Infectious disease/original researchResults of a Rapid HIV Screening and Diagnostic Testing Program in an Urban Emergency Department
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
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Cited by (99)
Routine HIV testing in acute care hospitals: Changing practice to curb a local HIV epidemic in Vancouver, BC
2020, Preventive MedicineCitation Excerpt :While, as expected, diagnostic yield declined with increased testing, it did remain above one diagnosis per 1000 tests, a diagnosis yield set by the US CDC for recommendation of routine HIV testing (Branson et al., 2006). This high diagnostic yield in hospital is consistent with other hospital HIV testing pilots in similar epidemics (Galbraith et al., 2016; Geren et al., 2014; Haukoos et al., 2010; Health Protection Agency, 2011; Hoxhaj et al., 2011; Hsieh et al., 2016; Palfreeman et al., 2013; Rucker et al., 2016; Torres et al., 2011; White et al., 2009), and provides support for this testing approach in concentrated epidemics. Additionally, a review of cost effectiveness for HIV testing and treatment initiatives in BC identified hospital-based testing, and ED testing in particular, to have the lowest incremental cost-effectiveness ratio ($30,216 per QALY gained), as well as greatest impact on incidence and mortality over the projected 25 year period (Nosyk et al., 2018).
Management of Human Immunodeficiency Virus in the Emergency Department
2018, Emergency Medicine Clinics of North AmericaA Comparative Effectiveness Study of Two Nontargeted HIV and Hepatitis C Virus Screening Algorithms in an Urban Emergency Department
2018, Annals of Emergency MedicineAssessment of Nurse Perspectives on an Emergency Department-Based Routine Opt-Out HIV Screening Program
2017, Journal of the Association of Nurses in AIDS CareDifferences Between Emergency Nurse Perception and Patient Reported Experience With an ED HIV and Hepatitis C Virus Screening Program
2016, Journal of Emergency NursingResults of a Rapid Hepatitis C Virus Screening and Diagnostic Testing Program in an Urban Emergency Department
2016, Annals of Emergency Medicine
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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.
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Publication date: Available online November 5, 2008.
Reprints not available from the authors.