Rapid HIV Testing Program Research Articles

Testing for HIV infection in the emergency departments of 2 hospitals in the Southeastern United States.

BackgroundIn 2006, the Centers for Disease Control and Prevention (CDC) recommended non‐targeted, opt‐out HIV screening in all healthcare settings, including emergency departments (EDs). Multiple HIV testing programs have been implemented in EDs across the United States with varying designs and testing platforms. We report findings from a free, non‐targeted, rapid HIV testing program in 2 EDs in the Southeastern United States.MethodsFrom 2008 to 2012, adults ≥18 years of age were offered free rapid HIV testing using an oral swab test (OraQuick ADVANCE Rapid HIV‐1/2 antibody test) in the EDs of a large academic medical center and an affiliated community hospital in Durham, North Carolina.ResultsIn total, 5443 ED patients were offered HIV testing. The overall acceptance rate was 66.9% (3639/5443). Younger persons were significantly more likely to accept testing (78.2% for 18–29 years old vs 67.1% for ≥30 years old; P < 0.001) as were Black participants (72.6% Black vs 66.5% White; P < 0.001). Acceptance rates improved significantly after opt‐out oral consent replaced written consent (71.3% vs 63.1%; P < 0.001). Seven new HIV diagnoses were confirmed during the testing program, resulting in a seropositivity rate of 0.19% (7/3639). There were 8 false–positive rapid oral HIV tests (positive predictive value = 46.7%).ConclusionsAlthough the number of new HIV diagnoses was low, implementation of this rapid, non‐targeted ED screening program was feasible with high acceptance rates, particularly after introducing the opt‐out oral consent approach.

Acceptance of Rapid Human Immunodeficiency Virus Testing in an Urban Emergency Department

Rapid HIV testing programs in emergency departments (EDs) have been shown to promote early diagnosis and linkage to specialty care. However, sensitivity of the subject-matter and stigmatization of disclosing associated risk factors may make patients reluctant to consent to testing in this setting. This study sought to determine whether men are more likely to refuse rapid HIV testing in the ED as compared to women and to analyze the influence of tester gender on the response. This retroactive study utilized demographic and testing information from a rapid HIV testing program housed within two urban EDs for a 5-month period. Gender and age were collected for both testers and patients, along with patient consent outcome. A total of 5358 patients (males = 2230; females = 3128) were approached and offered an HIV test by one of 19 testers during the study period. From the sample population, male and female patient refusal rates were similar (30.0% vs 29.1%, respectively). Female testers approached 57.8% (n = 3,095) of the patients; however, they had a significantly higher refusal rate compared to male testers (35.6% vs 21.4%; p < 0.001). We found a potential gender effect on HIV test consenting. Such a finding could have important implications on HIV screening program effectiveness and warrants further investigation.

Detecting HIV among persons accompanying patients to an infectious diseases clinic.

Infectious diseases (ID) clinics are locations where members of at risk social networks, including sex partners of HIV-infected patients, make contact with a medical care setting when they accompany HIV-positive patients to appointments. We implemented a free point-of-care rapid HIV testing program for anyone accompanying a patient to the University of North Carolina ID clinic. Acceptability of the program among the general clinic population was assessed via an anonymous survey 1 year after program implementation. Basic frequencies of those who underwent and received results of rapid HIV testing, the proportion of positive rapid tests and confirmatory HIV tests performed, and the level of University of North Carolina ID clinic patient satisfaction with the HIV testing program were calculated. Between October 2007 and June 2013, 450 (99.6%) of 452 individuals tested in the program received their results on the same day as testing. Twenty-two individuals (4.9%) tested HIV positive, of which 16 (72.7%) were newly positive, including 3 never previously tested. Excluding previously diagnosed individuals, HIV prevalence was 3.6% (16/446). Among those testing positive by rapid testing, 19 (86.4%) had confirmatory testing and immediately entered into HIV care at the clinic. The high positivity and confirmatory HIV rates in our program confirm that the provision of rapid HIV testing in an ID clinic capitalizes on missed opportunities among an at-risk population and allows immediate linkage to care.

