Comparison of HIV Screening Strategies in the Emergency Department

Jason S Haukoos,Jonathan D Campbell,Richard E Rothman,Michael S Lyons,Douglas A.e White ,Mark Thrun ,Allison L Sabel,Alia Al-Tayyib ,Danielle Signer,Emily Hopkins,Yu‐Hsiang Hsieh ,Meggan M Bucossi ,Stephen Peterson ,Tamara R Todorović ,Andrew H Ruffner,Sarah Rowan ,Rachel M Ancona,Sarah K Pfeil,Lucy Bradley-Springer,Matthew Toerper ,Mustapha Saheed,Edward M Gardner,Hiv Tested Trial Investigators

doi:10.1001/jamanetworkopen.2021.17763

Abstract

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.

Highlights

When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses
Targeted HIV screening was not superior to nontargeted HIV screening in the emergency departments (EDs)
Nontargeted screening resulted in significantly more tests performed, all strategies identified relatively low numbers of new HIV diagnoses

Summary

Introduction

Diagnosis of HIV is an important health priority and critical step in the care continuum.[1,2] While increased screening efforts in the US have reduced the number of those with undiagnosed HIV, a significant number of persons living with HIV remain undiagnosed.[3]The Centers for Disease Control and Prevention (CDC) and US Preventive Services Task Force (USPSTF) recommend routine nontargeted HIV screening in most medical settings, including emergency departments (EDs).[4,5,6,7] The alternative, targeted (risk-based) HIV screening,[8] was historically endorsed by the CDC and USPSTF.[9,10] Effectiveness of targeted HIV screening in ED practice has gone largely unexplored and comparative studies of varied implementation approaches, including targeted vs nontargeted screening, are limited.[11,12,13] Recently, the Denver HIV Risk Score (DHRS), a quantitative risk prediction tool, was validated to estimate HIV risk, and was shown in a nonrandomized ED study to be strongly associated with new HIV diagnoses when used to perform targeted screening and when compared with nontargeted screening.[14,15].

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Results

Discussion

Conclusion