ED-based HIV Screening Research Articles

Cost-Effectiveness of HIV Screening in Emergency Departments: Results From the Pragmatic Randomized HIV Testing Using Enhanced Screening Techniques in Emergency Departments Trial

Identification of HIV remains a critical health priority for which emergency departments (EDs) are a central focus. The comparative cost-effectiveness of various HIV screening strategies in EDs remains largely unknown. The goal of this study was to compare programmatic costs and cost-effectiveness of nontargeted and 2 forms of targeted opt-out HIV screening in EDs using results from a multicenter, pragmatic randomized clinical trial. This economic evaluation was nested in the HIV Testing Using Enhanced Screening Techniques in Emergency Departments (TESTED) trial, a multicenter pragmatic clinical trial of different ED-based HIV screening strategies conducted from April 2014 through January 2016. Patients aged 16 years or older, with normal mental status and not critically ill, or not known to be living with HIV were randomized to 1 of 3 HIV opt-out screening approaches, including nontargeted, enhanced targeted, or traditional targeted, across 4 urban EDs in the United States. Each screening method was fully integrated into routine emergency care. Direct programmatic costs were determined using actual trial results, and time-motion assessment was used to estimate personnel activity costs. The primary outcome was newly diagnosed HIV. Total annualized ED programmatic costs by screening approach were calculated using dollars adjusted to 2023 as were costs per patient newly diagnosed with HIV. One-way and multiway sensitivity analyses were performed. The trial randomized 76,561 patient visits, resulting in 14,405 completed HIV tests, and 24 (0.2%) new diagnoses. Total annualized new diagnoses were 12.9, and total annualized costs for nontargeted, enhanced targeted, and traditional targeted screening were $111,861, $88,629, and $70,599, respectively. Within screening methods, costs per new HIV diagnoses were $20,809, $23,554, and $18,762, respectively. Enhanced targeted screening incurred higher costs but with similar annualized new cases detected compared with traditional targeted screening. Nontargeted screening yielded an incremental cost-effectiveness ratio of $25,586 when compared with traditional targeted screening. Results were most sensitive to HIV prevalence and costs of HIV tests. Nontargeted HIV screening was more costly than targeted screening largely due to an increased number of HIV tests performed. Each HIV screening strategy had similar within-strategy costs per new HIV diagnosis with traditional targeted screening yielding the lowest cost per new diagnosis. For settings with budget constraints or very low HIV prevalences, the traditional targeted approach may be preferred; however, given only a slightly higher cost per new HIV diagnosis, ED settings looking to detect the most new cases may prefer nontargeted screening.

Comparison of HIV Screening Strategies in the Emergency Department

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.

