclosing a positive HIV test result. Patients and staff both view privacy and confidentiality as significant barriers to ED-based HIV testing. Although ED patients are overwhelmingly in favor of ED-based HIV testing, the staff is not. Patients and staff agree that physicians should deliver HIV test results to patients, but a significant number of physicians are not comfortable doing so. Historical barriers continue to hinder ED-based HIV testing programs.