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HIV testing in Emergency Departments: A Practical Guide
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ED HIV Test Guide

Assess Your Readiness

Purpose: This tool is designed to help you begin considering some of the major elements in launching an ED HIV testing program. We provide links relevant to sections in this guide for further information.

Engaging Key Stakeholders

Who needs to be on board?

Successfully implementing ED HIV testing requires that key players support the program, understand its need, and know how it will affect patient care in their daily practice. Factors that can help engage key stakeholders include:

  • ED leaders support the effort.
  • ED physician or leader champions the effort.
  • Additional resources are provided, such as staff to conduct the testing or obtain funding.
  • ED leadership and clinical staff have a public health orientation—that is, they see public health as part of their mission.
  • Hospital CEO is aware of and supports the effort.
  • HIV testing in the ED is part of a broader health improvement and prevention effort by the hospital or health system.
  • Pilot tests are conducted to assess the idea and demonstrate impact.
  • The ED serves a population that is at risk for HIV.

Factors that may make key stakeholders reluctant to support ED HIV testing include:

  • Concerns about patient flow.
  • Little awareness of the need and relevance of HIV testing in emergency medicine.
  • Reliance on ED providers for most aspects of the testing process.
  • Difficulty in demonstrating direct clinical benefit.
  • Competing priorities in treating patients' chief complaints or other public health issues that may be more pressing for an individual patient.

To engage key stakeholders, consider the following questions:

  • Who will champion HIV testing in the ED? Can this person convince ED leadership and clinical staff of the importance and relevance of HIV testing in the ED? Will he or she be able to ensure that the ED adopts the program? Will he or she be able to speak about the program to both internal and external audiences to build broad awareness and support?
  • Who needs to be informed and to buy in to having an ED-based HIV testing program in your institution? Does anyone require additional information or data to make the case for HIV testing in this ED?
  • Who has resources or important perspectives to contribute to the effort?
  • Who needs to be involved in program design and decision making?
  • Have they been contacted?
  • Do they have specific expectations about the program?
  • What are their concerns?

This chart serves as a tool for you to identify key stakeholders and track engagement and communication:

Key Stakeholder Engagement

Informed/
Buy-in

Resources /
Perspectives

Design/
Decision Making

Contacted?

Expectations

Concerns

ED Leadership checkbox checkbox checkbox checkbox checkbox checkbox
ED Physicians checkbox checkbox checkbox checkbox checkbox checkbox
ED Nurses checkbox checkbox checkbox checkbox checkbox checkbox
ED Registration and Triage checkbox checkbox checkbox checkbox checkbox checkbox
Laboratory checkbox checkbox checkbox checkbox checkbox checkbox
Health Department checkbox checkbox checkbox checkbox checkbox checkbox
Infectious Disease Leadership and Clinical Staff checkbox checkbox checkbox checkbox checkbox checkbox
HIV Counseling and Testing Services checkbox checkbox checkbox checkbox checkbox checkbox
Hospital Administration checkbox checkbox checkbox checkbox checkbox checkbox
Academic Research Department checkbox checkbox checkbox checkbox checkbox checkbox
Risk Management checkbox checkbox checkbox checkbox checkbox checkbox
Community-based Organizations checkbox checkbox checkbox checkbox checkbox checkbox
Social Services checkbox checkbox checkbox checkbox checkbox checkbox
Mental Health Leadership and Staff checkbox checkbox checkbox checkbox checkbox checkbox
Who else? checkbox checkbox checkbox checkbox checkbox checkbox


Next Steps:

  • For each area that has not been contacted, when do you plan to do so?
  • For any concerns, is there information or resources that would diminish those concerns? Plan to make presentations to provide this information. See Making the Case.
  • Think about how the program design can address and incorporate key players' viewpoints and contributions, so that the program's benefit is experienced quickly, even if on a small scale. See Operational Flow.
  • What resources—human, financial, space, and equipment—are currently available among stakeholders to support implementation? What are the gaps and who will address them?

For more information on potential roles and perspectives, go to Key Players.

Legal Considerations

Patient Selection

What patient population do you aim to reach with HIV testing in the ED?

  • All patients in the ED?
  • All patients in a particular area, such as urgent care or fast track?
  • All patients with unknown HIV status?
  • Anyone who wants a test?
  • Patients presenting with sexually transmitted infections (STI)?
  • Patients who present with symptoms, risk behaviors, or medical histories that may indicate HIV infection/AIDS?
  • Other?

The goal of the effort, along with the characteristics of the patient population, HIV (and other STI) prevalence, and the human and financial resources available for HIV testing, will inform which testing approach is the most practical for your ED.  For more information on testing approaches, click here.  For guidance on how to set up your program so you can measure your progress and success, go here.

Testing Approaches

May require additional staffing

Pilot recommended

Requires linking to care

Better for limited resources

Communities with <1% prevalence

Communities with >1% prevalence

Diagnostic testing   check check check check

 

Targeted testing check check check check check

check

Screening or universal testing check check check    

check

To ensure a smoother start and consistent running of the program over time, consider the range of financial, legal, operational, and staffing issues and address those issues early. Leave room to be flexible and adapt to unexpected issues. Program characteristics that may facilitate implementation include:

  • Clearly defined roles and responsibilities for specific staff members.
  • Staff dedicated to HIV testing.
  • Oversight by ED-based project manager.
  • Consistent funding source.
  • Easy access to a pool of dedicated staff (e.g., medical/nursing students, HIV counselors).
  • Testing functions coordinated with typical staff duties (e.g., nurses draw specimens, lab runs all tests, physicians deliver test results).
  • HIV testing made part of standard operations (e.g., all patients are offered an HIV test at triage and this is recorded in the medical record and executed by medical staff).
  • ED providers oriented to the testing program and given guidelines and protocols on when testing is to be offered.

Characteristics that can impede implementation include:

  • Limited space in the ED to accommodate additional staff.
  • Limited staff capacity in laboratory to run tests.
  • Turnover of supplemental staff dedicated to HIV testing.
  • Real and perceived burden on providers to obtain informed consent.
  • Real and perceived requirement to obtain informed consent.
  • Providers' belief that HIV testing is an ancillary activity, secondary to treatment of chief complaints.
  • Reliance on presence of counselor.
  • Lack of method to follow up with patients who initially decline.
  • Reliance on individual providers.
  • Busy periods in ED and quick turnover of fast-track patients.
  • Ongoing need for staff training.

Financial Issues

  • What major costs do you anticipate?
  • Do you have resources--financial and other--to cover these costs?

Legal Considerations

Legal Considerations

  • Do you know your state's laws regarding consent, confidentiality, testing, and reporting requirements?
  • Does your hospital have additional or conflicting policies, practices, or requirements?

For information on your state's laws, go here  For options on consent requirements, go here.

Flow, Staffing & Choosing a Test

Where in the ED will testing occur? Will the lab or ED or other staff administer the tests? Who will inform patients of test results? For more information, go here.

Which staff members will be involved in testing? How will you build awareness and acceptance among ED providers of the value and availability of HIV testing in the ED? What training and cultural competency are required? For more information, go here.

Will you use rapid or traditional tests? Who will be responsible for quality control? For more information, go here.

Delivering & Documenting Results

What information or counseling is provided to a patient when a test is negative? What about when a test is reactive (preliminary positive)? For more information, go here.

What are the documentation and reporting procedures or requirements? For more information, go here.

Linking to Care

If a confirmatory test is positive, how will the ED link the patient to care? Processes and characteristics that can help facilitate linkage to care include:

  • Infectious disease providers are proactively involved in the ongoing design, implementation, and evaluation of testing efforts.
  • Disease investigation specialists from the health department are actively involved in tracking patients who are lost to follow-up.
  • Same-day or standing appointments are offered at the referral clinic.
  • Referral clinic is located in the hospital or on the hospital campus.
  • Infectious disease provider assumes responsibility for linkage to care.
  • HIV counseling and care providers are actively involved in posttest counseling and discussion of treatment and care options when a preliminary positive result is given.
  • Confirmatory test specimen is drawn at the time a preliminary positive test result is given.
  • Counselors accompany patients to clinic.

Processes and characteristics that impede linkage to care include:

  • Those with the resources and expertise for linking patients to care are absent from planning and decision making about HIV testing in the ED.
  • No referral site is part of or located near the testing site.
  • No one is clearly accountable for ensuring that patients enter care.
  • No or little patient contact information is provided in the ED.
  • Data on patients linked to care are not collected or tracked by the ED testing program.

For more information, go here.

Sustainability

If a program is begun as part of a research project or pilot test, how will you sustain it when the original project or test ends? Factors that can ensure sustainability include:

  • Funding for ED HIV testing comes from state and local pools of HIV prevention and care funds.
  • Program is demonstrated to be cost efficient.
  • Partnership is established with local health department which can provide test kits, training, lab, and funding.
  • Program costs are absorbed by existing hospital budgets, such as supplies and laboratory.
  • Public health, ED, laboratory, and infectious disease departments contribute infrastructure and resources to the testing process.
  • Program staff participate in HIV planning councils/advisory groups.
  • Data are collected to monitor and promote track record.

Factors that threaten sustainability include:

  • Budget is cut at the federal level for HIV prevention and care.
  • Nonrenewable funding sources support program.
  • Testing is part of research study and attached to certain investigators and grants.
  • Priority shifts for public health interventions or research conducted in the ED.
  • No clear accountability or ownership of the testing process exists.
  • Testing process is part of a parallel effort and is not integrated into ED operations.
  • Program relies on one person to champion the effort after it has launched.


Making the Case

Why test for HIV in the emergency department?

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 to 17 percent in EDs across the country, with unrecognized disease rates of 1 to 5 percent.(20, 22-27)

The rest of this section summarizes current research on the following:

Cited Sources

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.

Clinical Benefit

In addition to promoting good public health, routine HIV testing can improve clinical care in the ED, especially for patients who present with conditions related to early, undetected HIV infection.

Earlier diagnosis of HIV through expanded testing efforts expedites access to appropriate treatment, thus improving the quality of care for infected patients. The remarkable developments in HIV treatment over the past ten years, specifically the introduction of highly active anti-retroviral therapy (HAART), dramatically reduce HIV-related morbidity and mortality.(11) Therefore, early identification and initiation of therapy, especially during the asymptomatic period, may delay disease progression and limit opportunistic infections, thus lengthening and improving the lives of those with HIV.

Click here for a clinical discussion of the value of HIV testing.

Cited Sources

11. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States - an analysis of cost-effectiveness. New England Journal of Medicine. Feb 10 2005;352(6):586-595.

Public Health Benefit

Approximately one-quarter of the 925,000 to 1,025,000 people infected with HIV are unaware of their infection.(2) Many learn of their HIV-positive serostatus only after it has progressed to AIDS.(3) Some estimate that those unaware of their HIV infection are 3.5 times more likely to transmit the virus to others.(4-6) In addition to preserving the health of those infected,(6, 7) early diagnosis of HIV infection can limit further transmission when those who are infected alter their risk behavior(8) and maintain sufficiently low viral loads.(9)

Analysts project that widespread use of HIV screening would be cost-effective(10-12) in all but the populations with lowest risk (<.02% HIV prevalence).(10, 11)

Cited Sources

2. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. National HIV Prevention Conference. Atlanta, GA; 2005.
3. Centers for Disease Control and Prevention. HIV/AIDS surveillance report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2005.
4. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. Sept 22, 2006;55(RR-14):1-17.
5. Marks G, Crepaz N, Janssen R. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. June 26 2006;20(10):1447-1450.
6. Marks G, Crepaz N, Senterfitt J, Janssen R. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39:446-453.
7. Palella F, Deloria-Knoll M, Chmiel J, et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Ann Intern Med 2003;138:620-626.
8. Colfax GN, Buchbinder SP, Cornelisse PGA, Vittinghoff E, Mayer K, Celum C. Sexual risk behaviors and implications for secondary HIV transmission during and after HIV seroconversion. AIDS. Jul 26 2002;16(11):1529-1535.
9. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. New England Journal of Medicine. Mar 30 2000;342(13):921-929.
10. Paltiel AD, Walensky RP, Schackman BR, et al. Expanded HIV screening in the United States: Effect on clinical outcomes, HIV transmission and costs. Annals of Internal Medicine. 2006;145:797-806.
11. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States - an analysis of cost-effectiveness. New England Journal of Medicine. Feb 10 2005;352(6):586-595.

