HIV screening in emergency departments/consent/counselingCounselor- Versus Provider-Based HIV Screening in the Emergency Department: Results From the Universal Screening for HIV Infection in the Emergency Room (USHER) Randomized Controlled Trial
Introduction
Knowledge of HIV seropositivity is the first critical step in obtaining appropriate medical care; it allows individuals to receive timely prevention counseling and therapeutic interventions,1 improves clinical outcomes of HIV-infected patients, and potentially decreases rates of HIV transmission. However, opportunities for HIV counseling, testing, and referral are still missed in many medical care settings, including emergency departments (EDs). In EDs, routine HIV screening and appropriate referral to care have historically been the exception, rather than the rule. Emerging data suggest that HIV screening in the ED would identify numerous HIV-infected individuals who commonly use the ED as their sole source of medical care.2, 3
In recognition of the expanding role of ED personnel in the provision of community preventive health care, recent literature has emphasized the critical role EDs could play as HIV testing sites.1 Although such data have motivated EDs nationwide to establish HIV testing programs,3, 4, 5, 6, 7 expansion of other public health efforts in this setting has stressed the already overworked staff and resources.8, 9, 10, 11 The numerous HIV screening strategies in the ED setting previously published are ultimately incomparable because of differences in eligibility, data collection and reporting. Thus, the most effective mechanism to test patients for HIV infection in the ED setting remains unclear.
Our objective was to examine, in a randomized trial, whether ED providers can and will assume the rapid HIV testing role without the addition of extra personnel12 or whether the introduction of an HIV testing “team” (eg, counselors, social workers) is a more effective implementation strategy.
Section snippets
Study Design
The National Institutes of Health–funded Universal Screening for HIV Infection in the Emergency Room (USHER) study is a single-center, randomized controlled trial of routine HIV screening. From February 7, 2007, to July 9, 2008, oral HIV testing was offered to eligible patients by either HIV counselors or emergency service assistants (existing members of ED personnel).13 All subjects provided separate written informed consent first for trial participation and again for rapid HIV testing. The
Results
From February 7, 2007, through July 9, 2008, 12,970 ED visitors seeking health care were screened for USHER trial eligibility according to initial Emergency Severity Index score alone. The most frequently documented reason for ineligibility was age (n=2,102; 44% of all ineligible). Among 8,187 eligible patients approached, 4,860 (59%) agreed to participate (Figure 1). The 3,327 eligible patients who refused trial enrollment were similar in sex and Emergency Severity Index score distribution to
Limitations
Results of this study should be interpreted within the context of its limitations. First, the USHER trial is a single-site study. Second, participants tested in the USHER trial were required to provide informed consent more than once for participation (one for trial, one for testing per Massachusetts state law, and one for confirmation of reactive results, if necessary). The lengthy consent process, though necessary to conduct a criterion standard randomized trial, may have affected
Discussion
In a randomized controlled ED-based trial, we found that routine, voluntary HIV testing was completed more than twice as frequently when personnel were dedicated specifically to this task. Ultimately, more individuals were tested when the responsibility did not solely rely on the current ED staff.
In contrast to our results, data reported by the CDC on 3 ED HIV testing implementation projects (New York, NY, Los Angeles, CA, and Oakland, CA) suggest improved testing rates with a provider-based
References (25)
Current Centers for Disease Control and Prevention guidelines for HIV counseling, testing, and referral: critical role of and a call to action for emergency physicians
Ann Emerg Med
(2004)- et al.
Confronting barriers to universal screening for domestic violence
J Prof Nurs
(2001) - et al.
Attitude changes among emergency department triage staff after conducting routine alcohol screening
Addict Behav
(2006) Missed opportunities for earlier diagnosis of HIV infection—South Carolina, 1997–2005
MMWR Morb Mortal Wkly Rep
(2006)- et al.
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) Rapid HIV testing in emergency departments—three US sites, January 2005–March 2006
MMWR Morb Mortal Wkly Rep
(2007)- et al.
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) - et al.
Detecting unsuspected HIV infection with a rapid whole-blood HIV test in an urban emergency department
J Acquir Immune Defic Syndr
(2007) - et al.
Adult and pediatric emergency department sexually transmitted disease and HIV screening: programmatic overview and outcomes
Acad Emerg Med
(2007) Barriers to effective screening for domestic violence by registered nurses in the emergency department
Crit Care Nurs Q
(1999)
Universal screening for intimate partner violence in the emergency department: importance of patient and provider factors
Ann Emerg Med
Advancing HIV prevention: interim technical guidance for selected interventions
Cited by (46)
Time From HIV Infection to Diagnosis in the U.S., 2014–2018
2021, American Journal of Preventive MedicineCitation Excerpt :Because promising approaches are implemented to expand HIV testing and to increase the testing frequency, the length of time from infection to diagnosis should decrease. Promising approaches include routinizing HIV screening in healthcare settings, providing expanded access to rapid testing in nonclinical settings, expanding HIV self-testing programs, expanding social network–based HIV testing to reach underserved or marginalized populations, and developing peer-led digital communications.35–39 NHSS can be used to provide data to locally tailor these testing initiatives in the various regions of the U.S. and to monitor and evaluate the expected decrease in the time a person is unaware of their positive HIV status.
An Assessment of Emergency Nurses’ Perspectives on Nurse-Driven Human Immunodeficiency Virus Testing in the Emergency Department
2020, Journal of Emergency NursingHepatitis C Management at Federally Qualified Health Centers during the Opioid Epidemic: A Cost-Effectiveness Study
2020, American Journal of MedicineCitation Excerpt :In this intervention, clinicians were prompted to test individuals with hepatitis C risk factors. Offer rates for routine testing were derived from a randomized controlled trial focused on HIV testing, because analogous hepatitis C testing data were unavailable.10 For background testing we used estimates from a commercially insured population.14
Management of Human Immunodeficiency Virus in the Emergency Department
2018, Emergency Medicine Clinics of North AmericaComparative effectiveness and safety of screening and counselling interventions conducted by non-physicians and physicians: A systematic review
2015, Zeitschrift fur Evidenz, Fortbildung und Qualitat im GesundheitswesenThe role of nurses in HIV screening in health care facilities: A systematic review
2014, International Journal of Nursing StudiesCitation Excerpt :In the selected studies, nurses had the responsibility of implementing the HIV screening process alongside physicians. Other staff members who participated in the screening process included nurse practitioners in 4 studies (Hecht et al., 2011; Knapp et al., 2011; McNaghten et al., 2014; Munday et al., 2005), emergency service assistants or nursing assistants in 2 studies (Arbelaez et al., 2012; Walensky et al., 2011) and licensed vocational nurses in 2 studies (Anaya et al., 2012; Kinsler et al., 2013). In 9 studies (30%), implementing the screening process and obtaining consent for the test were a novelty, particularly for nurses who worked in non-specialised settings.
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 as per ICMJE conflict of interest guidelines (see www.icmje.org). This research was funded by the National Institute of Mental Health (R01 MH073445, R01 MH65869) and the Doris Duke Charitable Foundation, Clinical Scientist Development Award to Rochelle P. Walensky. No authors have conflicts of interest to disclose.
Publication of this article was supported by Centers for Disease Control and Prevention, Atlanta, GA.