ED-based HIV Testing Research Articles

Rapid HIV Testing in an Urban Emergency Department: Using Social Workers to Affect Risk Behaviors and Overcome Barriers

In the 27 years since HIV was first reported in the United States, an estimated 1.6 million people have been diagnosed with HIV, and more than 525,000 have died as a result of AIDS (Centers for Disease Control and Prevention [CDC], 2005). Currently, approximately 250,000 individuals in the United States are unknowingly infected with HIV, and approximately 40,000 new infections occur each year (CDC, 2006). As the HIV epidemic continues, the populations most deeply affected are racial and ethnic minorities and those who are socially and economically marginalized. These populations currently represent almost 70 percent of new cases of HIV infection (CDC, 2007). In addition to the disproportionate spread of HIV among these populations, access to primary and ongoing medical or preventive care is often a financial or logistical impossibility. Emergency departments (EDs) serve as an important part of this country's medical safety net, and those without access to primary medical care commonly use EDs as their sole source of care. The ED, therefore, is often the only medical venue available to target patients at increased risk of harboring unrecognized HIV infection, to identify those who are infected, and to link them into ongoing care. Successful performance of these services may ultimately affect this epidemic (Rothman, 2004). CDC RECOMMENDATIONS FOR HIV TESTING The CDC first released recommendations for performing HIV testing in health care settings in 1986, and in that document it encouraged voluntary HIV counseling and testing (CDC, 1986). Revised in 1993, the CDC recommendations focused further on the importance of prevention counseling--the process of engaging a patient in a discussion regarding HIV transmission and risk behaviors--and considered counseling a critical integrated component of testing (CDC, 1993). As the recommendations evolved, they continued to specifically advise that counseling be provided by a professional trained in HIV-specific counseling (CDC, 2001) and, until 2006, strongly endorsed the provision of counseling as part of HIV testing. To increase the absolute number of individuals tested for HIV infection and to minimize barriers associated with HIV testing, the CDC again revised its recommendations in September 2006. The most recent guidelines call for the following: incorporating nontargeted opt-out rapid HIV screening (that is, performing rapid HIV testing on all patients unless they specifically decline) into routine medical practice, integrating informed consent for HIV testing into the general medical consent (previously, separate informed consent had been standard), and uncoupling prevention counseling from HIV testing (that is, instead of providing prevention counseling in all cases, prevention counseling is now only recommended for all patients who test positive for HIV infection) (CDC, 2006). STRATEGIES FOR PERFORMING HIV TESTING IN EDS Several distinct methods of performing HIV testing in EDs have been described and evaluated and include the following three: (1) identifying patients at increased risk of HIV infection and referring them from the ED for outpatient HIV counseling and testing; (2) performing conventional (nonrapid) HIV testing in the ED and referring the patients to obtain test results and counseling at an outpatient clinic; and (3) performing rapid HIV testing, in which patients are tested and receive test results during the same ED visit. Adherence rates with the former two methods are low, and therefore, various models of ED-based rapid HIV testing have been developed to determine how to most effectively test patients at risk of HIV infection. Current rapid HIV testing strategies in EDs have been described and include the following: diagnostic testing (that is, performing rapid HIV testing on the basis of a patient's clinical signs or symptoms), targeted screening (that is, performing rapid HIV testing on all patients with specific HIV-related risk characteristics), and nontargeted screening (that is, performing rapid HIV testing on all patients regardless of their risk characteristics) (Rothman, Lyons, & Haukoos, 2007). …

Emergency Department HIV Testing and Counseling: An Ongoing Experience in a Low-Prevalence Area

Despite recommendations, emergency department (ED)-based HIV screening is not widespread, and feasibility studies are generally limited to settings with high HIV prevalence (>1%). This investigation was to evaluate an ongoing, publicly funded, ED-based HIV counseling and testing program in a low-prevalence area. We reviewed a database of patients treated by an ED-based HIV counseling and testing program at a large, urban, teaching hospital for 1998 to 2002. ED patients at risk for HIV were targeted for standard serologic testing and counseling. Data were collected prospectively using standardized forms as part of clinical operations rather than in the context of rigorous research methodology; patient-oriented outcomes were not assessed. Counselors were trained according to Centers for Disease Control and Prevention guidelines, and health department guidelines for counseling and testing centers were followed. The main outcome measure was the number and proportion of patients newly diagnosed with HIV. Eight thousand five hundred seventy-four patients were approached; 5,504 consented to HIV testing. Mean age was 29 years (SD 9.4 years), 76% were black, and 50% were men. Five thousand three hundred seventy-four (97.6%) patients tested negative and 39 (0.7%) patients tested positive. Seventy-five percent of negative-test patients and 79% of positive-test patients were notified of test results. Information for seropositive patients not notified of results was forwarded to the health department. All notified HIV-positive patients entered treatment. Risk factors included sexually transmitted disease (47%), multiple sexual partners (40%), unprotected sex while using drugs or alcohol (30%), men having sex with men (5%), and intravenous drug use (4%). Identification of HIV-positive patients is possible in low-prevalence ED settings. In this instance, it was possible to perpetuate an ED-based HIV intervention program during an extended time. Although our work expands the profile of ED-based HIV counseling and testing beyond previous reports, the results should not be overgeneralized.