The Scope of Nationwide HIV Testing in EDs

According to a 2004 hospital survey, 57 percent of hospitals provide HIV tests in their emergency departments.(28) To date, routine testing for HIV in EDs has been close to nonexistent,(28, 29) even for patients with sexually transmitted diseases.(28, 30) Most hospitals provide HIV testing in cases of occupational exposure or at the provider's discretion based on clinical presentation or other risk factors.(28)

While levels of HIV testing in EDs are low, there is reason to believe that the number of EDs that provide HIV testing will grow significantly over the next few years. For example, a small number of EDs have piloted HIV testing and have published their findings.(20, 24, 25, 27, 31-38) Some health departments, including those in Massachusetts,(38) Ohio,(35) New Jersey,(39) and Michigan(40) are collaborating with EDs and urgent care settings to offer HIV testing. The Society of Academic Emergency Medicine's 2007 annual meeting has a number of presentations focused on ED-based HIV testing.(41)

Cites Sources

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.
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.
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.
28. Williams Torres G, Hasnain-Wynia R, Whitmore H, Pickreign J, Stanger JK. Hospital HIV Testing Policies and Practices: A National Survey: Health Research and Educational Trust; 2005.
29. Wilson SR, Mitchell C, Bradbury DR, Chavez J. Testing for HIV: current practices in the academic ED. American Journal of Emergency Medicine. Jul 1999;17(4):354-356.
30. Fincher-Mergi M, Cartone KJ, Mischler J, Pasieka P, Lerner EB, Billittier A. Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs. AIDS Patient Care & Stds. Nov 2002;16(11):549-553.
31. Centers for Disease Control and Prevention. Routinely recommended HIV testing at an urban urgent-care clinic - Atlanta, Georgia, 2000. Morbidity and Mortality Weekly Report. 2001;50(25):538.
32. Coil CJ, Haukoos JS, Witt MD, Wallace RC, Lewis RJ. Evaluation of an emergency department referral system for outpatient HIV testing. Journal of Acquired Immune Deficiency Syndromes: JAIDS. Jan 1 2004;35(1):52-55.
33. Glick NR, Silva A, Zun L, Whitman S. HIV testing in a resource-poor urban emergency department. AIDS Education and Prevention. 2004;16(2):126.
34. Haukoos JS, Witt MD, Zeumer CM, Lee TJ, Halamka JD, Lewis RJ. Emergency department triage of patients infected with HIV. Academic Emergency Medicine. 2002;9(9):880.
35. Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Health department collaboration with emergency departments as a model for public health programs among at-risk populations. Public Health Reports. May-June 2005;120:259-265.
36. Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Emergency department HIV testing and counseling: an ongoing experience in a low-prevalence area. Annals of Emergency Medicine. Jul 2005;46(1):22-28.
37. Lyss SB, Branson BM, Kroc KA, Couture EF, Newman DR, Weinstein RA. Detecting unsuspected HIV infection with a rapid whole-blood HIV test in an urban emergency department. J Acquir Immune Defic Syndr. 2007;44(4):435-442.
38. Walensky RP, Losina E, Malatesta L, et al. Effective HIV case identification through routine HIV screening at urgent care centers in Massachusetts. American Journal of Public Health. Jan 2005;95(1):71-73.
39. Paul SM, Cadoff E, Martin E, et al. Rapid HIV Testing in Emergency Departments: A Successful New Jersey Initiative. Prevention Health Week. New Brunswick; 2005.
40. Randall L. Personal communication. Michigan Department of Community Health; 2006: Key informant interview.
41. 2007 Society for Academic Emergency Medicine Annual Meeting Abstracts. Academic Emergency Medicine. 2007;14(5, Supplement 1).

Cost-Effectiveness and Feasibility

Early studies have found that HIV testing is feasible in busy, urban EDs.(20, 25, 33, 36, 38) The table below highlights findings from these studies.

Study Type of
Testing
Prevalence /
Setting
Acceptance
Rate
Received
Results
Reactive /
Positive tests
Coil, Haukoos et al. 2004(32) Referral to
outpatient testing
High / ED 11% of patients
followed up
NA 7%
Glick, Silva et al. 2004(33) Risk targeted High / ED 55% 40% 3%
Kelen, Hexter et al. 1996(25) Risk targeted High / ED 84% 62% 16%
Kelen, Shahan et al. 1999(20) Universal Offer High / ED 48% NA 5.4%
Kendrick, Kroc et al. 2002(42) Universal Offer High / ED 27% 98% 2.8%
Lyons, Lindsell et al. 2005(36) Risk targeted Low / ED 64% 75-77% 0.7%
Lyss, Branson et al. 2007(37) Screening High / ED 42% NA 1.2%
Lyss, Branson et al. 2007(37) Provider Referral High / ED 95% NA 11.6%
Walensky, Losina et al. 2005(38) Universal Offer High /
Urgent Care
37% 93% 2%

Some sites have demonstrated that even with modest resources (e.g., $75,000(33) to $141,975(20) for risk-based testing and $232,000(38) for routine testing), the numbers they test and HIV infections they identify are equal to or surpass benchmarks in community-based settings.(35, 38, 42)

A major consideration in the effectiveness of ED-based HIV testing is for patients to actually receive their results and be connected to care. When follow-up is required - such as when providers refer patients to outpatient HIV testing or when patients have to return for test results - adherence is poor and testing is ineffective.(27, 32) Intensive follow-up with patients to deliver test results is one approach that has been effective.(36) Another is the use of rapid HIV tests in which results can be available at a single visit. Rates of patient consent to rapid testing are comparable to those for standard testing.(20)

Cited Sources

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.
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.
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.
32. Coil CJ, Haukoos JS, Witt MD, Wallace RC, Lewis RJ. Evaluation of an emergency department referral system for outpatient HIV testing. Journal of Acquired Immune Deficiency Syndromes: JAIDS. Jan 1 2004;35(1):52-55.
33. Glick NR, Silva A, Zun L, Whitman S. HIV testing in a resource-poor urban emergency department. AIDS Education and Prevention. 2004;16(2):126.
35. Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Health department collaboration with emergency departments as a model for public health programs among at-risk populations. Public Health Reports. May-June 2005;120:259-265.
36. Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Emergency department HIV testing and counseling: an ongoing experience in a low-prevalence area. Annals of Emergency Medicine. Jul 2005;46(1):22-28.
37. Lyss SB, Branson BM, Kroc KA, Couture EF, Newman DR, Weinstein RA. Detecting unsuspected HIV infection with a rapid whole-blood HIV test in an urban emergency department. J Acquir Immune Defic Syndr. 2007;44(4):435-442.
38. Walensky RP, Losina E, Malatesta L, et al. Effective HIV case identification through routine HIV screening at urgent care centers in Massachusetts. American Journal of Public Health. Jan 2005;95(1):71-73
42. Kendrick SR, Kroc KA, Couture E, Weinstein RA. Comparison of point-of-care rapid HIV testing in three clinical venues. AIDS. Nov 5 2004;18(16):2208-2210.

Current Recommendations

HIV infection is consistent with all generally accepted criteria that justify screening:(4)

  1. It is a serious health disorder that can be diagnosed before symptoms develop;
  2. It is detectable by reliable, inexpensive, and noninvasive screening tests;
  3. Infected patients can have years of life to gain if treatment is initiated early, before symptoms develop;
  4. The costs of screening are reasonable in relation to the anticipated benefits.(43)

The U.S. Preventive Services Task Force recommends routine screening for patients at increased risk for HIV.(44) In 2006, the CDC expanded its recommendation for HIV screening in health care settings to include all patients ages 13 to 64, regardless of risk. The rationale for this new recommendation stems from evidence that people with HIV infection visit health-care settings years before receiving a diagnosis, but are not tested for HIV.(26, 45, 46) In addition, patients with unrecognized HIV often deny all risk factors, even when systematically assessed.(24, 26) An increasing number of new HIV infections are found among people younger than 20 years old, women, members of racial and ethnic minority groups, people who reside outside metropolitan areas, and heterosexual men and women who are often unaware that they are at increased risk for HIV.(4, 47) Missed diagnoses, denial of risk factors, and the changing demographics of HIV indicate that the effectiveness of risk-based testing may be diminishing.

Cited Sources

4. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. Sept 22, 2006;55(RR-14):1-17.
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.
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.
43. Wilson JM, Jungner G. Principles and practice of screening for disease. Geneva, Switzerland: World Health Organization; 1968.
44. U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. Accessed May 3, 2007.
45. Klein D, Hurley LB, Merrill D, Quesenberry CP Jr., Research Cf HIVAI. Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection. Journal of Acquired Immune Deficiency Syndromes. Feb 1 2003;32(2):143-152.
46. Liddicoat RV, Horton NJ, Urban R, Maier E, Christiansen D, Samet JH. Assessing missed opportunities for HIV testing in medical settings. Journal of General Internal Medicine. Apr 2004;19(4):349-356.
47. Institute of Medicine. No time to lose: getting more from HIV prevention. Washington, DC 2001.

