Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) continue to be a significant public health concern in the United States. It disproportionately affects persons in the Deep South of the United States, specifically African Americans. This is a descriptive report of an Emergency Department (ED)-based HIV screening program in the Deep South using the 2006 Centers for Disease Control and Prevention (CDC) recommendations for rapid testing and opt-out consent. Between May 2008 and March 2010, patients presenting for medical care to the ED Monday through Friday between 10 AM and 10 PM were approached for HIV screening. Patients were eligible for screening if they were 18 or older, had no previous history of positive HIV tests, were English-Speaking, and were not incarcerated, medically unstable, or otherwise able to decline testing. All patients were tested using the OraQuick® rapid HIV 1/2 antibody test. Patients with non-reactive results were referred to community anonymous testing sites for further testing. Patients with reactive results had confirmatory Western blot and CD4 counts drawn and were brought back to the ED for disclosure of the results. All patients with confirmed HIV positive via reactive Western blot were referred to the hospital-based infectious disease clinic or county health department. We tested 7,616 patients out of 8,922 approached. The overall test acceptance rate was 85.4%. 91.0% of patients tested were African American. The most common reason for refusal was recent HIV test. 1.7% of patients tested were confirmed HIV positive via Western blot. 95.2% of patients testing HIV positive were African American. The average CD4 count for patients testing positive was 276 cells/μl, with 42.0% of patients having CD4 counts ≤200 μl, consistent with an AIDS diagnosis. 88.4% of patients who had reactive oral swabs returned for Western blot results and 75.0% of patients attended their first clinic visit. We have been able to successfully carry out an ED-based HIV screening program in a resource-poor urban teaching facility in the Deep South. We define our success based on our relatively high test acceptance rate and high rate of attendance at first clinic visit. Our patient population has a relatively high undocumented HIV prevalence and are at advanced stage of disease at the time of diagnosis.
Emergency departments and jails provide medical services to persons at risk for HIV infection and are recommended venues for HIV screening. Our main objective in this study was to analyze the cost per new HIV diagnosis associated with the HIV screening program in these two venues. The emergency department’s parallel testing program was conducted at Grady Memorial Hospital in Atlanta, Georgia starting in 2008; the jail’s integrated testing program began at the Fulton County (GA) Jail in 2011. The two sites, four miles apart from one another, employed the same rapid HIV test. Ascertainment that cases were new differed by site; only the jail systematically checked identities against health department HIV registries. The program in the emergency department used dedicated HIV test counselors and made 242 diagnoses over a 40-month period at a cost of $2,981 per diagnosis. The jail program used staff nurses, and found 41 new HIV cases over 10.5 months at a cost of $6,688 per new diagnosis. Differences in methods for ascertainment of new diagnoses, previously undiagnosed HIV sero-positivity, and methodologies used for assessing program costs prevent concluding that one program was more economical than the other. Nonetheless, our findings show that testing in both venues yielded many new diagnoses, with the costs within the range reported in the literature.
Non-targeted, integrated HIV screening, with test offer and order by ED nurses during patient triage, is feasible and resulted in an increased frequency of HIV screening and a threefold increase in the absolute number of newly identified HIV-positive patients.
In the United States, men who have sex with men (MSM) constitute the risk group in which the prevalence of new HIV infection is increasing. The percentage of undiagnosed HIV infection and HIV risk behaviors in MSM and non-MSM participating in an emergency department-based rapid HIV screening program were compared. Medical records of all male patients participating in the program from May 2008 to October 2010 were reviewed. MSM were identified as male or male-to-female patients reporting oral and/or anal sex with a male. Males eligible for testing were aged 18 or older, English-speaking, not known to be HIV infected, and able to decline testing. A total of 6672 males were approached for testing; 5610 (84.1%) accepted, 366 (6.5%) were MSM, and 5244 (93.5%) were non-MSM. A total of 90.7% were black. Median age was 41. Fifty-nine MSM (16.1%) were diagnosed with HIV compared to 81 (1.5%) non-MSM. MSM were 10 times more likely than non-MSM to have undiagnosed HIV infection (odds ratio [OR] 10.4, 95% confidence interval [CI] 7.3, 14.0). HIV-infected MSM (median age, 26) were younger than non-MSM (median age, 41). HIV-infected non-MSM were 2 times more likely than MSM to have CD4 counts less than 200 cells per microliter. MSM were more likely to report previous HIV testing (OR 1.9, 95% CI 1.4, 2.5) and risk behaviors, including sex without a condom (OR 2.0, 95% CI 1.5, 2.6), sex with an HIV-infected partner (OR 14.6, 95% CI 8.3, 25.6) and sex with a known injection drug user (OR 4.1, 95% CI 2.0, 8.4). Further investigation of emergency department-based HIV testing and risk reduction programs targeting MSM is warranted.
for IT issues. We compared differences in non-opioid prescriptions of ED providers (attendings, MLPs, and EM residents) for a 6-month time frame pre and post guidelines in 2012 and 2013.Results: Over the same period where both percentages and absolute number of opioid pills and prescriptions decreased markedly, there was a significant increase in non-opioid analgesic prescriptions, although not matching the level of opioid decrease. The total number of non-opioid prescriptions (excluding tramadol) increased by 5.7 %. Acetaminophen and NSAIDS (in aggregate) increased by 5.3 %, muscle relaxants increased by 8.2% and tramadol decreased by 9.6%. The absolute number of non-opioid analgesics pills prescribed increased by 40,608 (1.3%), with an increase of 32,846 (+1.2%) in acetaminophen and NSAIDS and an increase of 22,624 (10.1%) of muscle relaxants. There was a decrease of 14,862 (-30.3%) of tramadol.Conclusion: There was a large and clinically important increase in all non-opioid pain relievers in a large public hospital system after the introduction of opioid prescribing guidelines.
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