Implementation of a rapid HIV testing program in psychiatric inpatient wards

Aim According to New York State law, HIV testing must be offered to every patient aged 13-64. However, acute mental health hospitalizations can be difficult settings in which to conduct HIV screening. Because individuals with mental illness have higher rates of HIV infection, routine testing of stabilized patients in psychiatric inpatient wards could be beneficial. This study describes the implementation of a rapid HIV testing program in this nontraditional setting.

Increased rates of rapid point-of-care HIV testing using patient care technicians to perform tests in the ED

BackgroundVarious emergency department (ED) HIV testing models are reported in the literature but may not all be sustainable. We sought to determine whether changing an ED rapid HIV testing program from counselor‐based to ED technician‐based resulted in more testing. MethodsWe evaluated data from an ED rapid HIV testing program. Triage nurses offered testing to patients. In 2009, counselors performed rapid testing weekdays from 10:00 am to 6:00 pm. In 2010, ED technicians were trained to perform the test and replaced counselors. We compared the numbers of tests performed during the same 6-month periods in 2009 and 2010. Study personnel abstracted results through medical record review. ResultsA total of 241 oral tests were performed in 2009 compared with 1483 in 2010, representing slightly more than a 6-fold increase. In 2010, there was a steady increase in testing month by month. Incorporating patient volume, testing rates increased from 1.3% to 8.1%. Oral testing yielded no positive test results in 2009, but 7 individuals (0.47%) tested newly positive during the testing period of 2010. Of those with a documented CD4 count within 100 days of the positive result, 4 of 5 had CD4 counts less than 200. ConclusionsWe present a novel approach to HIV testing using existing staff within the ED. This new ED technician–based model led to large increases in rates of testing.

Validation of an abbreviated version of the Denver HIV Risk Score for prediction of HIV infection in an urban ED

ObjectiveWe sought to evaluate the performance of an abbreviated version of the Denver HIV Risk Score in 2 urban emergency departments (ED) with known high undiagnosed HIV prevalence. MethodsWe performed a secondary analysis of data collected prospectively between November 2005 and December 2009 as part of an ED-based nontargeted rapid HIV testing program from 2 sites. Demographics; HIV testing history; injection drug use; and select high-risk sexual behaviors, including men who have sex with men, were collected by standardized interview. Information regarding receptive anal intercourse and vaginal intercourse was either not collected or collected inconsistently and was thus omitted from the model to create its abbreviated version. ResultsThe study cohort included 15184 patients with 114 (0.75%) newly diagnosed with HIV infection. HIV prevalence was 0.41% (95% confidence interval [CI], 0.21%-0.71%) for those with a score less than 20, 0.29% (95% CI, 0.14%-0.52%) for those with a score of 20 to 29, 0.65% (95% CI, 0.48%-0.87%) for those with a score of 30 to 39, 2.38% (95% CI, 1.68%-3.28%) for those with a score of 40 to 49, and 4.57% (95% CI, 2.09%-8.67%) for those with a score of 50 or higher. External validation resulted in good discrimination (area under the receiver operating characteristic curve, 0.75; 95% CI, 0.71-0.79). The calibration regression slope was 0.92 and its R2 was 0.78. ConclusionsAn abbreviated version of the Denver HIV Risk Score had comparable performance to that reported previously, offering a promising alternative strategy for HIV screening in the ED where limited sexual risk behavior information may be obtainable.

Targeted rapid HIV testing in public primary care services in Madrid. Are we reaching the vulnerable populations?