Selected Bibliography

  1. Hogg RS, Heath KV, Yip B, et al. Improved survival among HIV-infected individuals following initiation of antiretroviral therapy.[see comment]. JAMA. Feb 11 1998;279(6):450-454.
  2. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. National HIV Prevention Conference. Atlanta, GA; 2005.
  3. Centers for Disease Control and Prevention. HIV/AIDS surveillance report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2005.
  4. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. Sept 22, 2006;55(RR-14):1-17.
  5. Marks G, Crepaz N, Janssen R. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. June 26 2006;20(10):1447-1450.
  6. Marks G, Crepaz N, Senterfitt J, Janssen R. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39:446-453.
  7. Palella F, Deloria-Knoll M, Chmiel J, et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Ann Intern Med 2003;138:620-626.
  8. Colfax GN, Buchbinder SP, Cornelisse PGA, Vittinghoff E, Mayer K, Celum C. Sexual risk behaviors and implications for secondary HIV transmission during and after HIV seroconversion. AIDS. Jul 26 2002;16(11):1529-1535.
  9. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. New England Journal of Medicine. Mar 30 2000;342(13):921-929.
  10. Paltiel AD, Walensky RP, Schackman BR, et al. Expanded HIV screening in the United States: Effect on clinical outcomes, HIV transmission and costs. Annals of Internal Medicine. 2006;145:797-806.
  11. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States - an analysis of cost-effectiveness. New England Journal of Medicine. Feb 10 2005;352(6):586-595.
  12. Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. New England Journal of Medicine. Feb 10 2005;352(6):570-585.
  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.
  28. Williams Torres G, Hasnain-Wynia R, Whitmore H, Pickreign J, Stanger JK. Hospital HIV Testing Policies and Practices: A National Survey: Health Research and Educational Trust; 2005.
  29. Wilson SR, Mitchell C, Bradbury DR, Chavez J. Testing for HIV: current practices in the academic ED. American Journal of Emergency Medicine. Jul 1999;17(4):354-356.
  30. Fincher-Mergi M, Cartone KJ, Mischler J, Pasieka P, Lerner EB, Billittier A. Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs. AIDS Patient Care & Stds. Nov 2002;16(11):549-553.
  31. Centers for Disease Control and Prevention. Routinely recommended HIV testing at an urban urgent-care clinic - Atlanta, Georgia, 2000. Morbidity and Mortality Weekly Report. 2001;50(25):538.
  32. Coil CJ, Haukoos JS, Witt MD, Wallace RC, Lewis RJ. Evaluation of an emergency department referral system for outpatient HIV testing. Journal of Acquired Immune Deficiency Syndromes: JAIDS. Jan 1 2004;35(1):52-55.
  33. Glick NR, Silva A, Zun L, Whitman S. HIV testing in a resource-poor urban emergency department. AIDS Education and Prevention. 2004;16(2):126.
  34. Haukoos JS, Witt MD, Zeumer CM, Lee TJ, Halamka JD, Lewis RJ. Emergency department triage of patients infected with HIV. Academic Emergency Medicine. 2002;9(9):880.
  35. Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Health department collaboration with emergency departments as a model for public health programs among at-risk populations. Public Health Reports. May-June 2005;120:259-265.
  36. Lyons MS, Lindsell CJ, Ledyard HK, Frame PT, Trott AT. Emergency department HIV testing and counseling: an ongoing experience in a low-prevalence area. Annals of Emergency Medicine. Jul 2005;46(1):22-28.
  37. Lyss SB, Branson BM, Kroc KA, Couture EF, Newman DR, Weinstein RA. Detecting unsuspected HIV infection with a rapid whole-blood HIV test in an urban emergency department. J Acquir Immune Defic Syndr. 2007;44(4):435-442.
  38. Walensky RP, Losina E, Malatesta L, et al. Effective HIV case identification through routine HIV screening at urgent care centers in Massachusetts. American Journal of Public Health. Jan 2005;95(1):71-73
  39. Paul SM, Cadoff E, Martin E, et al. Rapid HIV Testing in Emergency Departments: A Successful New Jersey Initiative. Prevention Health Week. New Brunswick; 2005.
  40. Randall L. Personal communication. Michigan Department of Community Health; 2006: Key informant interview.
  41. 2007 Society for Academic Emergency Medicine Annual Meeting Abstracts. Academic Emergency Medicine. 2007;14(5, Supplement 1).
  42. Kendrick SR, Kroc KA, Couture E, Weinstein RA. Comparison of point-of-care rapid HIV testing in three clinical venues. AIDS. Nov 5 2004;18(16):2208-2210.
  43. Wilson JM, Jungner G. Principles and practice of screening for disease. Geneva, Switzerland: World Health Organization; 1968.
  44. U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. Accessed May 3, 2007.
  45. Klein D, Hurley LB, Merrill D, Quesenberry CP Jr., Research Cf HIVAI. Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection. Journal of Acquired Immune Deficiency Syndromes. Feb 1 2003;32(2):143-152.
  46. Liddicoat RV, Horton NJ, Urban R, Maier E, Christiansen D, Samet JH. Assessing missed opportunities for HIV testing in medical settings. Journal of General Internal Medicine. Apr 2004;19(4):349-356.
  47. Institute of Medicine. No time to lose: getting more from HIV prevention. Washington, DC 2001.
  48. Chen Z, Branson B, Ballenger A, Peterman TA. Risk assessment to improve targeting of HIV counseling and testing services for STD clinic patients. Sex Transm Dis 1998;25:539--43.
  49. CDC. Voluntary HIV testing as part of routine medical care---Massachusetts, 2002. MMWR 2004;53:523--6.
  50. CDC. HIV prevalence, unrecognized infection, and HIV testing among men who have sex with men---five U.S. cities, June 2004--April 2005. MMWR 2005;54:597--601.
  51. CDC. Anonymous or confidential HIV counseling and voluntary testing in federally funded testing sites---United States, 1995--1997. MMWR 1999;48:509--13.

Resources

Resources

 

 


Key Players

Who needs to be on board to implement HIV testing in the ED?

Emergency department leadership and staff are clearly essential to the HIV testing team, but working relationships outside and inside the hospital are critical, too. These will ensure adequate resources, organizational capacity, and linkage-to-care processes that can make or break a successful program.

Here we identify many players you might approach and suggest their potential contributions and concerns. Once engaged, your essential players must come to consensus on objectives, operations, and indicators of success. An early goal must be to identify and address their practical and political concerns and clearly define their roles and responsibilities.

 

 

 

 

Emergency Department

Leadership

Emergency department leaders are the clinical and administrative directors of the ED. These include medical chiefs, formal and informal physician and nurse leaders, administrative directors, and residency and fellowship directors. ED leaders can create a supportive environment for HIV testing. They can champion the effort among hospital administrators and ED staff. They can elicit buy-in among staff who would be responsible for the program and help secure human resources to oversee and execute the program.  ED leaders, particularly in high-prevalence settings, have acknowledged that knowing a patient's HIV status can promote accurate diagnosis and treatment of patients in the ED. These leaders are concerned with  increased burden on their staff and the disruption of service flow in the ED. Piloting HIV testing on a small scale will help demonstrate the likely effect (or lack thereof) of HIV testing on ED operations.

Clinical Staff

Clinical staff could perform some or all aspects of HIV testing. While many would favor knowing their patients' HIV status, in practice, they might give HIV testing low priority because of the patient's presenting condition and history or because they are simply too busy. Clinical staff may be concerned about the time required for informed consent and counseling, especially when the ED is overburdened and understaffed. They might more readily support a parallel, nonintrusive testing service in the ED rather than incorporating testing into routine care.

Registration and Triage

These staff can be the patients' first point-of-contact for HIV testing in the ED by providing information, offering the test to patients, or taking specimens in triage. Registration and triage staff can be an integral component of the program when the goal is universal testing. They can build awareness and create the expectation among patients that they can get tested and get their results. Of course, registration and triage can be chaotic environments. Additional responsibilities for HIV testing may be perceived as an increased burden on staff. See Operational Flow for more information on how to use registration and triage staff.

Laboratory

Support from the hospital laboratory director is critical. If the tests are performed at the point of care, the lab director's role may be pure oversight, depending on who in the ED is monitoring quality and performance.

At a minimum, lab directors are concerned about and legally responsible for proper test administration and interpretation of test results, so they will need to work with the ED to establish procedures for performing the test, storing test kits, and assuring quality.

Some labs may prefer to run all tests from the lab, requiring additional staff resources as well as expedited processes for delivering results in a timely manner. Tests that are not run through the lab or overseen by the lab are not recorded in patients' medical records; this has implications for the clinical use of results and perhaps for ongoing tracking.

Health Department

State and local HIV/AIDS directors and their staffs are key partners in the planning, development and ongoing support of ED-based HIV testing. They are interested in how to best allocate scarce HIV testing resources and must balance competing interests and politics.

Initiator

In many places, the health department has initiated the discussion with hospital leaders. They present the opportunity for HIV testing and its potential impact on identifying patients with unknown HIV, improving care for that patient at that ED visit, and presenting the opportunity for earlier care outside the ED for HIV-infected patients. They can also provide data to help inform decision making regarding implementation of HIV testing efforts, including the specific models or approaches that might be most appropriate to the population and/or prevalence.

An important part of this early discussion is cueing in to the ED's concerns that may present barriers. Questions to drive this discussion may include:

  • What are the ED's specific concerns about introducing routine HIV testing? These concerns may include consent and counseling requirements, burden of ED staff, interruptions in patient flow, and costs.   
  • What needs to happen to address those concerns? Sometimes the answer is as simple as clarifying any consent and counseling requirements or presenting the evidence on feasibility and cost. Or you may need a pilot test to demonstrate impact.
  • What is essential to the program design if it is going to work in this ED?
  • Who in the hospital would support this program? Who in the hospital would oppose it? Why?

Funding

Funding is the most direct way a health department can help launch HIV testing in an ED. While funding can open the door, though its not always available or sustainable. In addition to direct funding, health departments can help incubate a program by:

  • Funding a pilot program in the ED, which may demonstrate to other potential funders the feasability and possible results of HIV testing in that ED
  • Funding the incremental cost of developing the program, such as  salary support for hospital staff to develop a program and find alternative funding
  • Working with the hospital to identify other sources of funding and resources, including local and private, that may be more sustainable over time

Technical Assistance

Health departments can provide nonfinancial support through technical assistance and capacity-building efforts; this includes:

  • Free or low-cost rapid test kits
  • Laboratory services for confirmatory tests and other tests such as CD4 and viral loads
  • Assistance in interpreting public health codes in such areas as consent and counseling requirements
  • HIV counseling training for ED staff
  • Training for ED staff in administering HIV tests
  • Training in and use of information systems to collect and track data from the program
  • Placing HIV counselors in the ED to provide testing and counseling
  • Equipment, such as mobile carts
  • Partner notification and referral services
  • Referral resources
  • Disease intervention services, such as patient follow-up and tracking
  • Providing data to inform decision making about whether it is sensible to implement programs and, if so, which model might be most productive
  • Assistance and support in linking with other community resources
  • Identifying models and approaches to operationalize HIV testing

Infectious Disease and HIV Services

While the patients may learn their HIV status in an emergency department, they cannot receive their ongoing care there. Infectious disease and HIV services (either in the hospital or thourgh a community-based specialty care clinic) can pick up where the ED stops. The HIV or ID clinic located at or affiliated with the hospital will be where most HIV-infected patients are referred. The clinic will facilitate patients' ongoing primary and specialty care, as well as provide critical linkages to needed social and mental health services, both hospital and community-based. 

Chiefs and staff of the hospital's infectious disease department and affiliated clinics need to be at the table early in order to lay out the process for linking HIV-infected patients to systems of care. One concern for the clinic may be having adequate resources to meet increased demand for services.

HIV Counseling and Testing Services

The hospital's infectious disease department may offer HIV counseling,  testing and referral (CTR) services either in the hospital or at a free-standing or dedicated clinic. They may have trained counselors that can support testing in the ED, either by staffing the testing program or by providing post-test counseling and facilitating the linkage-to-care component. Possible issues with the hospital's HIV CTR include limited operating hours and limited resources the ED and CTR programs may be tapping into the same pool of funding for HIV testing.

Other Hospital Players

 

Administration

Hospital administration can facilitate the securing of equipment and resources for HIV testing. Administration is primarily concerned with unfunded activities and the impact of HIV testing on ED operations. Explore reimbursement and funding possibilities as part of your initial strategy to gain administration buy-in. 

Academic Research

Some long-running programs were conceived and implemented as projects of the research department.  In other cases, the hospital's research department can provide technical support and oversight in developing systems to collect and analyze program data.  Researchers may also have an interest developing manuscripts for publication based on results from HIV testing in the hospital's ED. This would contribute more broadly to the limited evidence base for ED-based testing.

Risk Management

Risk management ensures that hospital policies and procedures comply with laws and standards of care. They are an important resource that can advise the creation of policy and process. Risk management may err on the side of caution to protect the hospital from liability. Informed consent, counseling, divulging preliminary positive test results, getting test results to patients, and partner notification and follow-up may be sensitive issues for risk managers. Work with your risk managers and health department for information and clarification on the legal issues.

Community-based Organizations

CBOs provide an array of services targeted to special populations in the communities they serve and provide well-known, trusted resources to their communities. They can complement and enhance hospital-based services with constituent-tailored services and can meet the specific and longer-term care needs of patients with HIV.  When competition for HIV testing funding is a concern, hospitals and CBOs may explore opportunities together to leverage these scarce resources. For example, they may enter into a contractual arrangement to share or deploy a pool of testing staff to their respective sites. 

Resources


Approaches to HIV Testing

Will the program's approach achieve its goals? How do we measure progress?

What is the goal for HIV testing in this emergency department? Is it to offer HIV tests to all ED patients? Is it to screen all ED patients who present with indicating conditions or who report certain risks? Is it to identify patients with early HIV infection? Will your approach get you toward your goal? The goal of the effort with the characteristics of the patient population, HIV (and other STI) prevalence, and the human and financial resources available for HIV testing will inform which testing approach is the most practical for your emergency department. See Operational Flow for more information on identifying specific opportunities for HIV testing in the emergency department. See Measuring Progress for general guidelines on measuring success regardless of your approach.

Three Approaches to HIV Testing

  1. Diagnostic testing is the bare-minimum approach to HIV testing. The target population for HIV testing is patients who present with signs and symptoms of AIDS. Diagnostic testing does not require additional staffing but may require additional education and training so that providers recognize signs and symptoms consistent with HIV infection, opportunistic illnesses, and acute HIV infection. It will also require a protocol for linking patients with HIV infection to treatment and care.

