Andrew H. Ruffner

Randomized comparison of universal and targeted HIV screening in the emergency department.

Objective:Universal HIV screening is recommended but challenging to implement. Selectively targeting those at risk is thought to miss cases, but previous studies are limited by narrow risk criteria, incomplete implementation, and absence of direct comparisons. We hypothesized that targeted HIV screening, when fully implemented and using maximally broad risk criteria, could detect nearly as many cases as universal screening with many fewer tests. Methods:This single-center cluster-randomized trial compared universal and targeted patient selection for HIV screening in a lower prevalence urban emergency department. Patients were excluded for age (<18 and >64 years), known HIV infection, or previous approach for HIV testing that day. Targeted screening was offered for any risk indicator identified from charts, staff referral, or self-disclosure. Universal screening was offered regardless of risk. Baseline seroprevalence was estimated from consecutive deidentified blood samples. Results:There were 9572 eligible visits during which the patient was approached. For universal screening, 40.8% (1915/4692) consented with 6 being newly diagnosed [0.31%, 95% confidence interval (CI): 0.13% to 0.65%]. For targeted screening, 37% (1813/4880) had no testing indication. Of the 3067 remaining, 47.4% (1454) consented with 3 being newly diagnosed (0.22%, 95% CI: 0.06% to 0.55%). Estimated seroprevalence was 0.36% (95% CI: 0.16% to 0.70%). Targeted screening had a higher proportion consenting (47.4% vs. 40.8%, P < 0.002), but a lower proportion of ED encounters with testing (29.7% vs. 40.7%, P < 0.002). Conclusions:Targeted screening, even when fully implemented with maximally permissive selection, offered no important increase in positivity rate or decrease in tests performed. Universal screening diagnosed more cases, because more were tested, despite a modestly lower consent rate.

Comparison of Missed Opportunities for Earlier HIV Diagnosis in 3 Geographically Proximate Emergency Departments

OBJECTIVE Differences in the prevalence of undiagnosed HIV between different types of emergency departments (EDs) are not well understood. We seek to define missed opportunities for HIV diagnosis within 3 geographically proximate EDs serving different patient populations in a single metropolitan area. METHODS For an urban academic, an urban community, and a suburban community ED located within 10 miles of one another, we reviewed visit records for a cohort of patients who received a new diagnosis of HIV between July 1999 and June 2003. Missed opportunities for earlier HIV diagnosis were defined as ED visits in the year before diagnosis, during which there was no documented ED HIV testing offer or test. Outcomes were the number of missed opportunity visits and the number of patients with a missed opportunity for each ED. We secondarily reviewed medical records for missed opportunity encounters, using an extensive list of indications that might conceivably trigger testing. RESULTS Among 276 patients with a new HIV diagnosis, 123 (44.5%) visited an ED in the year before diagnosis or received a diagnosis in the ED. The urban academic ED HIV testing program diagnosed 23 (8.3%) cases and offered testing to 24 (8.7%) patients who declined. Missed opportunities occurred during 187 visits made by 76 (27.5%) patients. These included 70 patients with 157 visits at the urban academic ED, 9 patients with 24 visits at the urban community ED, and 4 patients with 6 visits at the suburban community ED. Medical records were available for 172 of the 187 missed opportunity visits. Visits were characterized by the following potential testing indicators: HIV risk factors (58; 34%), related diagnosis indicating risk (7; 4%), AIDS-defining illness (8; 5%), physician suspicion of HIV (29; 17%), and nonspecific signs or symptoms of illness potentially consistent with HIV (126; 73%). CONCLUSION Geographically proximate EDs differ in their opportunities for earlier HIV diagnosis, but all 3 sites had missed opportunities. Many ED patients with undiagnosed HIV have potential indications for testing documented even in the absence of a dedicated risk assessment, although most of these are nonspecific signs or symptoms of illness that may not be clinically useful selection criteria.

