Infectious disease/original research
Results of a Rapid HIV Screening and Diagnostic Testing Program in an Urban Emergency Department

Presented in part at the Society for Academic Emergency Medicine annual conference, May 2006, San Francisco, CA.
https://doi.org/10.1016/j.annemergmed.2008.09.027Get rights and content

Study objective

We describe outcomes of a rapid HIV testing program integrated into emergency department (ED) services, using existing staff.

Methods

From April 2005 through December 2006, triage nurses in an urban ED offered HIV screening to medically stable patients aged 12 years or older. Clinicians could also order diagnostic testing according to presenting signs and symptoms and suspicion of HIV-related illness. Nurses obtained consent, performed rapid testing, and disclosed negative test results. Clinicians disclosed positive test results and arranged follow-up. Outcome measures included number and proportion of visits during which screening was offered, accepted, and completed; number of visits during which diagnostic testing was completed; and number of patients with confirmed new HIV diagnosis and their CD4 counts.

Results

HIV screening and diagnostic testing were completed in 9,466 (8%) of the 118,324 ED visits (14.2% of the 60,306 unique patients were tested at least once). Screening was offered 45,159 (38.2%) times, accepted 21,626 (18.3%) times, and completed 7,923 (6.7%) times; diagnostic testing was performed 1,543 (1.3%) times. Fifty-five (0.7%) screened patients and 46 (3.0%) of those completing diagnostic testing had confirmed positive HIV test results. Median CD4 count was 356 cells/μL among screened patients and 99 cells/μL among those who received diagnostic testing.

Conclusion

Although existing staff was able to perform HIV screening and diagnostic testing, screening capacity was limited and the HIV prevalence was low in those screened. Diagnostic testing yielded a higher percentage of new HIV diagnoses, but screening identified greater than 50% of those found to be HIV positive, and the median CD4 count was substantially higher among those screened than those completing diagnostic testing.

Introduction

Urban emergency departments (EDs) are logical venues for HIV screening because the ED is often the only source of health care for many low-income, uninsured patients with a high prevalence of undiagnosed HIV infection.1, 2, 3, 4, 5 Since 1993, the Centers for Disease Control and Prevention (CDC) has recommended that HIV screening be offered routinely to all patients in high-prevalence settings, including urban EDs.6 In 2003, the CDC introduced strategies to make HIV testing a routine part of health care, promoting simplified procedures to make testing more practical.7 Despite these recommendations, several studies have subsequently shown that many patients with newly diagnosed HIV infection have made multiple previous visits to EDs, during which their HIV infection was not detected.8, 9, 10 In fact, ED HIV screening is rarely performed outside of research programs, even for high-risk patients,9, 11, 12, 13 and a recent national survey demonstrated that only 13% of academic EDs had a policy for HIV screening.13

In previous demonstration projects and research studies, ED-based HIV screening programs have successfully detected undiagnosed HIV infection in 0.6% to 14% of patients tested.4, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 To date, these programs have relied exclusively on supplemental staff to perform HIV counseling and testing and, often, risk assessment and recordkeeping. Such programs may be difficult to replicate in many EDs because of resource and space limitations. To our knowledge, no previous reports have examined the degree to which HIV screening with rapid tests can be incorporated into routine clinical practice, using existing staff.

In April 2005, according to the CDC's 2003 HIV testing guidelines,7 we developed and implemented a novel, 2-tiered program for providing ED-based HIV testing. The model included opt-in HIV screening, in which patients are routinely offered an HIV test by triage nurses and their assent is required, and diagnostic HIV testing, in which testing is ordered by clinicians according to the patient's presenting signs and symptoms and their suspicion of HIV-related illness. The model used existing ED staff, point-of-care rapid HIV tests, and abbreviated consent and counseling procedures. The objectives of this article are to describe this model and to report the results of its implementation.

