Barriers and mitigating strategies to routine HIV screening in emergency departments: A national qualitative study.

BackgroundMemorial University Medical Center conducts opt-out HIV screening in the Emergency Department (ED) for patients aged ≥ 13. After gaining consent, an electronic algorithm automatically orders an HIV test with...

Undiagnosed HIV-infected patients are mainly responsible for viral transmission in Western countries. Emergency departments (EDs) could represent a strategic point in healthcare systems to uncover HIV infection. This study aimed to analyze the time trends of HIV testing in EDs in Barcelona (Spain) and investigate if EDs have changed HIV screening patterns after the implementation of a targeted opt-in strategy for HIV testing. This is a quasiexperimental (pre/post) study. Monthly HIV tests performed by Microbiology Departments of four hospitals in Barcelona were recorded over 78 months, classified as ordered by ED or at other healthcare levels. Monthly ED attendances were compiled, along with new HIV diagnoses. Implementation of an opt-in strategy to test every ED patient with targeted conditions (community-acquired pneumonia, herpes zoster, mononucleosis syndrome, chemsex, postexposure prophylaxis, sexually transmitted diseases) in addition to other classical reasons for HIV testing. Determination of trends over time in HIV screening and new diagnoses in EDs during the 60-month preintervention and 18-month postimplementation periods, and estimation of the impact of intervention using interrupted time series analyses. A total of 659 885 HIV tests were performed, with 11 442 (1.7%) being ordered by EDs (0.29% of ED comers were tested), and 287 new HIV diagnoses made (positivity rate: 2.8%). During the preintervention period, HIV testing increased over time (overall and in EDs), new HIV diagnoses in EDs remained stable, and the rate of positive HIV tests decreased. The intervention increased the monthly average of HIV tests ordered in the ED by 106 (95% CI = 86-125), proportion of ED comers screened by 0.075% (95% CI = 0.032-0.118), and proportion of HIV tests made in Barcelona performed by EDs by 0.728% (95% CI = 0.424-1.032), but had no impact on new HIV diagnoses and rate of positive HIV tests in the EDs. In the last years, HIV screening in Barcelona increased, with EDs having a significant and increasing role in the overall HIV testing in Barcelona. The implementation of a targeted opt-in strategy for HIV screening in EDs increased the number of HIV tests performed, but not the number of HIV diagnoses made in EDs.

Comparison of Enhanced Targeted Rapid HIV Screening Using the Denver HIV Risk Score to Nontargeted Rapid HIV Screening in the Emergency Department

BackgroundRoutine HIV screening in emergency department (ED) settings may require dedicated personnel. We evaluated the outcomes, costs and cost-effectiveness of HIV screening when offered by either a member of the ED staff or by an HIV counselor.MethodsWe employed a mathematical model to extend data obtained from a randomized clinical trial of provider- vs. counselor-based HIV screening in the ED. We compared the downstream survival, costs, and cost-effectiveness of three HIV screening modalities: 1) no screening program; 2) an ED provider-based program; and 3) an HIV counselor-based program. Trial arm-specific data were used for test offer and acceptance rates (provider offer 36%, acceptance 75%; counselor offer 80%, acceptance 71%). Undiagnosed HIV prevalence (0.4%) and linkage to care rates (80%) were assumed to be equal between the screening modalities. Personnel costs were derived from trial-based resource utilization data. We examined the generalizability of results by conducting sensitivity analyses on offer and acceptance rates, undetected HIV prevalence, and costs.ResultsEstimated HIV screening costs in the provider and counselor arms averaged $8.10 and $31.00 per result received. The Provider strategy (compared to no screening) had an incremental cost-effectiveness ratio of $58,700/quality-adjusted life year (QALY) and the Counselor strategy (compared to the Provider strategy) had an incremental cost-effectiveness ratio of $64,500/QALY. Results were sensitive to the relative offer and acceptance rates by strategy and the capacity of providers to target-screen, but were robust to changes in undiagnosed HIV prevalence and programmatic costs.ConclusionsThe cost-effectiveness of provider-based HIV screening in an emergency department setting compares favorably to other US screening programs. Despite its additional cost, counselor-based screening delivers just as much return on investment as provider based-screening. Investment in dedicated HIV screening personnel is justified in situations where ED staff resources may be insufficient to provide comprehensive, sustainable screening services.