199 False Positive or Acute Seroconversion? Examination of Patterns of Equivocal HIV Screening in the ED.

We consider the clinical presentation of patients with equivocal HIV test results in the ED (HIV Ab/Ag +, HIV Ab -) found through routine ED-based HIV screening and further describe those patients who presented to the ED during acute seroconversion (acute +) compared to the clinical characteristics of patients who were ultimately found to have false + initial screening results. We analyzed 4 years of HIV testing data (2016-2020) and determined the number of patients who had a Ab/Ag + screen. Patients with Ab/Ag + but a non-equivocal HIV+ lab signature (Ab/Ag +, Ab +, viral load > 0) were removed. Then we determined the remaining number with an equivocal laboratory signature (Ab/Ag +, Ab -). We separated those patients into 2 groups: false + (Ab/Ag +, Ab -, viral load 0) and acute + (Ab/Ag +, Ab -, viral load > 0). We conducted chart review on all patients with an equivocal laboratory signature and the clinical presentation was considered to detail patterns in false + compared to acute + patients presenting to the ED. We screened approximately 55,224 patients for HIV (16% volume) in 4 years. 787 patients had a Ab/Ag + result (1.4%) and, of those, 688 had non-equivocal positive HIV results (87.4% of Ab/Ag +, 1.2% of tested). 99 (12.5% of Ab/Ag +, 0.13% tested) were Ab/Ag +, Ab -. Of those 99, 73 had no detectable HIV RNA (false +, 9.3% of Ab/Ag +, 0.13% tested). 26 of the 99 with equivocal results had viral load > 0 (acute +, 3.3% of Ab/Ag +, 0.05% tested). Qualitative review of equivocal patient charts during the Ab/Ag reactive screening encounter showed statistically significance for acute positive results in younger male patients who have sex with men. 787 patients had a reactive screening test but 99 had an equivocal laboratory signature (12.5% of Ab/Ag+), making the information difficult to interpret during an ED encounter in high prevalence populations and challenging the ability to scale up ED based HIV screening, especially given the long turn around time for HIV RNA testing via PCR. ED based screening is an important strategy to help reach the WHO goal of eliminating HIV as a public health threat by 2030. However, the current algorithm and existing testing technology may not be best designed for acute clinical encounters and false + encounters are higher than previously reported. The results of this study detail characteristics of patients with equivocal test results that may improve clinical decision making in patients with false + compared to acute + laboratory signatures and suggest that young men who have sex with men and have a reactive HIV screening test in the ED should be considered HIV positive.

Cost-effectiveness of HIV screening in emergency departments: a systematic review

ABSTRACT 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.

Factors associated with patients who prefer HIV self-testing over health professional testing in an emergency department-based rapid HIV screening program.

Kiosk-facilitated HIV self-testing has been shown to be accurate and well accepted by emergency department (ED) patients. We investigated factors associated with patients who preferred self-testing over testing performed by health professionals in an ED-based HIV screening program. This opt-in program evaluation studied 332 patients in an inner-city academic ED from February 2012 to April 2012, when a kiosk-based HIV self-testing program was standard of care. The first kiosk in the 2-stage system registered patients and assessed their interest in screening, while the second kiosk gathered demographic and risk factor information and also provided self-testing instructions. Patients who declined to self-test were offered testing by staff. Broad eligibility included patients aged 18-64 years who were not critically ill, English-speaking, able to provide informed consent, and registered during HIV program operational hours. Data were analyzed using descriptive statistical analysis and Chi squared tests; 160 (48.2%) of 332 patients consenting to testing chose to use a kiosk to guide them performing self-testing. Patients aged 25-29 years and those whose primary ED diagnosis was not infectious disease-related were more likely to prefer HIV self-testing (OR = 2.19, 95% CI: 1.17-4.10; OR = 1.79, 95% CI: 1.03-3.12). HIV self-testing in the ED could serve as a complementary testing approach to the conventional modality.

Unintended adverse consequences of electronic health record introduction to a mature universal HIV screening program

ABSTRACTEarly HIV detection and treatment decreases morbidity and mortality and reduces high-risk behaviors. Many Emergency Departments (EDs) have HIV screening programs as recommended by the Centers for Disease Control and Prevention. Recent federal legislation includes incentives for electronic health record (EHR) adoption. Our objective was to analyze the impact of conversion to EHR on a mature ED-based HIV screening program. A retrospective pre- and post-EHR implementation cohort study was conducted in a large urban, academic ED. Medical records were reviewed for HIV screening rates from August 2008 through October 2013. On 1 November 2010, a comprehensive EHR system was implemented throughout the hospital. Before EHR implementation, labs were requested by providers by paper orders with HIV-1/2 automatically pre-selected on every form. This universal ordering protocol was not duplicated in the new EHR; rather it required a provider to manually enter the order. Using a chi-squared test, we compared HIV testing in the 6 months before and after EHR implementation; 55,054 patients presented before, and 50,576 after EHR implementation. Age, sex, race, acuity of presenting condition, and HIV seropositivity rates were similar pre- and post-EHR, and there were no major patient or provider changes during this period. Average HIV testing rate was 37.7% of all ED patients pre-, and 22.3% post-EHR, a 41% decline (p < 0.0001), leading to 167 missed new diagnoses after EHR. The rate of HIV screening in the ED decreased after EHR implementation, and could have been improved with more thoughtful inclusion of existing human processes in its design.