Section snippets

Study Design

This is a descriptive report of a CDC-funded demonstration project designed to integrate routine HIV screening into emergency care services. Because we anticipated that providing point-of-care screening in the ED might influence clinicians to order diagnostic HIV tests, we evaluated diagnostic testing separately. The project was determined to be an evaluation of a public health program, and therefore review by the CDC's institutional review board was not required. However, the project received

Results

From April 1, 2005, to December 31, 2006, the medical center recorded 118,324 visits to the ED by patients aged 12 years or older. The Figure outlines the respective outcomes of screening and diagnostic testing. Overall, 8.0% of the age-eligible ED population received an HIV test during the project period. HIV screening was offered during 45,159 (38.2%), accepted in 21,626 (18.3%), and completed in 7,923 (6.7%) of the 118,324 ED visits. Diagnostic testing was performed in 1,543 (1.2%) ED

Limitations

This demonstration project was intended to explore clinical outcomes of an integrated HIV screening program and thus minimized data collection that might interfere with clinical activities. This imposed several limitations. There was no systematic assessment of reasons why triage nurses did not offer HIV screening to some patients, why patients declined screening, or why nurses did not perform tests on all patients who consented. Although nurses offered several anecdotal explanations for

Discussion

This demonstration project offers an illustration of what might be expected when an HIV testing program that includes screening and diagnostic testing is introduced into routine ED practice, using existing staff to perform point-of-care rapid testing. Approximately 14% of the 60,306 unique patients aged 12 years or older who presented to the ED in a 21-month period received a rapid HIV test. More than 9,400 tests were performed, 101 new HIV diagnoses were made, and the majority of patients

References (46)

  • G.D. Kelen et al.

    Trends in human immunodeficiency virus (HIV) infection among a patient population of an inner-city emergency department: implications for emergency department-based screening programs for HIV infection

    Clin Infect Dis

    (1995)
  • G.D. Kelen et al.

    Human immunodeficiency virus infection in emergency department patientsEpidemiology, clinical presentations, and risk to health care workers: the Johns Hopkins experience

    JAMA

    (1989)
  • K. Grumbach et al.

    Primary care and public emergency department overcrowding

    Am J Public Health

    (1993)
  • Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings

    MMWR Recomm Rep

    (1993)
  • Advancing HIV prevention: new strategies for a changing epidemic—United States, 2003

    MMWR Morb Mortal Wkly Rep

    (2003)
  • W.K.L. Duffus et al.

    Missed opportunities for earlier diagnosis of HIV infection—South Carolina, 1997-2005

    MMWR Morb Mortal Wkly Rep

    (2006)
  • R.V. Liddicoat et al.

    Assessing missed opportunities for HIV testing in medical settings

    J Gen Intern Med

    (2004)
  • A.M. Kuo et al.

    Recognition of undiagnosed HIV infection: an evaluation of missed opportunities in a predominantly urban minority population

    AIDS Patient Care STDS

    (2005)
  • M. Fincher-Mergi et al.

    Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs

    AIDS Patient Care STDS

    (2002)
  • P.D. Ehrenkranz et al.

    Availability of rapid human immunodeficiency virus testing in academic emergency departments

    Acad Emerg Med

    (2008)
  • Kroc K. Rapid HIV testing in an emergency department [abstract]. Presented at the National STD Prevention Conference,...
  • S.R. Kendrick et al.

    Comparison of point-of-care rapid HIV testing in three clinical venues

    AIDS

    (2004)
  • Routinely recommended HIV testing at an urban urgent-care clinic—Atlanta, Georgia, 2000

    MMWR Morb Mortal Wkly Rep

    (2001)
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    Supervising editor: David A. Talan, MD

    Author contributions: DAEW, JDS, BMB, and JDH conceived and designed the study. ANS acquired the data. DAEW, ANS, JDS, BMB, and JDH analyzed and interpreted the data. DAEW and ANS drafted the article, and all authors contributed substantially to its revision. Statistical analysis was provided by Barbara Grimes, PhD, University of California at San Francisco, Department of Epidemiology and Biostatistics (paid consultant). DAEW obtained the funding and takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Supported by grant PSU65/CCU924486 from the Centers for Disease Control and Prevention and by grant 1 UL1 RR024131-01 from the National Center for Research Resources, a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. The findings and conclusions in this publication are those of the authors and do not necessarily represent the views of the CDC or of the NCRR.

    Earn CME Credit: Continuing Medical Education is available for this article at: www.ACEP-EMedHome.com.

    Publication date: Available online November 5, 2008.

    Reprints not available from the authors.

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