To describe the population targeted for the rapid HIV testing program delivered via socio-culturally adapted services in primary care centers and to assess factors associated with uptake of first-time testing. This was a descriptive cross-sectional study. We analyzed consultations between April 29, 2010 and May 31, 2012. We assessed the differences in age, origin, education, and sexual history between men who have sex with men (MSM), heterosexual men (HM), and women, using a two-sided independent t-test and Chi-square statistics. Factors associated with first-time testing were analyzed by logistic regression. Of 1940 consultations, 45.1% were HM, 25.4% MSM, and 29.5% women; 35.4% were immigrants, 2.5% were or had been sex workers, and 15.4% had visited one. The test was reactive in 2.1%. Up to 44.2% had never been tested. The probability of being tested for the first time increased in HM, women, populations from the Indian Subcontinent, those with no casual sexual partners, those whose partner's serostatus was unknown, and those with no history of other sexually transmitted infections. This program managed to reach a high proportion of vulnerable people. First time HIV testing rates were high.

The Implementation of Opt-In Rapid HIV Testing in an Urban Emergency Department

In 2006 the CDC recommended that HIV testing be offered in all health care settings in an effort to increase the number of HIV-infected persons who are aware of their serostatus. Emergency departments (ED) are explicitly emphasized in the initiative as EDs often serve as a site for routine health care visits. In March 2013, the US Preventive Services Task Force released a drafted statement changing their assigned recommendation grade for routine HIV screening from a “C” to an “A”. Currently available commercial assays allow for increasingly early detection of HIV infection. Past studies have reported discouraging patient participation rates and feasibility evaluations for screening in the ED. An IRB-approved pilot study was developed to determine the feasibility of implementing a point-of-care (POC), opt-in, rapid HIV testing program in an urban, 54,000 volume, level 1 trauma center. The pilot program was performed over periods of 6 weeks and 10 weeks in the summers of 2011 and 2012, respectively. From Monday through Friday, for 8 hours/day, non-targeted English-speaking patients, between the ages of 18 and 64, triaged ESI level 3, 4, or 5 were offered a free bedside Oraquick Advance rapid, oral HIV test. Study personnel were trained in obtaining consent, administration of the test, disclosure of results and HIV counseling. A process for counseling and confirmatory testing of preliminary positives involved ED and infectious disease staff, social workers, and the State Health Department. Of 456 patients offered POC oral HIV tests, 422 (93%) consented to the test. The study period yielded one preliminary positive Oraquick ELISA, later invalidated via Orasure Western Blot by the Illinois Department of Public Health (IDPH). The mean age of participants was 38 years old; 50% had not previously received an HIV test. 64% of participants were minorities. Average test time was 24.5 minutes. High patient acceptance rate (93%) and minimal effect on ED flow suggest that rapid HIV testing is feasible in an emergency setting with additional staff support. The anticipated prevalence (≥ 0.1%) was not identified in this pilot.

Analysis of HIV Testing Acceptance and Risk Factors of an Adolescent Cohort Using Emergency Department–Based Multimedia HIV Testing and Counseling

The social environment in the Bronx, NY, has led to HIV infection rates among young people that are much higher than the national average. A prospective observational study on a convenience sample of medically stable emergency department (ED) patients was conducted from October 1, 2005, to August 31, 2012. Acceptability of the tested model was determined by assessing the number of patients tested and identified HIV infections. Data were compared with data from the rest of the ED that tested for HIV. A total of 10,149 adolescents were approached during this period, of which 9.5% refused or were ineligible to test. Of those approached, 38.9% of patients were male, 59.7% were Hispanic, and 33.6% were black. The mean age was 19.4 ± 1.4 years, and 8.2% of patients were men who have sex with men. For risk behavior profiles, 24.3% never used condoms in the past 3 months. Incidence of HIV was less than 1%, and 92.6% of HIV-positive patients were linked to care. Of the patients who completed a postsatisfaction survey, 82.4% felt influenced to change their sexual practices. A smaller percentage of adolescent had tested previously for HIV compared with nonadolescents (67.7% vs. 80.6%). There was a slightly larger percentage of adolescents that accepted HIV testing compared with nonadolescents (95.4% vs. 90.8%). Adolescents who were positive for HIV were tested earlier in the progression of the disease, with higher median CD4 cell counts and lower viral loads compared with nonadolescents. Adolescents were highly receptive to a multimedia-integrated ED-based HIV testing program, as indicated by their high uptake of testing.

