Making the Case
Why test for HIV in the ED?
HIV disproportionately affects populations that are likely to be without a regular source of care or have a history of barriers to care, which may contribute to delayed diagnosis and further transmission of HIV.(13) Many are dependent on the public sector for the financing and delivery of their care. It is estimated that 45 percent of HIV-infected persons have no health insurance; 30 percent receive coverage through Medicaid; and 2 percent have Medicare.(14) Consequently, EDs—whose patients include large numbers of underinsured and uninsured—are likely the only source of health care for many people with HIV or at risk for HIV.(15-19) High rates of newly diagnosed HIV infection among ED patients who are uninsured or with Medicaid support the argument that many ED patients with HIV do not seek or have ready access to other health care sources.(20)
The HIV disease burden in some EDs, particularly urban EDs, surpasses the threshold to warrant screening.(21) Rothman's review of HIV sero-prevalence studies found rates of 2 percent to 17 percent in EDs across the country, with unrecognized disease rates of 1 percent to 5 percent.(20, 22-27)
The rest of this section summarizes current research on the following:
- The clinical benefit of expanded HIV testing
- The public health benefit of expanded HIV testing
- The scope of HIV testing in EDs nationwide
- The feasibility and cost-effectiveness of ED-based HIV testing
- Current recommendations for HIV testing for health care providers
13. Levi J, Kates J. HIV: challenging the health care delivery system. Am J Public Health. July 2000;90(7):1033-1036.
14. Centers for Disease Control and Prevention. Questions and Answers for Professional Partners: Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Healthcare Settings. Accessed May 3, 2007.
15. Kaiser Family Foundation. Financing HIV/AIDS Care: A Quilt with Many Holes May 2004.
16. Medical Access Study Group. Nowhere to go: Medicaid patient access to primary care. New Eng J Med. 1994;330:1426-1430.
17. Sox C, Swartz K, Burstin H, Brennan T. Insurance or regular physician: Which is the most powerful predictor of health care. American Journal of Public Health. 1999;88(3):364-370.
18. Sue D, Shahan J, Kelen G. Primary care access for Medicaid versus privately insured patients. Acad Emerg Med. 1994;1:A1.
19. Zuvekas S, Weinick R. Changes in access to care, 1977-1996: The role of health insurance. Health Services Research. 1999;34(1):271.
20. Kelen GD, Shahan JB, Quinn TC. Emergency department-based HIV screening and counseling: experience with rapid and standard serologic testing. Annals of Emergency Medicine. Feb 1999;33(2):147-155.
21. Rothman RE, Ketlogetswe KS, Dolan T, Wyer PC, Kelen GD. Preventive care in the emergency department: should emergency departments conduct routine HIV screening? a systematic review. Academic Emergency Medicine. Mar 2003;10(3):278-285.
22. Schoenbaum E, Webber MP. The underrecognition of HIV infection in women in an inner-city emergency room. American Journal of Public Health. 1993;83:363-368.
23. Lindsay M, Grant J, Peterson H, Risby J, et al. Human immunodeficiency virus infection among patients in a gynecology emergency department. Obstetrics & Gynecology. 1993;81:1012-1015.
24. Kelen GD, Hexter DA, Hansen KN, Tang N, Pretorius S, Quinn TC. Trends in human immunodeficiency virus (HIV) infection among a patient population of an inner-city emergency department: implications for emergency department-based screening programs for HIV infection. Clinical Infectious Diseases. Oct 1995;21(4):867-875.
25. Kelen GD, Hexter DA, Hansen KN, et al. Feasibility of an emergency department-based, risk-targeted voluntary HIV screening program. Annals of Emergency Medicine. Jun 1996;27(6):687-692.
26. Alpert PL, Shuter J, DeShaw MG, Webber MP, Klein RS. Factors associated with unrecognized HIV-1 infection in an inner-city emergency department. Annals of Emergency Medicine. Aug 1996;28(2):159-164.
27. Goggin MA, Davidson AJ, Cantril SV, O'Keefe LK, Douglas JM. The extent of undiagnosed HIV infection among emergency department patients: results of a blinded seroprevalence survey and a pilot HIV testing program. Journal of Emergency Medicine. Jul 2000;19(1):13-19.
Sign up if you would like us to keep you informed regarding updates to the HIV Guide and this web site. We will not share your information with anyone.