Another look at Emergency Department HIV screening in practice: no need to revise expectations

Jeremy Brown,Vanessa Lee,Manya Magnus,Maggie Czarnogosrki

doi:10.1186/1742-6405-7-1

Abstract

BackgroundA recent study reported a lower than expected specificity and positive predictive value of the rapid oral HIV test in the setting of routine emergency department (ED) screening. These results appeared inconsistent with the findings in another urban Emergency Department during the same time period.ObjectiveTo compare the specificity and positive predictive vale (PPV) of an oral rapid HIV test used in an ED screening program in Washington DC with that performed in the USHER clinical trial.DesignPeriod cross-sectional analysis of rapid oral HIV testing conducted in an ongoing HIV screening program emergency department patients.SettingThe George Washington University Emergency Department (Washington DC) from 7 February to 1 October 2007.Patients1,560 adults seen in the ED for non-HIV-related presenting complaints, who participated in the HIV screening program.InterventionRapid HIV testing with the OraQuick ADVANCE Rapid HIV-1/2 Antibody Test (OraSure Technologies, Bethlehem, Pennsylvania). Patients with reactive rapid test results were offered Western blot testing for confirmation.MeasurementsSpecificity and positive predictive value for the program were determined. Findings were compared to those found in the USHER trial.ResultsOf 1,560 patients screened for HIV, 13 [0.8%, 95% CI 0.38% to 1.28%] had a reactive HIV screening test, and all were confirmed to be positive by Western Blot. The specificity was 100% (95% CI 99.6%-100%).LimitationSince non-reactive tests were not confirmed, the test sensitivity cannot be determined.ConclusionReview of our data conflict with findings from the USHER study surrounding false positive OraQuick HIV screening. Our data suggest that rapid HIV screening protocols implemented in EDs outside of the clinical trial paradigm perform effectively without an excess of false positive results. Compared with other screening tests, HIV rapid screening should remain an essential component of ED practice.

Highlights

A recent study reported a lower than expected specificity and positive predictive value of the rapid oral HIV test in the setting of routine emergency department (ED) screening
Of 1,560 patients screened for HIV, 13 [0.8%, 95% CI 0.38% to 1.28%] had a reactive HIV screening test, and all were confirmed to be positive by Western Blot
Since the Centers for Disease Control and Prevention (CDC) recommended routine opt-out HIV screening in emergency departments in 2006,[1] the George Washington Emergency Department has been conducting routine HIV testing among all patients that present

Summary

Introduction

Since the Centers for Disease Control and Prevention (CDC) recommended routine opt-out HIV screening in emergency departments in 2006,[1] the George Washington Emergency Department has been conducting routine HIV testing among all patients that present for care[2] In August 2008, the investigators for the Universal Screening for HIV infection in the Emergency Room (USHER) Trial published a report which described a larger than expected number of false positive tests [3] This led the authors to suggest that expectations from rapid HIV testing in the emergency department should be revised. The purpose of this study was to examine the impact of a real-world, non-clinical trial ED HIV screening program during the same time span and to examine the prevalence of false positives

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Conclusion