Bundled HIV and Hepatitis C Testing in the Emergency Department: A Randomized Controlled Trial

Abstract

IntroductionAn estimated 25% of the 1.2 million individuals living with human immunodeficiency virus (HIV) in the U.S. are co-infected with hepatitis C (HCV). The Centers for Disease Control and Prevention recommends HCV testing for high-risk groups. Our goal was to measure the impact of bundled HIV and HCV testing vs. HIV testing alone on test acceptance and identification of HCV and HIV.MethodsWe conducted a two-armed, randomized controlled trial on a convenience sample of 478 adult patients in the Jacobi Medical Center emergency department from December 2012 to May 2013. Participants were randomized to receive either an offer of bundled HIV/HCV testing or HIV testing alone. We compared the primary outcome, HIV test acceptance, between the two groups. Secondary outcomes included HIV and HCV prevalence, and HCV test acceptance, refusal, risk, and knowledge.ResultsWe found no significant difference in HIV test acceptance between the bundled HCV/HIV (91.8%) and HIV-only (90.6%) groups (p=0.642). There were also no significant differences in test acceptance based on gender, race, or ethnicity. A majority of participants (76.6%) reported at least one HCV risk factor. No participants tested positive for HIV, and one (0.5%) tested positive for HCV.ConclusionIntegrating bundled, rapid HCV/HIV testing into an established HIV testing program did not significantly impact HIV test acceptance. Future screening efforts for HCV could be integrated into current HIV testing models to target high-risk cohorts.

Centers for Disease Control and Prevention Recommendations for Hepatitis C Testing: The Need to Adopt Universal Screening in an Appalachian Emergency Department

“…The ED is an ideal setting to increase access to routine screening services for high-risk populations that have poor access to primary care services. HCV screening in an ED, when bundled with other infectious disease-related screenings such as HIV, has been shown to be successful in multiple studies 18,20 Many urban locations have successfully implemented screenings into their respective ED settings, demonstrating the feasibility of this process. 18,20 ED-based screening programs have also demonstrated that utilizing an "opt-out" format has been successful, where patients are screened unless they inform a provider they would not like to be tested.…”

“…HCV screening in an ED, when bundled with other infectious disease-related screenings such as HIV, has been shown to be successful in multiple studies 18,20 Many urban locations have successfully implemented screenings into their respective ED settings, demonstrating the feasibility of this process. 18,20 ED-based screening programs have also demonstrated that utilizing an "opt-out" format has been successful, where patients are screened unless they inform a provider they would not like to be tested. 18 Given that universal screening was not attained in this study despite opt-out, there may be additional barriers such as: 1) blood testing was not always needed during the ED visit and therefore the HCV screening tests could not be added and 2) provider compliance was not consistent.…”

Hepatitis C and HIV combined screening in primary care: A cluster randomized trial

“…Due to similarity in risk factors and transmission, and the high prevalence of HCV/HIV coinfection, 6 an overlap in screening services has been proposed. This combined screening could effectively use existing resources to address both epidemics and facilitate the linkage of HCV‐infected individuals to health care 16 . Combined HCV/HIV testing interventions have been evaluated in both emergency rooms and drug use treatment centres 16,17 but, to our knowledge, it has not been assessed in the primary care setting.…”

“…This combined screening could effectively use existing resources to address both epidemics and facilitate the linkage of HCV-infected individuals to health care. 16 Combined HCV/HIV testing interventions have been evaluated in both emergency rooms and drug use treatment centres 16,17 but, to our knowledge, it has not been assessed in the primary care setting. However, evaluation in a primary care setting is particularly interesting, as expanding effective testing interventions to primary care clinics will be key to meeting WHO goals for HIV and viral hepatitis elimination.…”

How to best conduct universal HIV screening in emergency departments is far from settled

“…Despite the notable successes of ED-based HIV screening, 3,11-13 significant obstacles to the efficiency and effectiveness of ED screening programs exist: poor linkage to care, 7,14 high cost per positive diagnosis, 15 low test acceptance among marginalized populations, 3,16 ineffective HIV screening staffing models, 17,18 redundant testing of patients with prior HIV diagnoses, 5 and lack of cultural competency incorporated into testing initiatives. 19,20 Although we have observed the successes and limitations of ED HIV screening programs for years, strategies to optimize program components, approaches, and methods are lacking.…”