Counselor-Based Rapid HIV Testing in Community Pharmacies

The purpose of this study was to examine the results of implementing a rapid counselor-based HIV testing program in community pharmacies. A prospective cross-sectional study was conducted on a convenience sample of clients at five community pharmacies in New York City (NYC). In 294 days of pharmacy testing, 2805 clients were eligible to receive testing, and 2030 individuals agreed to test. The average age was 33±15 years, 41% were male, 59% were Hispanic, 77% had been previously tested for HIV, and 34% were uninsured. HIV incidence was 0.3%, median CD4 cell count was 622.0, and the average age of the newly diagnosed positives was 36.0±13.9 years. Participants were satisfied with a counselor-based rapid HIV testing program in community-based pharmacies.

P3-S3.08 Sensitivity and specificity of rapid HIV testing in a community setting

BackgroundIt was estimated in 2005 that 13% of men who have sex with men (MSM) in Montréal were HIV-positive, and that 23% of these were not aware of their diagnosis....

Outcomes and Cost Analysis of 3 Operational Models for Rapid HIV Testing Services in an Academic Inner-City Emergency Department

We compare the outcomes and costs of alternative staffing models for an emergency department (ED) rapid HIV testing program. A rapid oral-fluid HIV testing program was instituted in an inner-city ED in 2005. Three staffing models were compared during 24.5 months: indigenous medical staff only, exogenous staff only, or exogenous staff plus medical staff (hybrid). Personnel obtained written consent and provided brief pretest counseling, obtained kits, collected specimens, returned specimens to the ED satellite laboratory, and performed posttest counseling and referral to care. Cost analysis was performed to estimate cost per patient tested and cost per patient linked to care. Overall, 44 of 2,958 (1.5%) patients tested received confirmed positive results and 30 (68%) were linked to care. The exogenous staff only model yielded the highest number tested per month (587), and indigenous medical staff only yielded the lowest (57). Significantly higher positivity rates were found in both indigenous medical staff only (2.2%) and hybrid (2.0%) models versus the exogenous staff only model (0.6%) (prevalence rate ratio: 3.7 [95% confidence interval {CI}1.5 to 9.3] versus 3.4 [95% CI 1.5 to 7.8], respectively). All patients with confirmed positive results were linked to care in the indigenous medical staff only model but only approximately 60% were linked to care in the 2 other models (linked to care rate ratio versus exogenous staff only: 1.8 [95% CI 1.1 to 4.4]; versus hybrid: 1.7 [95% CI 1.2 to 2.5]). The indigenous medical staff only model had the highest cost ($109) per patient tested, followed by the hybrid ($87) and the exogenous staff only ($39). However, the indigenous medical staff only model had the lowest cost ($4,937) per patient linked to care, followed by the hybrid ($7,213) and exogenous staff only ($11,454). The exogenous staff only model tested the most patients at the least cost per patient tested. The indigenous medical staff only model identified the fewest patients with unrecognized HIV infection and had the highest cost per patient tested but the lowest cost per patient linked to care.

Patient Satisfaction With Rapid HIV Testing in the Emergency Department

Patient satisfaction with HIV screening is crucial for sustainable implementation of the Centers for Disease Control and Prevention (CDC) HIV testing recommendations. This investigation assesses patient satisfaction with rapid HIV testing in the emergency department (ED) of an urban tertiary academic medical center. After receiving HIV test results, participants in the Universal Screening for HIV Infection in the Emergency Room (USHER) randomized controlled trial were offered a patient satisfaction survey. Questions concerned overall satisfaction with ED visit, time spent on primary medical problem, time spent on HIV testing, and test provider's ability to answer HIV-related questions. Responses were reported on a 4-point Likert scale, ranging from very dissatisfied to very satisfied (defined as optimal satisfaction). Of 4,860 USHER participants, 2,025 completed testing and were offered the survey: 1,616 (79.8%) completed the survey. Overall, 1,478 (91.5%) were very satisfied. Satisfaction was less than optimal for 34.5% (10 of 29) of participants with reactive results and for 7.5% (115 of 1,542) with nonreactive results. The independent factors associated with less than optimal satisfaction were reactive test result, aged 60 years or older, black race, Hispanic/Latino ethnicity, and testing by ED provider instead of HIV counselor. Most participants were very satisfied with the ED-based rapid HIV testing program. Identification of independent factors that correlate with patient satisfaction will help guide best practices as EDs implement CDC recommendations. It is critical to better understand whether patients with reactive results were negatively affected by their results or truly had concerns about the testing process.