  2. Targeted testing involves performing an HIV test for subpopulations of persons at higher risk, typically defined on the basis of behavior, clinical, or demographic characteristics. Note that targeted testing may fail to identify a substantial number of persons who are HIV infected (45, 26, 48) because they may not perceive themselves to be at risk for HIV or do not disclose their risks (49, 50, 51). However, a targeted approach may be in order when resources (human and financial) are limited or if the community's HIV prevalence is less than 1 percent. A targeted approach may also serve as a stepping stone to screening.

    Whether targeted testing requires additional staff depends on the volume of patients that fall into the target population. Additional staff may or may not be required when an opt-out approach or streamlined pretest process is employed. The more time-intensive the pretest process is, the more likely it is that the program will require additional staff.

    When a targeted approach is employed, patients eligible for testing can be identified on the basis of self-reporting, social and medical history, and/or medical evaluation. Providers will require a protocol that delineates which patients should be tested for HIV as well as procedures for follow up care. Some presenting conditions and histories that warrant HIV testing include the following:

    Historical Characteristics
    Men who have sex with men (MSM)
    Heterosexual with multiple partners
    Exchange of sex for drugs or money
    Injection-drug use
    History of sexually transmitted disease
    Unprotected sex with a partner who is HIV-infected or has risk factors for HIV
    Homeless
    Spent time in prison

    Clinical Characteristics
    Sexually transmitted diseases
    Abdominal pain and vaginal discharge and/or dysuria in women
    Testicular pain, dysuria, and/or discharge in men
    Pneumonia
    Tuberculosis
    Severe gingivitis or peridonitis
    Persistent oral candidiasis (thrush)
    Unexplained chronic diarrhea (greater than one month)
    Persistent fevers
    Unexplained severe weight loss
    Unexplained anemia, neutropenia, or thrombocytopenia (low blood platelets)
    Persistent generalized lymphadenopathy (swollen lymph nodes)
    Recurrent respiratory tract infections
    Recurrent oral ulceration, herpes zoster, Bell's palsy, and a variety of dermatologic conditions

  3. Screening, or universal testing, is performing an HIV test for all persons in a defined population. When HIV prevalence is unknown or if HIV and other STI prevalence is high, screening all ED patients is preferred. In addition, EDs that already have targeted testing and are ready to extend the reach of testing might consider screening. The CDC currently recommends universal testing of all patients 13 to 64 in health care settings, regardless of risk or symptoms.

    The operational challenge to universal screening lies in providing tests to all patients and then delivering results to all patients who are tested. Opt-out HIV testing policies can facilitate the process. Streamlined pretest procedures also help. Operational plans will need to address whether there is adequate staff capacity to administer any pretest requirements, to take specimens and run all the tests, and to ensure that patients receive the results of their tests and are linked to care.




    Cited Sources

    45. Klein D, Hurley LB, Merrill D, Quesenberry CP Jr. Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection. J Acquir Immune Defic Syndr 2003;32:143--52.

    26. Alpert PL, Shuter J, DeShaw MG, Webber MP, Klein RS. Factors associated with unrecognized HIV-1 infection in an inner-city emergency department. Ann Emerg Med 1996;28:159--64.

    48. Chen Z, Branson B, Ballenger A, Peterman TA. Risk assessment to improve targeting of HIV counseling and testing services for STD clinic patients. Sex Transm Dis 1998;25:539--43.

    49. CDC. Voluntary HIV testing as part of routine medical care---Massachusetts, 2002. MMWR 2004;53:523--6.

    50. CDC. HIV prevalence, unrecognized infection, and HIV testing among men who have sex with men---five U.S. cities, June 2004--April 2005. MMWR 2005;54:597--601.

    51. CDC. Anonymous or confidential HIV counseling and voluntary testing in federally funded testing sites---United States, 1995--1997. MMWR 1999;48:509--13.

Pilot Testing

Whether the program is just beginning, you are experimenting with new approaches, or you are scaling up, it is best to pilot your program on small scale first. Pilot testing is especially helpful when you have questions such as:

  • How many patients can we expect to test in the ED (or in a particular setting in the ED)?
  • What will be the impact on staff's workload or patients' flow?
  • Do some staffing models work better than others in this ED?
  • Do some settings work better than others for testing in this ED?

A pilot test will help demonstrate, with minimal up-front investment, what impact the program can have on a larger scale. It can also help work out any unforeseen kinks encountered in implementation.

A pilot program should be short-term—from a few weeks to a few months but no more than 6 months—and will have a targeted purpose or question it seeks to inform. Consider starting with a small group of staff who support HIV testing in the ED for this phase. At the end of the pilot, evaluate process and outcomes and make the necessary modifications before the full rollout.


Measuring Progress

Achieving success requires goals that are attainable and progress that can be monitored. Goals should be closely linked to the testing approach. Tracking data on process and outcomes is essential to refining or expanding HIV testing operations, as well as demonstrating impact and securing support from hospital leadership, policymakers, funders, and the community at large. As the program demonstrates benefit and gains resources, plans can be made to scale up the program and, in turn, set higher-level goals. This diagram depicts how the ongoing internal measurement and evaluation process cycle should progress.

Measuring Progress

What data should be collected?

At a minimum, data collected should include indicators of outcomes such as:

  • Number of patients eligible for HIV testing
  • Number of tests performed
  • Number of reactive tests
  • Number of patients that keep their initial follow-up appointment
  • CD4 counts at time of diagnosis to detect at what stage of illness patients are identified in the ED

To monitor testing operations and to explain outcomes, process indicators such as these, are helpful: 

  • Number of patients eligible for HIV testing
  • Number of patients offered a test 
  • Number of patients accepting a test 
  • Number of patients who receive test results 
  • Number of patients who receive confirmatory testing 
  • Number of patients who receive confirmation test results 
  • Number of HIV-positive patients referred to follow-up care 
  • Patient perceptions and satisfaction
  • Staff perceptions and satisfaction

In addition, a periodic evaluation of physical space, patient confidentiality, and turnaround times should be conducted.

What is the denominator?

The denominator should always represent the true target population for HIV testing. If a screening approach is adopted, data can be reported based on the total number of ED visits during that time period. But, if testing is limited to minor or urgent care patients, the proportion of patients tested should be calculated based on the census of urgent care patients during that period. If a risk-based approach is employed, the denominator could be the number of patients with risk or who are clinically symptomatic. Similarly, more strictly defined denominators would enable analyses to determine productivity and to identify opportunities for improvement. For example, in order to determine where to channel resources, consider how process and outcomes indicators compare across:

  • Different staff conducting the test
  • Testing at different times of the day, days of the week
  • Testing in different settings in the ED, such as urgent care, observation, waiting rooms, triage, bedside, etc.

Resources


Costs and Funding

What are the costs to plan for and how will they be covered?

When it comes to expanding HIV testing beyond when clinically indicated, cost and reimbursement are among hospitals' major concerns. Grant funds can be important in getting a program off the ground and demonstrating early outcomes; however, if a program is to be sustainable, existing funding streams will have to tapped and perhaps redirected to support testing in the ED when it is effective.   The next page provides possible sources to further explore for funding or in-kind support.

Potential Funding Sources

 

Third-party Payers

At present, third-party reimbursement policy for routine HIV testing is likely to be limited. For example, some public and private payers will reimburse an HIV test only when clinically indicated, therefore, ancillary services such as HIV counseling may not be reimbursable when conducted by someone other than a physician. Some payers may reimburse only one test, meaning that the screening test is reimbursed but the confirmatory test for a reactive result is not. Other potential barriers may be that reimbursement may not cover the full cost of the test. This is problematic when rapid HIV tests are more expensive than ELISA or Western Blot tests. A confounding issue may be EDs' ability to bill for the incremental cost of an HIV test when some EDs bill globally for services based on a diagnosis.

The good news is that many payers are reviewing their reimbursement policies for HIV testing. For example, New York's Medicaid Program has changed its reimbursement policy for rapid HIV testing in emergency departments (see yellow column to the right). Recently, America's Health Insurance Plans, the national association of health insurance providers, released a report for its constituents on the benefit of expanded HIV screening. According to the report, Humana, Aetna and Kaiser Permanente are reviewing their current HIV testing policies to provide more coverage for routine HIV testing.      

State and local health departments

Health departments use their state, local and federal dollars to support HIV testing and prevention in a range of venues. These may include public sites, community-based resources, private health care providers, and emergency departments. While health departments may be well positioned to provide financial and in-kind support, some are bound by law to allocate a certain amount of funding to localities and specific programs. Others have found through pilot programs that there is greater testing volume and linkage to care when testing is conducted in EDs and have elected to channel funding to those efforts. Federally mandated community planning (funded through the Ryan White Care Act) and prevention planning councils (funded through CDC grants to states) may be important venues to make the case for redirecting these funds.

Regardless of the amount of funding they can provide, health departments are invaluable resources for the technical support they can provide, which can include laboratory services for confirmatory tests, training of ED-based testing staff, and centralized test kit purchase and distribution, among other support.

340B Drug Pricing Program

Public hospitals and other disproportionate-share hospitals are eligible for 340B drug pricing, which sets an upper limit on the price that drug manufacturers receive from covered entities for outpatient drugs. Prime vendors in the 340B program provide their products at further reduced rates. At present, the Uni-Gold Recombigen Rapid HIV Antibody Test is available through the 340B Prime Vendor Program.

Local Health Commissions, City Councils, Local Foundations

Tapping into local resources is a good approach to ensure the sustainability of efforts. In communities with high HIV prevalence, the case can be made to direct local resources to where there is great likelihood for testing a high volume of people and immediately linking them to care. Making the case to local governing bodies such as health commissions, city councils, and foundations will inform their decisions about how to allocate local resources for HIV prevention and testing throughout the community.

Drug Manufacturers/Distributors

Some hospitals have successfully obtained funding from pharmaceutical companies to launch ED-based HIV testing programs. These funds have been used to pay for additional staff and equipment. These can be important early funds to launch the program, but it is unlikely that they will be sustainable over time.

Hospital Administration

Hospital administration can help launch the program by securing funding for staff (such as through development funds), directly funding program oversight, and paying for rapid test kits. Hospital administration can also help secure space, such as access to a workstation (desk, phone, fax machine, computer, file cabinets, copy machines, etc.) for administrative tasks and record keeping. If the test is run outside the laboratory, access to the ED's STAT lab or some other temperature-controlled space is required. Space needs are minimal - some sites have found space in unused closets.

Resources


Legal Considerations

Most states have enacted statutory and other legal requirements pertaining to HIV/AIDS testing and reporting.  Areas that states may choose to regulate are: pre- and posttest HIV counseling, use of rapid HIV tests, confirmatory testing of preliminary positive test results, informed consent, laboratory requirements, confidentiality, and training and authorization of health care personnel who may administer the HIV test and provide HIV counseling.

It is important that HIV screening program planners are familiar with how HIV/AIDS laws and regulations in their states are being interpreted, applied, and amended. In some jurisdictions, existing laws may bar or impede implementation of certain elements of the CDC's universal HIV screening recommendations in health care settings. In others, however, the National Alliance of State and Territorial AIDS Directors (NASTAD), found that statutes that appear to be restrictive have minimal effect on the CDC's new recommendations.  (In June, 2007, NASTAD published a report on its survey of state and local health departments on state HIV/AIDS laws and screening practices in health care settings.)

The CDC commissioned a legal analysis of state HIV laws in 2004. This  analysis (PDF), categorizes state HIV statutes into four major areas: personnel; pre-test requirements; testing; and posttest requirements. The following information is a summary of the report's analysis and is intended to provide general context for considering the legal issues. Please note that in states with no statutory requirements for various aspects of HIV testing, the requirements may have been established by case law, agency regulation, or custom. These required elements may nullify or impose additional requirements in one or more of the four major areas regulated by state HIV statutes.

Personnel

The personnel area concerns the regulation of who can offer HIV counseling and testing. Such laws are unlikely to be an impediment to HIV testing by physicians and nurses in hospital ED departments. With respect to counseling, most states regulate individuals who provide pre and posttest HIV counseling, many have legislated specific training requirements, and some require certification for all health care workers and social workers who function as HIV counselors.