Universal HIV screening is recommended but challenging to implement. Selectively targeting those at risk is thought to miss cases, but previous 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. 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 and >64 years), known HIV infection, or previous 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 deidentified blood samples. There were 9572 eligible visits during which the patient was approached. For universal screening, 40.8% (1915/4692) consented with 6 being newly diagnosed [0.31%, 95% confidence interval (CI): 0.13% to 0.65%]. For targeted screening, 37% (1813/4880) had no testing indication. Of the 3067 remaining, 47.4% (1454) consented with 3 being newly diagnosed (0.22%, 95% CI: 0.06% to 0.55%). Estimated seroprevalence was 0.36% (95% CI: 0.16% to 0.70%). Targeted screening had a higher proportion consenting (47.4% vs. 40.8%, P < 0.002), but a lower proportion of ED encounters with testing (29.7% vs. 40.7%, P < 0.002). 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.

CD4 Counts in Patients Diagnosed With HIV Through Routine HIV Screening in Two Urban Emergency Departments

The Centers for Disease Control and Prevention has recommended emergency department (ED) opt-out HIV screening since 2006. Routine screening can prove challenging due to the ED's complexity and competing priorities. This study examined the implementation and evolution of a routine, integrated, opt-out HIV screening program at an urban academic ED in Alabama since August 2011. ED routine, opt-out HIV screening was implemented as a standard of care in September 2011. To describe the outcomes and escalation of the screening program, data analyses were performed from three separate data queries: (1) encounter-level HIV screening questionnaire and test results from September 21, 2011, through December 31, 2013; (2) test-level, fourth-generation HIV results from July 9 through December 31, 2013; and (3) daily HIV testing rates and trends from September 9, 2011, through June 30, 2014. Of the 46,385 HIV screening tests performed, 252 (0.5%) were confirmed to be positive. Acute HIV infection accounted for 11.8% of all HIV patients identified using the fourth-generation HIV screening assay. Seventy-six percent of confirmed HIV-positive patients had successful linkage to care. Implementation of fourth-generation HIV instrument-based testing resulted in a 15.0% decline in weekly HIV testing rates. Displacement of nursing provider HIV test offers from triage to the bedside resulted in a 31.6% decline in weekly HIV testing rates. This program demonstrated the capacity for high-volume, routine, opt-out HIV screening. Evolving ED challenges require program monitoring and adaptation to sustain scalable HIV screening in EDs.

An automated best practice advisory increases both routine HIV screening and HIV cotesting with sexually transmitted infections in the emergency department

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

ABSTRACTHigh operating costs challenge sustainability of successful US emergency department (ED) HIV screening programs. Free-standing registration kiosks could potentially reduce the marginal costs of ED HIV screening. We investigated incremental cost-effectiveness ratio (CER) per new HIV diagnosis for a kiosk-based approach for offering screening at ED registration versus a testing staff-based approach to offer testing at the bedside. A rapid oral-fluid HIV screening program, instituted in a US ED since 2005, had a rate of new HIV diagnosis 0.16% in 2012. A two-phase quasi experimental design, including a testing staff-based approach to offer testing at the bedside (Phase I, August and September 2011) and a kiosk-based approach to offer testing at ED registration (Phase II, December 2011 and January 2012), was performed. CER per new HIV diagnosis was defined as total cost of the screening program divided by number of newly diagnosed cases. Costs included screening program personnel (study coordinator, testing staff, and kiosk helpers), diagnostic assays (rapid and confirmatory tests), and kiosks (2 kiosks, software, and IT consulting fees). Sensitivity analyses were performed. Data from our dedicated testing staff (DTS) program (Phase I) resulted in an estimated 5434 patients tested in one year and 9 newly diagnosed HIV-infected patients (95% CI: 3, 18). Data from the kiosk program (Phase II), resulted in a projected 4571 ED patients tested in one year and 21 newly diagnosed HIV-infected patients (95% CI: 4, 70). The overall cost was $ 201,433 for the DTS program, versus $292,008 for the kiosk program. Incremental CER per new HIV diagnosis for kiosk-based approach was $7523 (range: $1780–90,025 by sensitivity analysis). Our pilot data demonstrated that the use of kiosks for HIV screening was potentially more cost-effective than a testing staff-based bedside approach.