Testing and Linkage to Care Outcomes for a Clinician-Initiated Rapid HIV Testing Program in an Urban Emergency Department

The urban emergency department is an important site for the detection of HIV infection. Current research has focused on strategies to increase HIV testing in the emergency department. As more emergency department HIV cases are identified, there need to be well-defined systems for linkage to care. We conducted a retrospective study of rapid HIV testing in an urban public emergency department and level I trauma center from June 1, 2008, to March 31, 2010. The objectives of this study were to evaluate the increase in the number of tests and new HIV diagnoses resulting from the addition of targeted testing to clinician-initiated diagnostic testing, describe the demographic and clinical characteristics of patients with newly diagnosed HIV infection, and assess the effectiveness of an HIV clinic based linkage to care team. Of 96,711 emergency department visits, there were 5340 (5.5%) rapid HIV tests performed, representing 4827 (91.3%) unique testers, of whom 62.4% were male and 60.8% were from racial/ethnic minority groups. After the change in testing strategy, the median number of tests per month increased from 114 to 273 (p=0.004), and the median number of new diagnoses per month increased from 1.5 to 4 (p=0.01). From all tests conducted, there were 65 new diagnoses of HIV infection (1.2%, 95% confidence interval [CI] 0.9%, 1.5%). The linkage team connected over 90% of newly diagnosed and out-of-care HIV-infected patients to care. In summary, the addition of targeted testing to diagnostic testing increased new HIV case identification, and an HIV clinic-based team was effective at linkage to care.

Low Perceived Risk and High HIV Prevalence Among a Predominantly African American Population Participating in Philadelphia's Rapid HIV Testing Program

African Americans are disproportionately infected with HIV/AIDS. Despite Centers for Disease Control and Prevention (CDC) guidelines recommending routine opt-out testing for HIV, most HIV screening is based on self-perceived HIV risks. Philadelphia launched a rapid HIV testing program in seven public health clinics in 2007. The program provides free rapid oral HIV tests to all patients presenting for health services who provide informed consent. We analyzed demographic, risk behavior, and HIV serostatus data collected during the program between September 2007 and January 2009. We used multivariable logistic regression to estimate the association between behavioral and demographic factors and newly diagnosed HIV infection. Of the 5871 individuals testing for HIV, 47% were male, 88% were African American, and the mean age was 34.7 years. Overall HIV prevalence was 1.1%. All positive tests represented new HIV diagnoses, and 72% of individuals reported testing previously. Approximately 90% of HIV-positive individuals and 92% of individuals with more than five recent sex partners never, or only sometimes, used condoms. Two thirds of individuals testing positive and 87% of individuals testing negative assessed their own HIV risk as zero or low. Individuals reporting cocaine use and ever having a same sex partner both had 2.6 times greater odds of testing positive. Condom use in this population was low, even among high-risk individuals. Philadelphia's program successfully provided HIV testing to many underserved African Americans who underestimate their HIV risk. Our results nevertheless suggest greater efforts are needed to encourage more individuals to undergo HIV testing in Philadelphia, particularly those who have never tested.