An emergency department registration kiosk can increase HIV screening in high risk patients

We evaluated the feasibility and the patient acceptability of integrating a kiosk into routine emergency department (ED) practice for offering HIV testing. The work was conducted in four phases: phase 1 was a baseline, in which external testing staff offered testing at the bedside; phase 2 was a pilot assessment of a prototype kiosk; phase 3 was a pilot implementation and phase 4 was the full implementation with automated login. Feasibility was assessed by the proportion of offering HIV tests, acceptance, completion and result reporting. During the study period, the number of ED patients and eligible patients for screening were similar in the three main phases. However, the number and proportion of patients offered testing of those eligible for screening increased significantly from phase 1 (32%) to phase 3 (37%) and phase 4 (40%). There were slightly higher prevalences of newly diagnosed HIV with kiosk versus bedside testing (phase 1, 0%; phase 3, 0.2%; phase 4, 0.5%). Compared to patients tested at the bedside, patients tested via the kiosk were significantly younger, more likely to be female, to be black, and to report high risk behaviours. ED-based HIV screening via a registration-based kiosk was feasible, yielded similar proportions of testing, and increased the proportion of engagement of higher-risk patients in testing.

Understanding Providers’ Offering and Patients’ Acceptance of HIV Screening in Emergency Departments: A Multilevel Analysis. ANRS 95008, Paris, France

ObjectiveWe assessed the EDs’ characteristics associated with the offer and acceptance rates of a nontargeted HIV rapid-test screening in 29 Emergency Departments (EDs) in the metropolitan Paris region (11.7 million inhabitants), where half of France’s new HIV cases are diagnosed annually.MethodsEDs nurses offered testing to all patients 18–64-year-old, able to provide consent, either with or without supplemental staff (hybrid staff model or indigenous staff model). The EDS’ characteristics collected included structural characteristics (location, type, size), daily workload (patients’ number and severity, length of stay in hours), staff’s participation (training, support to the intervention, leadership), type of week day (weekends vs weekdays) and time (in days). Associations between these variables and the staff model, the offer and acceptance rates were studied using multilevel modeling.ResultsIndigenous staff model was more frequent in EDs with a lower daily patient flow and a higher staff support score to the intervention. In indigenous-model EDs, the offer rate was associated with the patient flow (OR = 0.838, 95% CI = 0.773–0.908), was lower during weekends (OR = 0.623, 95% CI = 0.581–0.667) and decreased over time (OR = 0.978, 95% CI = 0.975–0.981). Similar results were found in hybrid-model EDs. Acceptance was poorly associated with EDs characteristics in indigenous-model EDs while in hybrid-model EDs it was lower during weekends (OR = 0.713, 95% CI = 0.623–0.816) and increased after the first positive test (OR = 1.526, 95% CI = 1.142–2.038).The EDs’ characteristics explained respectively 38.5% and 15% of the total variance in the offer rate across indigenous model-EDs and hybrid model-EDs vs 12% and 1% for the acceptance rate.ConclusionOur findings suggest the need for taking into account EDs’ characteristics while considering the implementation of an ED-based HIV screening program. Strategies allowing the optimization of human resources’ utilization such as HIV targeted screening in the EDs might be privileged.

Commentary

Commentary

Comparison of emergency department HIV testing data with visit or patient as the unit of analysis