Pretest Requirements

Almost all states have enacted statutes concerning pretest HIV requirements. Relevant statutes govern mandatory pretest counseling, which usually entails disclosure of the risks associated with HIV/AIDS, a description of the HIV test, the risks and benefits of testing, the implications of test results, and how test results will be communicated. Twenty-four states require pretest counseling and the provision of specific information. Only one-third of states mandate risk assessment and risk reduction as components of pretest counseling. The required disclosures under most pretest counseling laws are not time-prohibitive and can be performed by health care providers in a routine medical setting.

Thirty-two states require prior informed consent to HIV testing, posing a potential conflict with the CDC's new recommendation that consent is inferred unless the individual opts out of testing. In addition, the CDC's recommendation that a general consent form for all medical care replace a specific consent form for HIV testing may be problematic under state HIV test informed consent statutes. To the extent that those who perform HIV testing are trained to comply with a state's informed consent requirements, such laws may not pose a problem for opt-out screening. However, compliance may be time-consuming, defeating one of the purposes of opt-out screening. Ultimately, interpretation of these statutes may vary across jurisdictions. In one state, an informed consent statute may be found to bar opt-out screening and the general consent form, but in another state a similar statute may pose no legal impediment at all to the new CDC screening method. Currently, one-third of states are contemplating changing their laws to allow opt-out testing.

Testing

Testing requirements set forth in state laws may regulate the specific type of HIV test that is used such as ELISA or Western Blot, mandate confirmatory testing of positive HIV test results, and dictate when positive test results can be released. A few states specifically authorize the use of rapid HIV tests either by statute or by regulation. Some states impose additional requirements on clinical laboratories that perform HIV tests beyond federal CLIA requirements. Testing protocols in some states may interfere with HIV rapid testing.

Posttest Requirements

Posttest legislation concerns confirmatory testing, where it may be performed, which confirmatory tests may be used, and the delivery of test results. A number of states require posttest counseling regardless of the test result. Many states mandate that test results be given face-to-face by trained HIV counselors. It is believed that state statutes requiring posttest counseling will be the most problematic type of state HIV laws for implementing the new CDC HIV screening recommendations and guidelines.

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Operational Flow

What are the "natural moments" for HIV testing in the ED?

In the pages that follow, we suggest opportunities during the visit and patient areas where EDs may incorporate HIV testing for patients. Our intent is to generate ideas about how HIV testing might work in your facility with minimal disruption to the existing operational flow. Please consider this information in the context of your ED's selected approach.

After reading these pages, we encourage you to spend time observing your EDs' flow and services at various times of the day and various days of the week. This will inform the time and resources required to complete the testing process and help determine what steps are reasonable at what points of service. Observation will also help identify any unanticipated bottlenecks that may impede service.

While observing, consider these aspects of the ED's design:

  • Is there an urgent care or fast-track setting?
  • Is there an observation unit?
  • Where do ambulatory patients wait to see the provider? Is there more than one location?
  • At what points in the visit do patients wait for 30 minutes or more?
  • Is the ED an open ward where there are many beds in one room, separated by curtains? Or are there private rooms?
  • Are there any private rooms or spaces where sensitive results could be disclosed?
  • Is there a STAT lab in the ED or other temperature-controlled space for storing and running rapid HIV tests at the point-of-care?
  • Is there a place where testing staff can complete paperwork and have space to store materials?

Consider design and flow issues in conjunction with these program elements:

  • What ED patients will likely receive HIV tests? What are the goals of the program?
  • Will testing will be provided on an opt-out basis, or will a streamlined pretest counseling approach be employed?
  • Which staff members are available to offer tests to patients, run HIV tests, and deliver results?

Which patient area?

 ED patients have varying levels of acuity, with primary complaints ranging from broken fingers to gunshot wounds. As HIV testing is voluntary, it is important that patients understand and consent to their HIV test. Urgent care (fast track) and observation medicine units (or 23-hour admits) provide practical areas of the ED in which to offer HIV tests to patients. 

Urgent care or Fast Track

Urgent care or fast-track areas see a large volume of patients with minor, often nonemergent conditions. They may be located in the ED proper or in a nearby location. They often have their own waiting areas and are staffed by nurses and physician assistants. Urgent-care patients are typically ambulatory and alert—good candidates for HIV testing. However, quick turnover of patients can present a challenge. In some sites, urgent care patients are seen within 30 minutes. When using rapid tests, testing programs can take advantage of multiple opportunities for approaching and testing patients so that patients receive their test results during their visit.

ED's observation unit

The ED's observation unit houses patients who have been treated and stabilized but will not be admitted. The patients' stay may last a few hours, and they will be discharged within 23 hours of arriving in the ED. A patient's consciousness must be an important consideration in this setting.

Presenting Conditions and Histories

When a targeted approach is employed, patients eligible for testing can be identified on the basis of self-reporting, social and medical history, and/or medical evaluation.

Historical Characteristics
Men who have sex with men (MSM)
Heterosexual with multiple partners
Exchange of sex for drugs or money
Injection-drug use
History of sexually transmitted disease
Unprotected sex with a partner who is HIV-infected or has risk factors for HIV
Homeless

Clinical Characteristics
Sexually transmitted diseases
Abdominal pain and vaginal discharge and/or dysuria in women
Testicular pain, dysuria, and/or discharge in men
Pneumonia
Tuberculosis
Severe gingivitis or peridonitis
Persistent oral candidiasis (thrush)
Unexplained chronic diarrhea (greater than one month)
Persistent fevers
Unexplained severe weight loss
Unexplained anemia, neutropenia, or thrombocytopenia (low blood platelets)
Persistent generalized lymphadenopathy (swollen lymph nodes)
Recurrent respiratory tract infections
Recurrent oral ulceration, herpes zoster, Bell's palsy, and a variety of dermatologic conditions

When in the visit?

The time to test during a visit depends on staff availability and informed consent requirements. Generally, there are five points in the ED visit during which HIV testing can take place in whole or in part. For the broadest reach, HIV testing should be available at multiple points of contact during the visit, and multiple personnel should be accountable for their roles in the HIV testing process. Testing should be available 24 hours a day, seven days a week. When this is not feasible, aim to offer testing when patient volume is high, such as afternoons and evenings and weekends. Below we describe examples of implementation of HIV testing at triage, at registration, in waiting areas, at bedside, and at discharge. Each description includes a discussion of potential concerns or operational challenges. Where possible, we provide strategies to address challenges.

Triage

Ambulatory patients will first meet with a triage nurse, who conducts a general intake of chief complaint, vital signs, and some medical history. This initial point of contact provides the opportunity to:

  1. Inform the patient that an HIV test will be made available at that visit;
  2. Provide pretest information and obtain consent;
  3. Document in the chart than an HIV test is accepted or declined;
  4. Take the specimen when taking other vital signs.

Operational Concerns. Lengthy informed consent or activities outside the scope of what is typically done at triage risks creating a bottleneck in patient flow. Streamlined pretest information processes, such as using informational handouts, and opt-out testing may minimize the time the triage nurse spends on HIV testing. For more information, go to Informed Consent.  

Registrar

Patients will sign in with the registrar either before or after seeing the triage nurse. Registration can best serve as an opportunity to inform patients of the availability of HIV testing during their visit. For example:

  • The registration clerk can be responsible for informing patients of the availability of an HIV test during their ED visit.
    • If patients would like an HIV test, they notify the registration clerk to note in their chart.
  • Signage or HIV test brochures can be made available at the registration desk. These materials might include:
    • Tear-out informed consent forms that a patient signs and gives to the person administering the HIV test.
    • A card that patients may hand to providers to "silently" indicate they would like a test.

Operational Concerns. Registration can see high volumes of patients at a time, so registration staff are limited in terms of how much time they can spend conveying information to patients about HIV testing. The information they provide should be easily presented, such as brochures, signage, or handouts. Registration staff should be included in educational sessions on the rationale and processes for testing in the ED so they are able to answer or direct any questions that patients may have about HIV in general and the testing process at the facility specifically. 

Waiting Room

The waiting room presents an opportunity both to convey information about HIV testing and to actually conduct the test. Patients can spend a significant amount of time in the ED waiting to see a provider; in this sense they may be a "captive audience" for HIV testing. If separate signed informed consent is required for HIV testing, take advantage of patients' waiting time to provide pretest information.

Conveying information about HIV testing in the waiting room may include:

  • Signage and brochures such as: 
    • Tear-out informed consent forms that a patient signs and gives to the person administering the HIV test
    • A card that patients may hand to providers to "silently" indicate they would like a test
  • Rolling video or kiosks to provide the information necessary for informed consent

Operational Concerns. Testing patients in the waiting room entails the availability of staff and space. Potential solutions include:

  • Setting up an outpost in the ED waiting room for counseling and testing staff from the hospital, the public health department, or community-based organizations to obtain informed consent, take specimens, run tests, and deliver results
  • Dedicating ED staff dedicated to offering and administering HIV tests which may include a rotation of nurses, physician's assistants, or dedicated counselors
  • Finding a quiet space for a chair and a curtain to ensure privacy. This approach would need to mitigate the perception that this is the HIV area.

Testing in the waiting room will also require a protocol for completing the testing process with patients who are called in for treatment while they are being tested.  

Bedside

Patients may be tested for HIV by a provider or a counselor at the time they are being treated for their chief complaint. This can be implemented in a number of ways:

  • The provider (nurse or physician) offers the test to the patient and takes the specimen.
  • The provider refers the patient for HIV testing and a counselor administers the test.
  • The counselor approaches the patient for HIV testing in between the provider's treatment.

Ideally, patients will have been informed of the availability of HIV testing prior to being approached by a provider or a counselor at bedside.

Operational Concerns. The priority at the provider encounter will be treating the patient's chief complaint. If the provider is the primary source for offering and administering the test, it may not happen when workloads are heavy. If additional counseling staff are used, they will need to communicate with the provider about when to see the patient. Both ED staff and counselors will need to negotiate rules for when counselors can approach patients during their treatment in the ED. In addition, it is challenging to ensure privacy when beds are separated only by curtains. Some counselors report that using low voices and standing in close proximity to the patient is sufficient to ensure privacy.

Discharge

The major opportunity at discharge is ensuring that patients that were tested received the results of their test. Anecdotally, after a long ED visit, patients are unwilling to stay additional time for an HIV test. The lesson learned is to take advantage of patients' waiting time.

Resources


Staffing

Who in the ED will perform the various functions associated with HIV testing? The intensity of each of these functions will vary according to what testing approach is used and what resources are available. For many, existing staff can be tapped from internal and external sources, including the emergency department, other departments in the hospital, health departments and even community-based organizations. This section describes how multiple sources of staff can fulfill the various functions of HIV testing in the ED. We include a discussion of possible tradeoffs for each.

Program Oversight

Ideally, oversight will be provided by a manager in the ED, such as an attending physician, nursing director or manager, or ED administrative manager, even if the program is an outpost operation of the health department or other organization. These leaders can demonstrate immediate credibility with the ED staff and leadership. The person providing program oversight will be a key person in the implementation of the program and will design, execute, and troubleshoot the testing program. They may be supported by a project coordinator for day-to-day administration and management.

Administration of HIV Tests

There are a number of staffing possibilities, ranging from posting HIV counselors or other specially trained testing staff in the ED to using "indigenous," or pre-existing ED staff, in which nurses, attending physicians, residents, and other ED clinical staff incorporate HIV testing into their routine delivery of care. A third possibility is a team-based approach in which indigenous and supplemental staff together provide HIV testing to patients.

staff models

Indigenous ED Staff

Using indigenous staff to perform HIV testing can facilitate a more seamless integration of HIV testing into ED services. ED staff are already present and can incorporate testing into the rest of treatment. A potential drawback to relying on ED staff, particularly when universal testing is the goal, is that they may view HIV testing as an optional, add-on service that can be skipped when workloads are heavy. Informed consent requirements primarily contribute to providers' perceived burden of providing HIV testing to patients. An indigenous model can work when targeted testing is provided. A fully integrated model - one in which ED staff provide expanded screening to all patients - may require additional policy changes such as an opt-out approach and general medical consent.

