HIV screening in emergency departments/process/model
Routine, Rapid HIV Testing of Medicine Service Admissions in the Emergency Department

https://doi.org/10.1016/j.annemergmed.2011.03.027Get rights and content

Objective

We identify undiagnosed HIV among adult emergency department (ED) patients awaiting medicine admission through rapid testing, expedite their redirection to the inpatient HIV service, and improve linkage to ambulatory HIV care.

Methods

Two ED health educators offered rapid testing to patients aged 18 to 64 years from the high-acuity ED area from which most medicine admissions originate. Heath educators obtained consent, obtained fingerstick blood, and performed point-of-care testing. Patients with reactive results received counseling, confirmatory testing, and appointments at the affiliated HIV clinic.

Results

Between March 1, 2008, and February 28, 2009, 4,755 patients received testing. Thirty patients (0.6%) had received a new diagnosis of HIV; 26 were admitted and redirected to the HIV service. Characteristics of HIV positive patients were mean age 38 years, 87% men, 64% black, and 33% Hispanic; 76% had CD4 counts less than 200 cells/mm3; 67% had HIV-related diagnoses; and 93% reported for ambulatory HIV care in a median of 10 days. During 2 preceding years, these patients had a mean of 3 previous health system visits without testing. During a 6-month quality assurance interval of the 5,340 ED medicine admissions, 31% of patients were eligible for testing, of whom 88% received testing (1% positive) and 12% declined; 29% of the 5,340 were not approached for testing; and 40% were deemed ineligible. Common reasons for ineligibility included older age, recent previous test, and known HIV-positive status.

Conclusion

Patients who receive a diagnosis of HIV in our ED before admission are extremely ill, most having AIDS. Targeted HIV screening of ED patients awaiting hospital admission facilitated timely diagnosis and reliable linkage to inpatient and outpatient HIV care.

Introduction

Although few reports document the extent to which the 2006 Centers for Disease Control and Prevention (CDC) HIV testing guidelines have been followed for patients admitted to the hospital, research does demonstrate the efficacy of screening inpatients for HIV.1 Mehta et al2 described screening patients for HIV in different clinical venues, including inpatient wards, where HIV prevalence was found to be 1.2%. Few of these inpatients with newly diagnosed disease had documented behavioral risks that would have prompted risk-based HIV testing. That study also found seropositivity for inpatients to be twice that of patients tested in the emergency department (ED).2 Walensky et al3 also reported screening for HIV among medicine inpatients at an urban Boston-area hospital, comparing testing rates for the program period versus a preceding historical control period. That initiative increased inpatient testing rates 3.4-fold, from a baseline of 2% to 6.4% of medicine admissions tested, and yielded a 3.8% prevalence of undiagnosed HIV in low-risk patients who otherwise would not have been tested. Extrapolation to all 72 similar urban public hospitals in the United States, were routine HIV testing instituted for all inpatients, was estimated to potentially identify 30,000 additional HIV patients annually.

Routine inpatient HIV screening has also been shown to be cost-effective. Researchers estimate inpatient screening to cost $38,600 per quality-adjusted life-year gained, comparing favorably with other commonly used preventive health screening interventions (eg, annual mammograms cost approximately $58,000 per quality-adjusted life-year gained).4, 5

ED rapid HIV testing programs have also been shown to facilitate care of newly identified HIV inpatients.6 Our group previously reported that inpatients receiving a new diagnosis of HIV in the ED by rapid testing had shorter lengths of stay and were less likely to be discharged unaware of their HIV serostatus compared with inpatients tested conventionally on the medicine floor.7

The 2009 Society for Academic Emergency Medicine Consensus Conference convened a group of emergency medicine experts who identified major research goals for ED-based HIV prevention efforts.8 Seventy-seven percent believed that investigating targeted screening techniques to improve testing efficiency was a high priority. We describe our effort to perform ED-based, targeted HIV screening of patients awaiting admission.

Although admitted patients may represent a population with a high proportion of previously undiagnosed HIV, to our knowledge no previous reports describe implementation of an ED-based program of rapid HIV testing and early linkage to care targeting patients slated for hospital admission.6, 9, 10, 11, 12, 13

Section snippets

Setting

We initiated a targeted, rapid HIV screening program in the John H. Stroger, Jr. Hospital of Cook County adult ED beginning March 2008. The John H. Stroger ED has an annual census of 130,000 and provides safety-net care to adult Chicago-area patients. Screening patients waiting for admission represents a “targeted screening” approach, as defined by the 2007 Conference of the National Emergency Department HIV Testing Consortium.14

Selection of Participants

Targeted screening was implemented in a 2-step process according

Results

Between March 1, 2008, and February 28, 2009, John H. Stroger ED red team health educators performed rapid HIV tests for 4,755 patients, including patients admitted to the hospital and those discharged directly from the ED, newly diagnosing disease for 30 (0.6%) patients with confirmed HIV infection. Three patients tested falsely positive, resulting in a test specificity of 99.9% (95% confidence interval 99.8% to 99.9%) and positive predictive value of 90.9% (95% confidence interval 74.5% to

Limitations

Our project had several important limitations. Although we tested a relatively high proportion of eligible admitted patients, during the 12-month testing period 64% of eligible medicine admissions did not receive ED testing. These missed testing opportunities related to the limited testing capacity of our health educator–based program compared with integrated testing strategies using existing ED staff.13 Although we attempted to perform targeted HIV testing of patients awaiting admission,

Discussion

Previous studies suggest that inpatients may have a higher proportion of undiagnosed HIV compared with the general public and even perhaps compared with the general ED population.2 This report supports targeted testing of high-acuity ED patients as an effective tool for identifying patients with previously undiagnosed HIV who are awaiting medicine admission. In our ED, patients who received a new diagnosis were more likely to be younger than HIV-negative patients and were more likely to be

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Cited by (12)

  • Evaluation of hidden HIV infections in an urban ED with a rapid HIV screening program

    2016, American Journal of Emergency Medicine
    Citation Excerpt :

    Opt-out approaches for HIV test (at the point of triage and by the clinical staff) could help overcome at least some of those gaps. Alternatively, addition of scaled-up routine inpatient screening programs for all ED admitted patients could minimize potential missed ED opportunity for identifying those with undiagnosed infections [19]. In our own ED, that could have resulted in an additional 31 undiagnosed infections (or 51% of the total undiagnosed who were not offered) being detected.

  • HIV care continuum for HIV-infected emergency department patients in an inner-city academic emergency department

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    For the HIV Care Continuum, we propose consideration of 3 new stages that are particularly relevant for ED populations in this study, namely, provider awareness of HIV diagnosis, patient receiving antiretroviral treatment—patient self-aware, and viral load suppression—patient self-aware. Provider awareness of HIV diagnosis is well recognized to be important for ED clinical management decisions and has been previously reported to affect clinical decisionmaking.48,49 Patient self-awareness of receiving antiretroviral therapy may be relevant for ED management decisions (including referral for treatment, potential medication-related complications, or contraindications for medications prescribed in the ED).

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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 project was funded by an unrestricted grant from Gilead Sciences, Inc., Foster City, CA. Gilead had no input or influence on the implementation of the program or over the content of this article. Dr. Lubelchek serves on a speaker's bureau for Gilead Sciences Inc., Foster City CA. For all other authors no disclosures.

Publication of this article was supported by Centers for Disease Control and Prevention, Atlanta, GA.

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