Outcomes in an episodic care setting like an emergency department (ED) are traditionally evaluated in comparison with the number of visits as opposed to the number of unique patients, although patients commonly present to the ED multiple times. We examined the differences in HIV screening programme outcomes that would occur if the analysis were conducted at the patient-level, rather than the traditional visit-level. We hypothesized that while our ED-based HIV screening programme does test some patients repeatedly, the primary programme outcome of percent positive is not substantially altered by the unit of analysis. We reviewed the clinical database of an ED HIV screening programme at a large, urban, teaching hospital in the United States from 2003-2007. Data were analyzed descriptively. The main outcome measure was the rate of positive test results computed with either the visit or the patient as the unit of analysis. HIV testing was provided at 9629 visits, representing 8450 unique patients. For patient-level analysis, the proportion of patients found to be positive was 0.91%. For visit-level analysis, the proportion of tests with positive results was 0.83%. Of the 910 patients with repeat testing, 7 (0.77%) were identified as positive at a repeat test. The median time between tests was 383 days (range 1-1742). Results changed little regardless of whether unique patients or unique visits were used as the unit of analysis. Any differences in positive rates were mitigated by the contribution of repeat testing to the identification of newly infected patients. Given these findings, and the difficulty of tracking repeat testing over time, visit-level analysis are appropriate for comparing programme outcomes when detailed modeling of epidemiology, cost, and/or outcomes is not required.

Commentary

Although emergency physicians would rarely find themselves in a position to make decisions regarding perinatal HIV prophylaxis, this report does bring up some new issues that could affect care in the emergency department (ED). Rapid HIV tests that have recently become available could have several useful applications in the ED setting. Pregnant women with no prenatal care are more likely to present to EDs when they are ready to deliver or when they have a problem. 1 Minkoff HL McCalla S Feldman J The relationship of cocaine use to syphilis and HIV infection among inner city parturient women. Am J Obstet Gynecol. 1990; 163: 521-526 Abstract Full Text PDF PubMed Google Scholar Emergency physicians should be aware that HIV testing and perinatal antiretroviral treatment can reduce the likelihood of transmitting HIV to infants, but it would be a rare circumstance in which this would be done in the ED. More important applications for rapid HIV testing in the ED would include (1) testing patients with unknown HIV status who present with problems that could possibly be due to opportunistic infections associated with AIDS, (2) testing of source patients involved in blood/body fluid exposures, and (3) ED-based HIV screening programs for persons at risk.

Feasibility of an Emergency Department–Based, Risk-Targeted Voluntary HIV Screening Program

Study objective: To assess the feasibility and effectiveness of an emergency department–based, risk-targeted voluntary HIV screening program. Methods: We prospectively enrolled consenting adult IV drug users (IDUs) not known to have HIV infection in the ED of a large inner-city hospital with a high rate of HIV infection among patients during a 10-week trial. Study patients were given confidential HIV pretest and risk-reduction counseling, with 10- to 14-day on-site ED follow-up. Follow-up included posttest counseling, reinforcement of risk-reduction practices, and a $10 incentive to cover transportation costs. HIV seropositive patients were referred to the hospital HIV clinic for further evaluation and treatment. Results: Of 200 eligible IDUs, 168 (84%) consented to HIV testing. Of the 104 (62%) who returned for follow-up, 17 (16%) tested positive for HIV. Of these patients, 6 (35%) kept their initial hospital HIV clinic referral appointment, a rate consistent with the experience of the hospital HIV clinic. Of nine patients in whom CD4+ counts were performed at time of the visit, three (33%) had counts less than 200. At 3-month follow-up, 4 of 20 active IDUs (20%) had reportedly ceased drug use because of the program. The complete program cost was an estimated $16,659, $99 per enrolled patient and $521 per HIV-positive patient. Conclusion: An ED-based, risk-targeted HIV screening program is feasible and over time could detect a significant number of asymptomatic HIV-infected individuals, including those who should receive antiretroviral therapy and prophylaxis for Pneumocystis carinii pneumonia therapy (CD4+ count less than 200). An additional benefit of ED-based HIV screening in high-prevalence EDs is the opportunity to conduct successful risk-reduction counseling in some high-risk individuals. [Kelen GD, Hexter DA, Hansen KN, Humes R, Vigilance PND, Baskerville M, Quinn TC: Feasibility of an emergency department–based, risk-targeted voluntary HIV screening program. Ann Emerg Med June 1996;27:687-692.]