Supplemental Counseling Staff

Supplemental counseling staff can be an important resource addition for HIV testing in the ED, especially when separate informed consent and pre-test counseling are required. ED staff report they could more fully support HIV testing in their ED, as long as there are additional staff to do it. In addition, ED staff report they quickly see the value of HIV counselors in the ED, because they can call on these counselors to perform HIV tests in cases when they suspect HIV infection or in cases of occupational exposure.

Counseling staff may be hired directly by the ED, or they may come from the hospital's HIV counseling, testing and referral (CTR) services, social services, the health department, or community-based organizations. Students such as nursing, medical, public health, and social work students, even undergraduates, are another possible source. Concerns with students include their limited availability, competing priorities, and high turnover, which can translate into high recruitment and training costs. While some programs report good outcomes with students, others maintain that the staff providing the counseling and testing services need to be dedicated professionals. The use of supplemental staff raises the question of integration. ED staff will need to be educated about the presence of the counselors, their role, and how to work with them. These "external" staff will need to be fully integrated members of the ED team to foster communication and seamless operation.

The use of supplemental staff raises the question of integration. ED staff will need to be educated about the presence of the counselors, their role, and how to work with them. These "external" staff will need to be fully integrated members of the ED team to foster communication and seamless operation.

Another consideration in counselor models is that results may not get entered into the patient's medical record because counselors, depending on their credentials, may not have access to those records.

Testing Teams

Team-based approaches make use of indigenous and supplemental staff. These include the physician referral model, in which clinicians will call in trained counselors when a patient needs an HIV test. Some sites with targeted approaches use the physician referral model. One way this model has been implemented is a pager system in which the physician pages the on-call counselor in the hospital's CTR department.

Counselor-facilitated models are another approach. In such a model, a counselor identifies patients for testing, completes all pretest information requirements, and then advises the provider that the patient would like an HIV test. The provider then steps in to administer the test and deliver results to the patient. One pilot study of this approach found that more patients accepted testing when it was first discussed with a counselor rather than a physician.

Data Collection, Analysis, and Reporting

Reporting will fall under the project director's domain of responsibility and entails collecting and analyzing data on process and outcomes and submitting reports to key stakeholders. See Measuring Progress for more information on data collection and measuring progress. The hospital's research department can help in setting up data collection systems and analysis support.

Staff Educator

All ED staff will need to be educated about the rationale, goals, and implementation of HIV testing in the ED. Staff administering HIV tests will need additional training and competency testing in performing the test and interpreting results. See Training Staff for more information on training requirements. Training can be provided by the project oversight staff, the health department, or staff educators in the hospital.

Quality Assurance Oversight

The hospital laboratory director will provide quality assurance oversight if rapid tests are being performed under the lab's CLIA waiver. In some cases it can be public health laboratory if the ED is operating as a satellite testing site of the health department. See Choosing a Test for more information on quality assurance requirements.

Linkage-to-Care Liaison

This is a staff person of the HIV or infectious disease clinic who facilitates the entry-to-care of HIV-infected patients identified in the ED. This person will interact on a regular basis with either the testing program director or his/her designate to set appointments and provide feedback on the referral process and to track the number of patients who keep their follow-up appointments. See Linking to Care for more information on this process.

Policy Development / Fiscal Management

These are services that can be provided or supported by the hospital's compliance and financial departments, respectively.

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Choosing a Test

What to consider when choosing what HIV test to use?

Today a number of new HIV testing technologies are available that use less-invasive specimens—such as whole blood from a finger stick or saliva from an oral swab—and that provide rapid results. 

Laboratory directors, with input from clinical staff, are responsible for choosing which HIV test will be used in a facility. They will evaluate the performance, quality assurance requirements, and cost of various tests and will evaluate the tradeoffs of using traditional tests or rapid tests as well as performing tests in the laboratory or at the point of care.  The following pages offer some general information on HIV tests and direct readers to useful resources to help guide their test selection.

Traditional vs. Rapid HIV Tests

All HIV tests detect the presence of HIV antibodies. The most commonly used HIV tests are EIAs (enzyme immunoassays) and ELISAs (enzyme-linked immunoassays). These traditional HIV tests and the newer rapid tests perform comparably. They have similar accuracy rates, and both have varieties that can test specimens collected by venipuncture or by less-invasive methods, such as oral fluid, urine, and fingerstick blood. Traditional and rapid tests both need to have reactive (positive) test results confirmed with a more specific test, such as a Western Blot.

The major difference between traditional and rapid tests is how quickly their results are available. Rapid HIV tests can produce results in as little as 20 minutes, while traditional tests can take several days. Another feature of rapid tests is that some can be used at the point of care. Immediate results and the flexibility to perform tests at the point of care make rapid tests very useful in emergency departments, where medical encounters are short and the interaction between provider and patient is a one-time occurrence.

Using Rapid HIV Tests

Five rapid HIV tests have been licensed for use in the United States:

  • OraQuick Rapid HIV-1 and Advance Rapid HIV-1/2 Antibody Tests, manufactured by OraSure Technologies, Inc.
  • UniGold Recombigen HIV Test, manufactured by Trinity Biotech
  • Reveal G-2 Rapid HIV-1 Antibody Test, manufactured by MedMira, Inc.
  • Multispot HIV-1/HIV-2 Rapid Test, manufactured by Bio-Rad Laboratories
  • Clearview HIV 1/2 Stat-Pack and Complete 1/2, manufactured by Inverness Medical Innovations

These tests are all interpreted visually on the device itself and require no additional instruments. They differ in terms of what specimens they use and whether or not they have been designated by CLIA as appropriate for point-of-care use. This chart compares the characteristics of the FDA-approved rapid tests.

Test results from rapid HIV tests are interpreted the same as other HIV test results.

  • A negative result from a single test is considered negative. However, if the person being tested has been exposed to HIV within the past three months, a repeat test at a later time is recommended because the rapid antibody test may not show a very recent infection.
  • A positive (or reactive) result from a rapid HIV test is considered a preliminary positive and must be confirmed by a whole blood or serum-based Western Blot or IFA before the diagnosis of HIV infection is established. If such confirmatory testing yields negative or indeterminate results, follow-up testing should be performed on a blood specimen collected four weeks after the initial reactive rapid HIV test result.
  • When internal controls show that an HIV test is invalid, the patient should be offered the option of retesting with another rapid test or submitting a sample for lab-based standard testing and returning for the result or referral to outpatient testing facility.

Considering the Costs

Rapid tests tend to be more expensive than traditional tests. The current retail price of rapid HIV tests is $14 to $26 per unit. Of course, this price can be significantly lower when tests are purchased in large volumes or through other purchasing arrangements. For example, some health departments have purchased test kits and then redistributed them to testing venues throughout the state or locality, including hospitals. Other programs, such as the federal 340B Drug Pricing Program, make devices and drugs on their formulary available to qualified hospitals at a discounted rate. Products in the 340B Prime Vendor Program are available at even further reduced rates.

In some states, Medicaid is creating new codes for facilities to bill separately for rapid HIV tests. Some private insurers are also evaluating their HIV testing reimbursement policies. As payers devise better reimbursement policies to support routine HIV testing, hospital-based testing can prioritize the use of free or discounted test kits for patients without insurance.

Considering Lab or POC Tests

Considering Laboratory or Point-of-Care Tests

Only 1 in 10 hospitals that use rapid HIV tests use them at the point of care. The major considerations for whether to use lab-based tests or point-of-care tests include:

  • Logistics in the ED, such as availability of a small space to properly store, run, and read tests
  • Availability of trained staff to perform the test
  • Capacity of the laboratory to consistently convey rapid HIV test results quickly

If tests are to be run from the laboratory, the lab will likely require additional staff to handle the high volume (if tests are done routinely) and to ensure timeliness of reading and informing providers of results. If tests are to be performed at the point of care, laboratories will be very concerned with providing oversight and ensuring that all point-of-care requirements are met.

Some tests require serum or plasma specimens and can only be performed in the laboratory (e.g., Reveal and Multispot). Tests that use whole blood (e.g., UniGold, Clearview Complete) or oral fluid (e.g., Oraquick Advance) can be performed easily at the point of care by trained personnel.

What is Required for Point-of-Care Tests?

The Clinical Laboratory Improvement Amendments (CLIA) of 1988 regulates laboratory testing in the United States. The Centers for Medicare and Medicaid Services (CMS) are charged with interpreting CLIA and work closely with the Food and Drug Administration (FDA) and the CDC on their implementation. Some states may have stricter regulations for laboratory testing that make them exempt from CLIA.

CLIA classifies tests according to their complexity. A test may receive a CLIA waiver if it uses direct, unprocessed specimens (such as whole blood or oral fluid) and is easy to perform with little chance of error. Waived tests may be performed outside traditional laboratories by individuals without formal laboratory training. To date, OraQuick ADVANCE, Unigold Recombigen, and Clearview COMPLETE are CLIA-waived; Reveal and Multispot are categorized as moderately complex, which in turn requires that laboratories using those tests adhere to more stringent standards for personnel, quality assurance, and proficiency testing.

Laboratories using waived tests must be registered with the CLIA program. The fee is $150, and it must be renewed every two years. An emergency department can operate as satellite site under another laboratory's CLIA license. Typically, this would be the hospital laboratory's license. Waived laboratories must ensure that all tests performed under their license, including at satellite sites, are used according to manufacturers' instructions and that quality assurance measures are in place (see below).

Click here for more information on registering with CLIA.

Quality Assurance

Effective quality assurance programs minimize the risk of mistakes that can occur in terms of:

  • Storage and testing-area temperature
  • Test-kit shelf life
  • Specimen collection
  • Test performance
  • Results interpretation
  • Confirmatory testing

Hospital laboratory staff are responsible for oversight of quality assurance for any point-of-care testing. They should be involved in developing and maintaining:

  • Clear and concise procedures
  • Training of personnel
  • Verification of competence of personnel
  • Proper performance of quality control procedures
  • Recognition of when testing does not comply with procedures

For CLIA-waived rapid HIV tests performed at the point of care, nurses or other designated staff can assume responsibility for both collection and testing. Staff must be trained in how to administer the test and provide appropriate quality assurance to ensure that the test continues to be administered pursuant to manufacturer instructions. Hospitals will need to work to develop, implement, and maintain capacity to provide training and quality assurance on an ongoing basis to staff conducting rapid HIV testing. For more information, see Training Staff.

Alternatively, you may decide to send rapid HIV tests to the laboratory. In a laboratory, these duties would be managed by a Quality Control or Quality Assurance (QA) Compliance Officer.  In a point-of-care testing setting, it is important to establish a POC coordinator (typically a laboratorian) who is responsible for training, quality control, and quality assurance issues.

The College of American Pathologists Commission on Laboratory Accreditation has developed a comprehensive checklist for point-of-care testing that can inform the implementation of point of care testing. In addition, the CDC maintains comprehensive rapid HIV testing web resources, which include detailed and up-to-date information on CLIA, quality assurance and studies on rapid HIV testing.

Resources


Training Staff

What training does staff require?

Staff will need to be trained on several levels.

  • All staff in the ED will need to be informed of the basics of HIV, and why expanded screening has clinical and public health value, as well as how HIV testing can be accomplished in the ED.   
  • Staff responsible for HIV testing in the ED will need additional training in ED operations and culture (if they are external staff) in addition to HIV testing operations. 
  • Clinical staff will require additional training on recognizing the clinical signs and symptoms of HIV and AIDS, including acute HIV infection. These may be refresher courses for some. 
  • Testing staff will need to demonstrate proficiency in administering tests and interpreting results.

States may have specific training requirements that are determined by statute or regulation.  Providers should contact their state health department to ascertain what requirements apply to them and staff performing testing in an ED. 

This section provides general considerations for training staff.  The resources we provide can inform and be adopted for training in your facility. Local and state health departments and AIDS Education and Training Centers (PDF) (AETCs) are excellent resources for training on HIV generally and HIV testing specifically.