Linkage to Care, Antiretroviral Treatment Initiation, and Viral Suppression of Acute HIV-Infected Individuals Identified From an Emergency Department–Based HIV Screening and Linkage-to-Care Program

In 2016 worldwide, 1.8 million people were newly infected with HIV. About 36.7 million had HIV but 14 million were unaware, did not seek treatment and were likely to infect others. Undiagnosed HIV infection is a major contributor to transmission. Therefore, screening is critical to prevention. Although CDC recommends routine screening in the emergency department (ED), implementation is not universal or sustained. Cost-effectiveness of ED-based screening could enhance implementation. We address the question: Is HIV screening in the ED cost-effective? Using the Joanna Briggs Institute guidelines, we conducted a systematic review of economic evaluations of ED-based HIV screening. We found 311 studies with 12 duplicates. We excluded 276 studies that did not conduct economic evaluations and another three for lack of quantitative data, leaving 20 articles for the full review. We reviewed cost-effectiveness ratios (CER), incremental cost-effectiveness ratios (ICER), and average costs per diagnosis, quality-adjusted life years, averted transmissions and per patient linked to care. CER and ICER were below CDC thresholds indicating that HIV screening in the ED is cost-effective. Therefore, ED-based HIV screening should be widely implemented, supported and sustained as a cost-effective tool for combating HIV/AIDS.

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.

ObjectiveMultiple HIV outbreaks among persons who inject drugs (PWID) have occurred in the US since 2015. Emergency departments (EDs), recognized as essential venues for HIV screening, may play a unique role in identifying undiagnosed HIV among PWID, who frequently present for complications of injection drug use (IDU). Our objective was to describe changes in HIV diagnoses among PWID detected by an ED HIV screening program and estimate the program’s contribution to HIV diagnoses among PWID county-wide during the emergence of a regional HIV outbreak.MethodsThis was a retrospective study of electronically queried clinical records from an urban, safety-net ED’s HIV screening program and publicly available HIV surveillance data for its surrounding county, Hamilton County, Ohio. Outcomes included the change in number of HIV diagnoses and the ED’s contribution to case identification county-wide, overall and for PWID during 2014–2018.ResultsDuring 2014–2018, the annual number of HIV diagnoses made by the ED program increased from 20 to 42 overall, and from 1 to 18 for PWID. We estimated that the ED contributed 18% of HIV diagnoses in the county and 22% of diagnoses among PWID.ConclusionsThe ED program contributed 1 in 5 new HIV diagnoses among PWID county-wide, further illustrating the importance of ED HIV screening programs in identifying undiagnosed HIV infections. In areas experiencing increasing IDU, HIV screening in EDs can provide an early indication of increasing HIV diagnoses among PWID and can substantially contribute to case-finding during an HIV outbreak.

The National HIV Strategic Plan for the US recommends HIV screening in emergency departments (EDs). The most effective approach to ED-based HIV screening remains unknown. To compare strategies for HIV screening when integrated into usual ED practice. This randomized clinical trial included patients visiting EDs at 4 US urban hospitals between April 2014 and January 2016. Patients included were ages 16 years or older, not critically ill or mentally altered, not known to have an HIV positive status, and with an anticipated length of stay 30 minutes or longer. Data were analyzed through March 2021. Consecutive patients underwent concealed randomization to either nontargeted screening, enhanced targeted screening using a quantitative HIV risk prediction tool, or traditional targeted screening as adapted from the Centers for Disease Control and Prevention. Screening was integrated into clinical practice using opt-out consent and fourth-generation antigen-antibody assays. New HIV diagnoses using intention-to-treat analysis, absolute differences, and risk ratios (RRs). A total of 76 561 patient visits were randomized; median (interquartile range) age was 40 (28-54) years, 34 807 patients (51.2%) were women, and 26 776 (39.4%) were Black, 22 131 (32.6%) non-Hispanic White, and 14 542 (21.4%) Hispanic. A total of 25 469 were randomized to nontargeted screening; 25 453, enhanced targeted screening; and 25 639, traditional targeted screening. Of the nontargeted group, 6744 participants (26.5%) completed testing and 10 (0.15%) were newly diagnosed; of the enhanced targeted group, 13 883 participants (54.5%) met risk criteria, 4488 (32.3%) completed testing, and 7 (0.16%) were newly diagnosed; and of the traditional targeted group, 7099 participants (27.7%) met risk criteria, 3173 (44.7%) completed testing, and 7 (0.22%) were newly diagnosed. When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses (enhanced targeted and traditional targeted combined: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.7; 95% CI, 0.30 to 1.56; P = .38; and enhanced targeted only: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.70; 95% CI, 0.27 to 1.84; P = .47). Targeted HIV screening was not superior to nontargeted HIV screening in the ED. Nontargeted screening resulted in significantly more tests performed, although all strategies identified relatively low numbers of new HIV diagnoses. ClinicalTrials.gov Identifier: NCT01781949.