Public Health and Clinical Impact of Increasing Emergency Department–Based HIV Testing: Perspectives From the 2007 Conference of the National Emergency Department HIV Testing Consortium

Kecojevic, Aleksandar; Lindsell, Christopher J.; Lyons, Michael S.; Holtgrave, David R.; Torres, Gretchen Williams; Heffelfinger, James D.; Brown, Jeremy; Couture, Eileen; Jung, Julianna; Connell, Samantha; Rothman, Richard E.

doi:10.1016/j.annemergmed.2011.03.040

Cited by 20 publications

(23 citation statements)

References 34 publications

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“…Public health advocates have called for universal or non-targeted screening. 1,18,24 This requires many tests, and concerns persist about feasibility and effectiveness, 15,25–42 particularly when prevalence is low or presumed low. Selectively targeting increased likelihood of undiagnosed infection requires fewer tests, but failure to identify all cases is frequently cited.…”

Section: Introductionmentioning

confidence: 99%

Randomized Comparison of Universal and Targeted HIV Screening in the Emergency Department

Lyons¹,

Lindsell²,

Ruffner³

et al. 2013

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Objective Universal HIV screening is recommended but challenging to implement. Selectively targeting those at risk is thought to miss cases, but prior studies are limited by narrow risk criteria, incomplete implementation, and absence of direct comparisons. We hypothesized that targeted HIV screening, when fully implemented and using maximally broad risk criteria, could detect nearly as many cases as universal screening with many fewer tests. Methods This single-center, cluster-randomized trial compared universal and targeted patient selection for HIV screening in a lower prevalence urban emergency department. Patients were excluded for age (<18, >64), known HIV infection, or prior approach for HIV testing that day. Targeted screening was offered for any risk indicator identified from charts, staff referral, or self-disclosure. Universal screening was offered regardless of risk. Baseline seroprevalence was estimated from consecutive de-identified blood samples. Results There were 9,572 eligible visits during which the patient was approached. For universal screening, 40.8% (1,915/4,692) consented with six newly diagnosed (0.31%, CI95 0.13%–0.65%). For targeted screening, 37% (1,813/4,880) had no testing indication. Of the 3,067 remaining, 1,454 (47.4%) consented with 3 newly diagnosed (0.22%, CI95 0.06%–0.55%). Estimated seroprevalence was 0.36% (CI95 0.16%–0.70%). Targeted screening had a higher proportion consenting (47.4% v. 40.8%, p<0.002), but a lower proportion of ED encounters with testing (29.7% v. 40.7%, p<0.002). Conclusions Targeted screening, even when fully implemented with maximally permissive selection, offered no important increase in positivity rate or decrease in tests performed. Universal screening diagnosed more cases, because more were tested, despite a modestly lower consent rate.

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Section: Introductionmentioning

confidence: 99%

Randomized Comparison of Universal and Targeted HIV Screening in the Emergency Department

Lyons¹,

Lindsell²,

Ruffner³

et al. 2013

JAIDS Journal of Acquired Immune Deficiency Syndromes

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“…Finally, it remains unknown whether certain clinical venues, especially non-traditional HIV testing settings like EDs and urgent cares, will be able to routinely provide nontargeted HIV screening, or whether a targeted approach is better suited for these sites. 25–27 …”

Section: Discussionmentioning

confidence: 99%

Brief Report

Haukoos

Hopkins

Bucossi

et al. 2015

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Routine screening is recommended for HIV detection. HIV risk estimation remains important. Our goal was to validate the Denver HIV Risk Score (DHRS) using a national cohort from the CDC. Patients ≥13 years of age were included, 4,830,941 HIV tests were performed, and 0.6% newly-diagnosed infections were identified. Of all visits, 9% were very low risk (HIV prevalence = 0.20%); 27% low risk (HIV prevalence = 0.17%); 41% moderate risk (HIV prevalence = 0.39%); 17% high risk (HIV prevalence = 1.19%); and 6% very high risk (HIV prevalence = 3.57%). The DHRS accurately categorized patients into different HIV risk groups.

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“…Short duration of stay has previously been cited as an explanation for poor testing rates [15] and certainly the MDOS of patients in our ED was the lowest of all IP services studied. However, that higher testing rates were observed in medical OP compared to all IP services suggests that the length of patient contact is not so critical; perhaps the opportunity for privacy and confidentiality is more important than the time spent with each patient [24]. Perhaps beliefs that HIV risk factors ‘do not relate’ to the primary role of the ED play a role [24], [25].…”

Section: Discussionmentioning

confidence: 99%

“…However, that higher testing rates were observed in medical OP compared to all IP services suggests that the length of patient contact is not so critical; perhaps the opportunity for privacy and confidentiality is more important than the time spent with each patient [24]. Perhaps beliefs that HIV risk factors ‘do not relate’ to the primary role of the ED play a role [24], [25]. Whatever the reason(s), as previous studies have shown that measures to optimise ED testing rates produce modest if any improvement [8], [15], we can propose two approaches to optimise testing in patients who pass through this service.…”

Section: Discussionmentioning

confidence: 99%

HIV Testing Practices by Clinical Service before and after Revised Testing Guidelines in a Swiss University Hospital

et al. 2012

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ObjectivesTo determine 1) HIV testing practices in a 1400-bed university hospital where local HIV prevalence is 0.4% and 2) the effect on testing practices of national HIV testing guidelines, revised in March 2010, recommending Physician-Initiated Counselling and Testing (PICT).MethodsUsing 2 hospital databases, we determined the number of HIV tests performed by selected clinical services, and the number of patients tested as a percentage of the number seen per service (‘testing rate’). To explore the effect of the revised national guidelines, we examined testing rates for two years pre- and two years post-PICT guideline publication.ResultsCombining the clinical services, 253,178 patients were seen and 9,183 tests were performed (of which 80 tested positive, 0.9%) in the four-year study period. The emergency department (ED) performed the second highest number of tests, but had the lowest testing rates (0.9–1.1%). Of inpatient services, neurology and psychiatry had higher testing rates than internal medicine (19.7% and 9.6% versus 8%, respectively). There was no significant increase in testing rates, either globally or in the majority of the clinical services examined, and no increase in new HIV diagnoses post-PICT recommendations.ConclusionsUsing a simple two-database tool, we observe no global improvement in HIV testing rates in our hospital following new national guidelines but do identify services where testing practices merit improvement. This study may show the limit of PICT strategies based on physician risk assessment, compared to the opt-out approach.

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Public Health and Clinical Impact of Increasing Emergency Department–Based HIV Testing: Perspectives From the 2007 Conference of the National Emergency Department HIV Testing Consortium

Cited by 20 publications

References 34 publications

Randomized Comparison of Universal and Targeted HIV Screening in the Emergency Department

Randomized Comparison of Universal and Targeted HIV Screening in the Emergency Department

Brief Report

HIV Testing Practices by Clinical Service before and after Revised Testing Guidelines in a Swiss University Hospital

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