HIV screening in emergency departments/consent/counseling
Counselor- 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

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Objective

We compare rates of rapid HIV testing, test offer, and acceptance in an urban emergency department (ED) when conducted by dedicated HIV counselors versus current members of the ED staff.

Methods

The Universal Screening for HIV Infection in the Emergency Room [USHER] trial is a prospective randomized controlled trial that implemented an HIV screening program in the ED of an urban tertiary medical center. ED patients were screened and consented for trial enrollment by an USHER research assistant. Eligible subjects were randomized to rapid HIV testing (oral OraQuick) offered by a dedicated counselor (counselor arm) or by an ED provider (provider arm). In the counselor arm, counselors—without other clinical responsibilities—assumed nearly all testing-related activities (consent, counseling, delivery of test results). In the provider arm, trained ED emergency service assistants (nursing assistants) consented and tested the participant in the context of other ED-related responsibilities. In this arm, ED house officers, physician assistants, or attending physicians provided HIV test results to trial participants. Outcome measures were rates of HIV testing and test offer among individuals consenting for study participation. Among individuals offered the test, test acceptance was also measured.

Results

From February 2007 through July 2008, 8,187 eligible patients were approached in the ED, and 4,855 (59%) consented and were randomized to trial participation. The mean age was 37 years, 65% were women, and 42% were white. The overall testing rate favored the counselor arm (57% versus 27%; P<.001); 80% (1,959/2,446) of subjects in the counselor arm were offered an HIV test compared with 36% (861/2,409) in the provider arm (P<.001). HIV test acceptance was slightly higher in the provider arm (counselor arm 71% versus provider arm 75%; P=.025).

Conclusion

Routine rapid HIV testing in the ED was accomplished more frequently by dedicated HIV counselors than by ED staff in the course of routine clinical work. Without dedicated staff, HIV testing in this setting may not be truly routine.

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

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    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.

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