For Staff Affected by HIV Testing in the ED

The patient care team (emergency department and infectious disease) should be educated about HIV testing and the purpose of HIV testing in your ED. Training of staff should include:

  • Rationale for increased HIV testing in acute care settings, including the advantages and disadvantages of risk-based testing in identifying HIV infection
  • Local, regional, and national HIV/AIDS statistics
  • State and local statues regarding HIV testing, including reporting and Partner Counseling and Referral Services (PCRS)
  • CDC recommendations for HIV testing in health care settings
  • Benefits of early HIV diagnosis
  • Strategies to ensure confidentiality
  • Interpretation methods for test results
  • Local referrals and follow-up care for HIV-infected patients

In addition, staff will be informed about:

  1. What patients are eligible for HIV testing
  2. How patients will be identified or approached
  3. Conducting the test
  4. Interpreting results
  5. Consent process and local testing laws
  6. Confidentiality and recordkeeping
  7. Privacy
  8. Delivering test results
  9. Providing patient follow-up
  10. Quality controls/Quality assurance processes

For Staff Responsible for HIV Testing in the ED

In addition to the general orientation to HIV and HIV testing operations described above, staff who will be conducting tests will need training in test administration. Laboratory, medical and/or nursing staff, health department, or other hospital staff educators will train these staff in specimen draws, procedures for sending them to the lab, as well as documentation. If rapid tests are used, they will train personnel to perform rapid HIV tests at point-of-care.  

A comprehensive training session for rapid HIV testing will enable participants to:

  • Review the rapid test package insert along with the facility's standard operating procedure
  • View the rapid HIV testing video provided by the manufacturer (when relevant)
  • Observe a demonstration of how to set up the rapid HIV test
  • Perform a panel of 5 known specimens and obtain 100 percent accuracy
  • Take a competency test on the rapid HIV test with 100 percent accuracy or counseling documented for incorrect answers

The following points should be emphasized throughout training, and all staff should be able to comfortably:

  • Handle requests for rapid HIV testing
  • Verify that appropriate positive and negative controls have been performed on the lot number in use and match expected results before setting up a patient's specimen
  • Read the rapid HIV test 15-45 minutes after setup (the specific time according to the type of rapid test). A timer can be clipped onto one's uniform to ensure that the test is read within the time limit.
  • Report results as soon as possible
  • Document all rapid HIV test results and inform the patient's health care provider according to protocol
  • Refer all specimens that test preliminary reactive to the appropriate laboratory for confirmatory testing

Special Considerations

The busy emergency department does not offer many opportunities for formal in-service training. Careful thought is needed to present content and make it available at times that are convenient for ED staff and providers. How the training program is delivered should be tailored to the needs of the staff that will be conducting the test. For example, the methods used to train nurses may be different from the methods used to train counselors. Motivation for learning can be increased if CME (continuing medical education) and nursing CE (continuing education) contact hours are provided. Hospitals should consider facilitating periodic opportunities for staff conducting rapid HIV tests and HIV care providers to "cross-train" in order to facilitate connections to follow-up care.

Click here for more information on training design and implementation.

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Informed Consent

How to communicate about informed consent for HIV testing in the ED?

The CDC recommends that HIV testing be voluntary.  As such, no patient should be tested unless he or she has provided informed consent. The informed consent process ensures that the provider and the patient have communicated about information the patient needs to make an informed decision to undergo or to decline HIV testing.

While informed consent is a key part of the testing process, it should facilitate not impede patients' acceptance of HIV testing. For this reason, the CDC recommends that HIV testing in health care settings need not be linked with other HIV teaching efforts, such as prevention counseling.  However, state and local statutes govern content and procedures for informed consent, so it is important to contact your health department for clarification on informed consent requirements.

This section addresses some elements in CDC's recommended approach to informed consent, namely opt-out testing, streamlined pretest information, and general consent forms.  It also provides some approaches to delivering pretest information to patients

Streamlined Pretest Information

Streamlined pretest information disconnects risk assessment from the pretest process. In a streamlined pretest information session, patients would receive oral or written information on the meaning and ramifications of HIV testing, the risks and benefits of testing, the implications of preliminary test results, and how and when test results will be communicated to them.  Patients would also have the opportunity to raise and discuss any questions they may have. Intensive counseling and referral for further care would be employed when patients are diagnosed with HIV or when HIV testing and counseling are otherwise consistent with the medical visit, such as when the visit is related to a behavioral or clinical risk factor (e.g., substance abuse or symptoms of an STD) or when other health promotion services are usually offered (e.g., as part of comprehensive health assessments, reproductive health care, or family planning).

When undergoing rapid HIV testing, patients must be additionally advised that:

  • Results of their rapid HIV test will be available quickly, within as little as 20 minutes of administering the test
  • Positive rapid tests are preliminary results and a second test will need to be performed to confirm the test result

The FDA also requires that an information pamphlet on the specific rapid HIV test used be given to the patient. These are available from the test manufacturers and distributors. 

Delivering Information to Patients

Ways in which pretest information can be provided to patients include:

  • One-on-one staff discussions with patients based on scripts and training
  •  Fliers/posters posted throughout the emergency department with required information
  • Pamphlets with required information handed out at registration or triage; these are appropriate to the patient's culture, language, sex, sexual orientation, age, developmental level, and literacy level
  •  Rolling videos broadcast in waiting rooms and low urgency exam rooms
  • Computer-aided, self-administered tutorials
  •  Manufacturers' information pamphlets
  • Handouts describing HIV transmission, the rapid test procedure, and methods to prevent transmission

Informational materials should be easily understood and made available in the languages of the ED's commonly encountered populations. The competence and availability of interpreters and bilingual staff to provide language assistance to patients with limited English proficiency must be ensured. Patients who do not read, or who do not read well (which may be a significant proportion of the ED clientele) should have the option of having information delivered orally.

 

See side bar for advice on delivering pretest information to patients.

 

Opt-out Versus Opt-in Testing

Opt-out testing means performing an HIV test after notifying the patient that the test is normally performed but that the patient may elect to decline or defer testing. Assent is then assumed unless the patient declines testing. Opt-in testing means testing is offered and the patient is required to actively give permission before it can occur. The CDC recommends opt-out testing policies in health care settings.

Note that opt-out testing does NOT eliminate the need for informed consent, which is required by medical ethics. It also might not eliminate the need to formally document the patient's consent (e.g., by having the patient sign a consent form), since that is governed by state laws and sometimes local hospital policies. For more on written consent forms and HIV testing go to Consent Forms.

Consent Forms

Some states require written informed consent for all HIV testing (but not necessarily on a separate form); others specifically exempt health care providers from this requirement; and several explicitly state that no separate consent for an HIV test is necessary when a general consent for medical care is in effect. The CDC recommends incorporating informed consent for HIV testing into the general consent for medical treatment. Specifically, separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.  However, each facility must be familiar with laws governing informed consent in its own state and carefully consider their legal meaning in light of the HIV testing objectives.  

Resources

Resources


Delivering Results

What happens once you have the test results?

Once the test has been administered, patients will need to be informed of their results and, if necessary, linked to follow-up treatment and care. On the following pages, we list basic steps that take place when a patient has a negative test result or a preliminary positive test result. Consult Staffing and Operational Flow to help you identify who will disclose results and where.

When a Test Is Negative

  • Patients may be given their result and informed that no further testing is required at that time.
  • Patients should be advised that if they are at high risk for HIV, they should have an HIV test at least once a year. Patients likely to be at high risk include injection-drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, men who have sex with men (MSM), and heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test. At the time the negative test result is given, providers may decide to provide or refer patients to intensive prevention counseling.
  • Advise patients that if they suspect they have been exposed to HIV in the past three months, it may be too soon to detect it. Providers should refer patients to their primary care provider or a community-based testing site for retesting in three months.

When a Test Is Reactive

When a Test is Reactive (Preliminary Positive)

  1. Disclosure: Preliminary positive results should be communicated confidentially in person by a clinician, nurse, mid-level practitioner, counselor, or other skilled and previously trained staff. When disclosing results in the ED, patients should be in a private area. Because of the risk of stigma and discrimination, family or friends should not be used as interpreters to disclose HIV-positive test results to patients with limited English proficiency. Providers should have easy access to HIV counselors or mental health providers for support in counseling patients.

  2. Follow-up appointment: Patients should be able to set an appointment time with the infectious disease clinic or HIV clinic at the time their results are disclosed. See Linking to Care for more information on how the ED can facilitate this process.

  3. Confirmatory test: Patients should be advised that a second test will be performed to confirm their positive HIV test result. Patients should be told how they will be informed about the results of this confirmatory test (e.g., at their first follow-up appointment, via telephone, or some other way).

    Standard practice and working relationships in your area will determine whether specimens will be sent to the public health laboratory or the hospital laboratory for confirmatory testing. Protocol should establish that specimens are flagged so the lab will know that a positive rapid HIV test result has already been received.

    Laboratories are encouraged to progress directly to the Western Blot or IFA to confirm a rapid test result. If confirmatory testing yields negative or indeterminate results, follow-up testing should be performed on a blood specimen collected four weeks after the initial reactive rapid test result.

    If the patient receives their test result in the ED, the confirmatory test specimen could be drawn before the patient leaves and the results sent to the referral clinic. The patient will require blood draws for CD4 counts and viral loads to determine their stage of illness. This lab work may be ordered at that time, or it may take place at the initial follow-up appointment.

  4. Surveillance and reporting: If the Western Blot or IFA test results confirm HIV infection, the facility must follow all applicable local and state requirements regarding the reporting of HIV infection or AIDS. If personnel are uncertain about the HIV/AIDS reporting requirements in their area, they should contact their state health department HIV/AIDS surveillance unit.

Providers should be aware that the Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) prohibits use or disclosure of a patient's health information, including HIV status, without the patient's permission.  Some states may have laws or regulations regarding the disclosure if a patient's HIV status.  Consult with your health department for more information.

Resources


Documenting Results

The clinical value of HIV testing means that an HIV test result becomes part of the patient's medical chart, so that all providers caring for a patient have access to that information. Sites should consider documenting the following in the patient's chart:

  • Whether an HIV test was declined
  • Negative test results
  • Confirmatory results (if applicable)
  • Referral to follow-up care (if applicable)
  • Viral loads and CD4 counts at the time of diagnosis (To help the ED track at what stage of illness they are detecting HIV in their patients.)

Key considerations for documenting test results include:

  • Who has access to patient records and can input data? It is common practice that only laboratory or clinical staff may document test results in patients' charts.
  • Does the ED use electronic medical records?
  • Will results go into the patients' chart or into a separate, parallel documentation system for HIV testing? When the testing program operates as a separate and distinct program from the ED's medical services, it is likely that the test results will not be entered into the patient's medical record, but into a parallel tracking system.


Linking to Care

How will the ED facilitate the linkage to care?

Facilitating the linkage to care for patients with HIV-positive test results will be a relatively small, albeit crucial, component of the HIV testing in the emergency department. EDs are not geared to provide extensive follow-up services. The role of the ED in terms of linking to care is to inform the patient how they can access primary and specialty care and to aid patients in setting up their initial visit. This can be performed by counselors, clinical staff, or a linkage-to-care liaison from the HIV or ID clinic. See Staffing for more information.

Considerations that should be factored into the linkage-to-care process include:

  • Does the hospital maintain onsite or community-based infectious disease or primary care clinics that can treat and manage the care of patients with HIV?
  • What other, unaffiliated clinics are available in the community? If the ED refers patients to these clinics, does a formal agreement or contract need to be in place?
  • What processes will the ED and each referral clinic use to communicate about new patients?
  • Will ED staff, counselors, or clinic staff walk patients to the clinic to initiate the follow-up process? This works well when the clinic is co-located or in close proximity to the ED.
  • Will the clinic maintain same-day appointments for patients tested in the ED?
  • Will the clinic have standing appointment times for which testing staff can schedule patients?
  • How will the ED provide real-time, daily, or other timely updates to clinic staff on new patients?
  • How will the clinic report information back to the ED on the number of patients who keep their initial visit? This will be important information for the ED to track its effectiveness in linking patients to care.
  • What measures can be taken if follow-up rates are low? Transportation vouchers, retail gift certificates, child care, and transportation service are some incentives that have been used at different sites with varying levels of success.