Risk, reasons for refusal, and impact of counseling on consent among ED patients declining HIV screening ☆ ☆☆

Screening for HIV in the emergency department (ED) is recommended by the Centers for Disease Control and Prevention. The relative importance of efforts to increase consent among those who currently decline screening is not well understood. We compared the risk characteristics reported by patients who decline risk-targeted, opt-in ED screening with those who consent. We secondarily recorded reasons for declining testing and reversal of the decision to decline testing after prevention counseling. Of 199 eligible patients, 106 consented to testing and 93 declined. Of those declining, 60 (64.5%) of 93 completed a risk assessment. There were no differences in HIV risk behaviors between groups. Declining patients reported recent testing in 73.3% of cases. After prevention counseling, 4 (6.7%) of 60 who initially declined asked to be tested. Given similarities between those who decline and those who consent to testing, efforts to increase consent may be beneficial. However, this should be tempered by the finding that many declined because of a recent negative test. Emphasizing risk during prevention counseling is not a promising strategy for improving opt-in consent rates.

Relationship of Self-Reported Prior Testing History to Undiagnosed HIV Positivity and HIV Risk

Screening everyone for HIV at least once is estimated to be cost-effective. Screening in health care settings is recommended to help achieve that goal. Health care settings often encounter the same patient repeatedly, and it is unknown if limited resources are better allocated to conduct repeat screening, or to screen patients not yet tested. We reviewed data for a targeted ED based HIV screening program for 2003-2007. The role of prior testing history as a predictor of undiagnosed HIV positivity was assessed using a negative binomial model adjusted for demographics and risk behaviors. HIV testing was provided to 8,450 unique patients. There were 5,781 (70%) self-reporting a prior HIV test. Compared with patients reporting no prior test, the relative risk of HIV positivity for those reporting a test within the prior year was 0.90 (95%CI 0.48-1.66), and for those reporting a prior test more than a year previously the relative risk was 0.91 (95%CI 0.48-1.73). Among patients testing positive, those who did not report a prior test had a median CD4 count that was 228 cells/mm(3) lower than those with a prior test (CI(95) of the difference in medians 20-436 cells/mm(3)). Diagnosis of prevalent HIV among those who are at risk but have never been tested should be a priority. However, repeat screening of target populations for incident infection remains important and results in earlier diagnosis. Recent self-reported testing history is not associated with undiagnosed positivity among targeted patients irrespective of the timing of the prior test.

Prevalence of Undiagnosed Acute and Chronic HIV in a Lower-Prevalence Urban Emergency Department

OBJECTIVES We estimated the seroprevalence of both acute and chronic HIV infection by using a random sample of emergency department (ED) patients from a region of the United States with low-to-moderate HIV prevalence. METHODS This cross-sectional seroprevalence study consecutively enrolled patients aged 18 to 64 years within randomly selected sampling blocks in a Midwestern urban ED in a region of lower HIV prevalence in 2008 to 2009. Participants were compensated for providing a blood sample and health information. After de-identification, we assayed samples for HIV antibody and nucleic acid. RESULTS There were 926 participants who consented and enrolled. Overall, prevalence of undiagnosed HIV was 0.76% (95% confidence interval [CI] = 0.30%, 1.56%). Three participants (0.32%; 95% CI = 0.09%, 0.86%) were nucleic acid-positive but antibody-negative and 4 (0.43%; 95% CI = 0.15%, 1.02%) were antibody-positive. CONCLUSIONS Even when the absolute prevalence is low, a considerable proportion of undetected HIV cases in an ED population are acute. Identification of acute HIV in ED settings should receive increased priority.

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

Objectives 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. Methods 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. Results 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). Conclusions 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.

Effect of an Emergency Department HIV Testing Program on the Proportion of Emergency Department Patients Who Have Been Tested

OBJECTIVE The lack of well-described population-level outcome measures for emergency department (ED) HIV testing is one barrier to translation of screening into practice. We demonstrate the impact of an ED diagnostic testing and targeted screening program on the proportion of ED patients ever tested for HIV and explore cumulative effects on testing rates over time. METHODS Data were extracted from electronic HIV testing program records and administrative hospital databases for January 2003 to December 2008 to obtain the monthly number of ED visits and HIV tests. We calculated the proportions of (1) patients tested in the program who reported a previous HIV test or had been previously tested in the program, and (2) the cumulative number of unique ED patients who were tested in our program. RESULTS During the study period, 165,665 unique patients made 491,552 ED visits and the program provided 13,509 tests to 11,503 unique patients. From 2003 to 2008, tested patients who reported a history of an HIV test increased by 0.085% per month (95% confidence interval [CI] 0.037% to 0.133%), from 67.7% to 74.4%; the percentage of tested patients who had previous testing in the program increased by 0.277% per month (95% CI 0.245% to 0.308%), from 3.2% to 21.2%; and the percentage of unique ED patients previously tested in the program increased by 0.100% per month (95% CI 0.096% to 0.105%), reaching a cumulative proportion of 6.9%. CONCLUSION Our HIV testing program increased the proportion of ED patients who have been tested for HIV at least once and repeatedly tested a subset of individuals. HIV screening, even during a minority of ED visits, can have important cumulative effects over time.

