To Test or Not To Test? HIV, Emergency Departments, and the New Centers for Disease Control and Prevention Guidelines

Abstract

To test or not to test; that is the question. Emergency department (ED)–based HIV testing has become more common in the past several years because of lower-priced and faster tests, increased clinical recognition of risk factors and at-risk patients, and recent research on testing in the ED. Recently released Centers for Disease Control and Prevention (CDC) guidelines call for routine HIV testing of patients in all health care settings. They also call for testing to be performed on all patients unless they opt out of testing. Under the new guidelines, separate consent for testing does not need to be performed, and patients should be notified that testing is routine. In addition, persons at high risk should also be tested annually, and furthermore, pretest counseling is not required. This is a marked change from previous recommendations. The CDC has previously called for testing in high-acuity settings such as some urban EDs and uncoupled the outdated recommendations for extensive counseling. These new guidelines present significant challenges and opportunities to emergency medicine. The ED cannot provide all services to all patients but clearly does provide the key role in evaluation of patients with acute presentations. HIV infection has remained rampant despite notably improved testing and treatment. There are clearly populations at risk who do not access traditional health care systems such as local health departments and primary care offices. Improved education and community-based resources have not been as effective as hoped, which should come as no surprise to the emergency physician who deals daily with the problems of access and delivery in modern health care. There are clearly challenges to the new guidelines. Although testing programs are relatively low cost, routine screening programs do carry a significant cost to EDs that are struggling to balance operational budgets and collecting a minor fraction of their billings. There are challenges of patient discussions and in the testing protocol that result in false-positive and -negative tests. Dealing with these challenges presents barriers to testing in the ED. However, perspective should be maintained when comparing the challenges against the risk of a transmittable infectious disease in our patients who can be easily tested. EDs surmount these barriers daily for other transmittable infectious diseases.