221 Effectiveness of Opt-Out, Non-Targeted Human Immunodeficiency Virus and Hepatitis C Virus Testing in an Urban Emergency Department

Abstract

Opt-out, non-targeted screening has been recommended by the Centers for Disease Control and the US Preventive Services Task Force, yet these recommendations are not widely implemented. In 2017, our emergency department (ED) initiated opt-out, non-targeted HIV and HCV screening. This study will evaluate the effectiveness of this process to detect new HIV diagnoses by comparing the number of rapid HIV tests, reflexed confirmatory tests, and new HIV positive diagnoses between the traditional targeted, opt-in process and the recommended opt-out, non-targeted HIV screening approach. A retrospective analysis compared the first 12 months of opt-out, non-targeted HIV and HCV screening and 12 months of opt-in, targeted HIV testing results in an urban emergency department. Opt-out, non-targeted HIV testing included all patients age 13 or older and HCV screening included all patients age 18 or older, presenting to the ED who required serum labs as part of their standard medical evaluation in the ED. The electronic medical record was utilized to create an integrated screening process, provide rapid confirmation testing, and provider notification for positive HIV and HCV results. Per California state law, patients were notified of testing and given a chance to opt-out, but were not explicitly consented. Rapid HIV screening was done via 4th generation Antigen Antibody tests which were auto-reflexed for in house confirmatory testing via the Genius analyzer. HCV screening was done via the Architect analyzer and auto-reflexed for RNA and PCR confirmatory testing. An additional tube was collected along with ordered serum labs and later used for confirmatory testing without the need to re-stick the patient. Additionally, confirmatory testing for HIV was done onsite, enabling same-day results and patient notification HIV status. In an effort to not increase turnaround time to discharge (TATd) any results acquired after patient discharge or elopement were added to an electronic worklist that was reviewed the following day to notify the patient and link them to follow-up care. The previous 12-month period utilizing opt-in, targeted testing yielded 2,273 initial HIV tests, 72 confirmatory tests, and 21 new HIV diagnoses (positive rate = 0.9%). Opt-out, non-targeted HIV testing over a 12-month period yielded 11,794 rapid HIV tests, 121 reflexed confirmatory tests, and 38 new HIV diagnoses (positive rate = 0.3%). Opt-out, non-targeted HCV testing yielded 12,304 initial HCV tests, 1,053 positive antibody results, 469 positive RNA results (positive rate = 3.8%). This new testing algorithm produced a 6-fold increase in the number of HIV tests and, more importantly, doubled the number of new HIV diagnoses. Despite the reduction in positive rate from 0.9% in targeted testing to 0.3% in non-targeted testing, opt-out, non-targeted testing is effective in identifying more new diagnoses that otherwise would have gone undetected. Same-day results in the ED provided an opportunity to engage the patient in a dialog about HIV, explain the disease, treatment options, and other expectations. Additionally, prompt diagnosis coupled with dedicated work of an HIV-specific care coordinator the new diagnoses as well as many known positives are now connected to proper care and anti-retro viral therapy.