Patient Perception of Whether an HIV Test Was Provided during the Emergency Department Encounter

This cross-sectional study approached emergency department (ED) patients after the treating physician’s disposition decision to measure patient understanding of whether or not they had received an HIV test during their ED encounter. Of the 300 respondents, 24 were excluded due to missing data or because they had received an ED HIV test. Mean age was 41 years, 51% were men, 61% were black, and 29% had no high school degree. There were 5.8% (95% confidence interval: 3.5%-9.4%) who erroneously reported HIV test delivery during their ED course. Our results suggest a small but significant minority of patients falsely assume that they have been tested for HIV during their ED visit. This misperception could have broad implications, leading to less frequent subsequent testing, false reassurance of HIV-negative status, and inaccuracies in surveillance estimates or surveys that depend on self-report.

Preliminary Program Evaluation of Emergency Department HIV Prevention Counseling

OBJECTIVE Controversy surrounds the linkage of prevention counseling with emergency department (ED)-based HIV testing. Further, the effectiveness and feasibility of prevention counseling in the ED setting is unknown. We investigate these issues by conducting a preliminarily exploration of several related aspects of our EDs HIV prevention counseling and testing program. METHODS Our urban, academic ED provides formal client-centered prevention counseling in conjunction with HIV testing. Five descriptive, exploratory observations were conducted, involving surveys and analysis of electronic medical records and programmatic data focused on (1) patient perception and feasibility of prevention counseling in the ED, (2) patient perceptions of the need to link prevention counseling with testing, and (3) potential effectiveness of providing prevention counseling in conjunction with ED-based HIV testing. RESULTS Of 110 ED patients surveyed after prevention counseling and testing, 98% believed privacy was adequate, and 97% reported that their questions were answered. Patients stated that counseling would lead to improved health (80%), behavioral changes (72%), follow-up testing (77%), and discussion with partners (74%). However, 89% would accept testing without counseling, 32% were willing to seek counseling elsewhere, and 26% preferred not to receive the counseling. Correct responses to a 16-question knowledge quiz increased by 1.6 after counseling (95% confidence interval 1.3 to 12.0). The program completed counseling for 97% of patients tested; however, 6% of patients had difficulty recalling the encounter and 13% denied received testing. Among patients undergoing repeated testing, there was no consistent change in self-reported risk behaviors. CONCLUSION Participants in the ED prevention counseling and testing program considered counseling acceptable and useful, though not required. Given adequate resources, prevention counseling can be provided in the ED, but it is unlikely that all patients benefit.

Opportunities for earlier HIV diagnosis in a pediatric ED

OBJECTIVES Emergency department (ED) HIV screening is recommended but challenging to implement and of uncertain effectiveness in pediatric EDs (PEDs). We sought to determine whether there were opportunities for earlier HIV diagnosis in the PED for a cohort of young adults diagnosed with HIV. METHODS This retrospective cohort study reviewed PED records of a group of young adults receiving HIV care in an urban hospital setting. Pediatric ED visits were selected for review if they took place after the patients estimated time of HIV acquisition and before their eventual diagnosis. Charts were reviewed to determine whether HIV infection was suspected and whether testing was offered. RESULTS Among a cohort of HIV-positive young adults, only 3 (3.6%; 95% confidence interval, 0.9-10.8) of 84 were seen in the PED during the time they were undiagnosed but likely to be infected with HIV. Among these subjects, there was no documentation that HIV testing was offered or refused nor was there documented suspicion of HIV. CONCLUSIONS There are opportunities for earlier diagnosis of HIV in PEDs, affirming the importance of HIV screening implementation in these settings. However, PEDs are unlikely to have the same frequency of contact with undiagnosed individuals as do adult EDs. Alternative methods of accessing at-risk adolescent populations must be identified.