Evaluation of a Rapid HIV Testing Initiative in an Urban, Hospital-Based Dental Clinic

Performing rapid HIV testing in nontraditional clinical settings such as dental clinics is a potential method for targeting high-risk individuals who may not otherwise access health care settings that offer HIV testing. In March 2008, Harlem Hospital Center, located in New York City, launched a counselor-based rapid HIV testing initiative in its on-site dental clinic. A full-time, trained counselor consented and tested patients as they waited for their appointments. HIV screening was performed using a whole-blood, finger-stick rapid HIV test. Through this initiative, 3864 HIV tests were performed from March 1, 2008 to December 31, 2009, representing 3565 unique individuals and 97.6% of dental patients approached for testing. Of those tested, the mean age was 38.5 years, with 47.1% female, 75.5% black, and 20.6% Hispanic. Self-reported HIV risk behaviors included 73.5% with recent unprotected heterosexual intercourse, 4.6% with recent or past injection drug use, and 2.6% who identified as men who have sex with men. Nineteen previously undiagnosed individuals (0.53%) were confirmed HIV positive. Of these individuals, mean age was 38.3 years with males representing 84.2%. Fifteen newly diagnosed patients (78.9%) were linked to care. Of those linked to care, median initial CD4 cell count was 317 cells/mm(3); 6 of these individuals (40%) had CD4 cell counts below 200 cells/mm(3). Our results demonstrate that a counselor-based rapid HIV testing program with linkage to specialized HIV care can be successfully integrated into the dental clinic setting.

Results From a New York City Emergency Department Rapid HIV Testing Program

Results From a New York City Emergency Department Rapid HIV Testing Program

Rapid HIV testing program implementation: lessons from the emergency department.

BackgroundThe US Centers for Disease Control and Prevention (CDC) guidelines and the World Health Organization (WHO) both recommend HIV testing in health-care settings. However, neither organization provides prescriptive details regarding how these recommendations should be adapted into clinical practice in an emergency department.MethodsWe have implemented an HIV-testing program in the ED of a major academic medical center within the scope of the Universal Screening for HIV Infection in the Emergency Room (USHER) Trial—a randomized clinical trial evaluating the feasibility and cost-effectiveness of HIV screening in this setting.Results and conclusionDrawing on our collective experiences in establishing programs domestically and internationally, we offer a practical framework of lessons learned so that others poised to embark on such HIV testing programs may benefit from our experiences.

Results of a Rapid HIV Screening and Diagnostic Testing Program in an Urban Emergency Department

We describe outcomes of a rapid HIV testing program integrated into emergency department (ED) services, using existing staff. From April 2005 through December 2006, triage nurses in an urban ED offered HIV screening to medically stable patients aged 12 years or older. Clinicians could also order diagnostic testing according to presenting signs and symptoms and suspicion of HIV-related illness. Nurses obtained consent, performed rapid testing, and disclosed negative test results. Clinicians disclosed positive test results and arranged follow-up. Outcome measures included number and proportion of visits during which screening was offered, accepted, and completed; number of visits during which diagnostic testing was completed; and number of patients with confirmed new HIV diagnosis and their CD4 counts. HIV screening and diagnostic testing were completed in 9,466 (8%) of the 118,324 ED visits (14.2% of the 60,306 unique patients were tested at least once). Screening was offered 45,159 (38.2%) times, accepted 21,626 (18.3%) times, and completed 7,923 (6.7%) times; diagnostic testing was performed 1,543 (1.3%) times. Fifty-five (0.7%) screened patients and 46 (3.0%) of those completing diagnostic testing had confirmed positive HIV test results. Median CD4 count was 356 cells/microL among screened patients and 99 cells/microL among those who received diagnostic testing. Although existing staff was able to perform HIV screening and diagnostic testing, screening capacity was limited and the HIV prevalence was low in those screened. Diagnostic testing yielded a higher percentage of new HIV diagnoses, but screening identified greater than 50% of those found to be HIV positive, and the median CD4 count was substantially higher among those screened than those completing diagnostic testing.

258: Can Physician Education Improve Patient Use of a Free Rapid HIV Testing Program?

258: Can Physician Education Improve Patient Use of a Free Rapid HIV Testing Program?