Resources


The Clinical Value of HIV Testing in the ED

By Richard Rothman, MD, PhD

The availability of rapid HIV testing in emergency departments provides a useful tool for clinicians that can inform treatment and disposition decision making for patients, as well as guide decision making in cases of occupational exposure and sexual assault. Although no formal studies have been done as of yet to evaluate the impact of rapid testing for practice, significant anecdotal experience is being gathered from sites around the United States that have been involved in screening, risk-targeted testing, or testing based on clinical suspicion. This section discusses the clinical course of HIV in relation to current CDC guidelines and should prove useful for the practicing emergency physician, as well as those involved in establishing HIV testing programs at their institution.

Stages of HIV Infection: Implications for Clinical Suspicion and Diagnostic Testing

The new CDC guidelines provide the following specific recommendations for diagnostic testing for HIV:

  • Clinicians should maintain a high level of suspicion for acute HIV infection in any patients who has a compatible clinical syndrome and who reports recent high-risk behavior. When acute retroviral syndrome is a possibility, a plasma RNA test should be used in conjunction with an HIV antibody test.
  • Any patient with signs or symptoms consistent with HIV infection or an opportunistic illness characteristic of AIDS should be tested for HIV.

Physicians practicing in emergency settings should thus be aware of the stages of HIV infection and the commonly associated clinical conditions.

Following initial infection, there is a brief period of rapid viral replication, resulting in a short interval of high viremic load and a drop in the patient's CD4 cell count (see fig. 1, below). Up to 80% of patients develop a viral syndrome (termed "acute seroconversion reaction"), characterized by fever (occurs in greater than 90% of cases), followed most commonly by fatigue (70-90%), pharyngitis (>70%) rash (40-80%), headache (30-70%) lymphadenpathy (40-70%), diarrhea and headaches (40-50%). From a diagnostic testing standpoint, this stage of disease is termed the "window period" (e.g., the patient has not yet mounted a sufficient antibody response to detect disease by classical diagnostic testing, (HIV antibody), but the disease can be identified instead by direct detection of the HIV virus (RNA assay). Since the timing of the clinical syndrome and development of antibodies to HIV is not exact, the CDC advises performing both antibody and RNA testing in patients who present with a viral syndrome and who have a history of recent high-risk behavior (e.g., intravenous drug use or unprotected sex with a high-risk partner). Diagnosis at this stage is considered to be particularly important for the patient (since initiation of treatment may lower the viral set point and delay progression of disease) as well as the community (an "unaware" infected patient poses a particularly high risk for transmission due to high viral load). From a practical standpoint in the emergency department, diagnostic testing for those with acute seroconversion has been relatively low yield as of yet due to the highly nonspecific nature of the clinical syndrome. Further awareness of this entity, however, may improve detection.


Fig. 1 - Changes in CD4 cell counts and plasma viraemia during HIV infection (modified
from Fauci(5) with permission). During primary infection, CD4 cell counts drop while plasma
viraemia - measured by p24 antigen assay or polymerase chain reaction - is high, and in this early
period HIV antibody levels can still be undetectable. Jolles, S. et al. BMJ 1996;312:1243-1244

Most patients with unrecognized HIV who come to the emergency department are in the "clinically latent" phase of infection (which typically lasts from 8 to 10 years in untreated individuals). The early "asymptomatic period" (CD4 count > 500) occurs after resolution of the acute HIV seroconversion reaction. Although technically coined "latent", testing should be considered for patients who present to the ED with unrelated chief complaints, but are found on review of systems or physical examination to have persistent generalized lymphadenopathy. Other nonspecific complaints which may be recognized by the astute clinician to be associated with HIV include complaints of recurrent respiratory tract infections (e.g. sinusitis, pharyngitis, and otitis media), recurrent oral ulceration, herpes zoster, Bell's palsy and a variety of dermatologic conditions (most commonly papular pruritic eruptions, seborrhoeic dermatitis and fungal nail infections).

Patient with seborrhoeic dermatitis

seborrhoeic
Source: http://en.wikipedia.org/wiki/Image:
Seborrhoeic_dermatitis.jpg

Patient with onchomycosis

onchomycosis
Source: www.myfootshop.com

Patient with herpes zoster

herpes zoster
Source: http://en.wikipedia.org/wiki/
Image:Herpes_zoster_neck.png

Symptomatic HIV infection develops when the immune system begins to fail, but prior to the occurrence of the classic conditions known to be associated with AIDS. At this stage, patients with underlying HIV may present to the ED with a primary complaint related to their being infected with HIV, but HIV may remain unrecognized since these conditions also occur in healthy non-immune-compromised populations. Strong evidence exists that the ED is one of the most common sites of interaction with the health care system prior to the diagnosis of AIDS (i.e., patients frequently present with clinical indicator conditions but are not diagnosed at the time of their ED presentation). Clinicians should thus strongly consider HIV testing in patients who present with any of following conditions, particularly those who endorse any of the recognized behavioral risk factors.

  • Pneumonia
  • Tuberculosis
  • Severe gingivitis or peridonitis
  • Persistent oral candidiasis
  • Unexplained chronic diarrhea (longer than one month)
  • Persistent fevers
  • Unexplained severe weight loss
  • Unexplained anemia, neutropenia, or thrombocytopenia

Patient with oral thrush

oral thrush
Source: www.thachers.org/images/
AIDS_oral_candidiasis

Even patients with typical lobar
infiltrates
should be tested for HIV

typical lobar
Source: www.lumen.luc.edu/.../
images/cxr4/Dscn028.jpg

Patients with AIDS often present to emergency departments with complaints related to an AIDS-defining illness. At this point, it is critical to consider that HIV, as a missed diagnosis, may lead to significant morbidity and mortality due to inadequate treatment and/or inappropriate disposition. Examples include:

  1. A patient with suspected "viral" pneumonia who has underlying PCP—here, failure to consider PCP in the differential diagnosis of a patient with dyspnea on exertion and nonspecific interstitial infiltrates may lead to inadequate antibiotic coverage and inappropriate disposition.
  2. A patient who has headache, weakness, and low-grade fever with unrecognized risk factors and/or other sign of HIV (e.g., thrush or significant weight loss)—here, failure to consider serious CNS infections such as cryptococcal meningitis would likely lead to significant morbidity and mortality.

By definition, AIDS occurs when the patient's immune system becomes severely compromised (CD4 count less than 200). This table lists common AIDS-defining illnesses and associated common clinical presentation that should be considered in the ED.

Common Clinical Presentation of AIDS-defining Illnesses

Conditions to Consider Presenting Complaint Additional Comments
Pulmonary
PCP(a)
(see images below)
Dyspnea on exertion; fever, indolent cough CXR typically shows perihilar infiltrates.
Atypical CXR patterns common in later stage disease with 25% normal—look for hypoxemia.
Recurrent bacterial pneumonia Cough, fever Routinely inquire about history of prior pneumonia
Neurologic
Cryptococcal meningitis Headaches, fever, change in mental status most common Serum and CSF crypotococcal antigen testing
Toxopasmosis(b)
(see image below)
Headache, fever, change in mental status most common; may see focal neurologic findings CT (with contrast): ring-enhancing lesion
Encephalitis Personality changes, headache, weakness CT shows diffuse atrophy
Lymphoma Headache, weakness, delta ms, may see focal neurologic findings CT shows single lesion
Gastrointestinal
Candidiasis (esophogeal) Dysphagia; odonphagia; dehydration Direct examination of scraping: presence of pseudohyphal elements
Cryptosporidiosis; isosporiasis Prolonged diarrheal illness with dehydration Requires diagnostic testing of stool (culture, ova, and parasites)
Other
Dermatologic:
Kaposi's sarcoma(c)
(see image below)
Darkly pigmented lesions Biopsy of lesion: proliferation of spindle cells and endothelial cells; hemosiderin-laden macrophages; extravasated RBCs
Systemic:
Salmonella septicemia (recurrent)
Prolonged or recurrent fevers, anorexia, fatigue, malaise; or local infection in bone, joints, pleura pericardium Culture: isolation of serotypes in blood, bone marrow, or site of infection
HIV wasting syndrome Weight loss >10% with fever, chronic diarrhea or fatigue > 1 month; severe muscle wasting Inquire about unintentional weight loss; look for temporal wasting.
Opthamologic:
CMV retinitis
Painless progressive loss of vision; blurred vision; "floaters"; blind spots Fundoscopy (generally requires slit-lamp examination); findings include perivascular hemorrhage and exudate.
Gynecologic:
Cervical cancer(d)
(see image below)
Genital warts or history of HPV
is a recognized risk. Consider early cervical CA in patients with genital warts and low-grade fever, fatigue, or weight loss
In women with history of genital warts or suspicious lesions, refer for Pap smear (squamous intraepithelial lesions). Cone biopsy advised in cases of serious cervical dysplasia

*Selected Images from Table

a. Two examples of diffuse interstitial infiltrates on chest x-ray in patients with PCP pneumonia
(the one on the left is more subtle)

Diffuse Interstitial Infiltrates
Source: www.ispub.com/.../ijid/vol5n1/hiv.xml

Diffuse Interstitial Infiltrates
Source: www.mevis.de/~hhj/Lunge/xSammlungInf2Fr.html

b. Multiple toxoplasmosis enhancing
lesion on CT with contrast

Multiple Toxoplasmosis Enhancing Lesion


c. Patient with Kaposi's lesions on skin

Kaposi's Lesions
Source: www.pdrhealth.com/.../images/BHG01ID11F02.GIF

d. Human papilloma virus (HPV) lesions around perianal region

Human Papilloma Virus
Source: www.medscape.com

Post-exposure Prophylaxis (PEP): The Clinical Value of Readily Available HIV Testing

The CDC provides detailed recommendations regarding PEP for both occupational and nonoccupational exposures. Critical elements of PEP that the emergency physician should be aware of include indications, timing, and procedures for referral in cases where ED treatment is initiated. The availability of ED-based rapid HIV testing is a crucial component of effective PEP because (1) decision making regarding treatment relies on rapid determination of the risk of the source patient, and (2) treatment may be rapidly initiated.

A detailed but easy-to-follow discussion of guidelines for PEP can be found on the CDC website for occupational exposure and non-occupational exposure (PDF).

Occupational Exposure

Compelling data from retrospective case control studies found an 81% reduction of HIV infection in exposed health care workers (HCWs) who used PEP. Accordingly, PEP should be considered in all potential cases of HCW exposure. Because exposures often occur outside of weekday working hours, EDs serve as an important resource for HCWs in their own hospital, as well as those of nearby clinics and other health care facilities. The two fundamental considerations in determining need for PEP is information about the source (ideally, HIV serostatus) and the severity of exposure (e.g., mucus membrane or needle-stick exposure). Simple tables that guide treatment decisions can be found on the CDC website. In general, if the source patient can be tested immediately and is found to be HIV seronegative, PEP is considered unnecessary and not recommended. In those cases where the source is seropositive, treatment can be initiated almost immediately and in compliance with the recommended time frame for treatment initiation (within one hour if possible). Several ED-based programmatic studies have been conducted over the past several years demonstrating both the need and he effectiveness of HIV rapid testing services in EDs for health care workers who use PEP.

Nonoccupational Exposure

There are several routes of potential nonoccupational exposure to HIV for which the ED should (or may be asked to) consider PEP. These include victims of sexual assault and high-risk cases of unprotected sex and intravenous needle-sharing.

In 2005, CDC released new guidelines (PDF) regarding nonoccupational HIV PEP: For persons seeking care less than 72 hours after nonoccupational exposure to blood, genital secretions, or other potentially infectious bodily fluids of a person known to be HIV-infected (when that exposure represents a substantial risk for transmission), PEP is recommended and medications should be initiated as soon as possible after exposure. For those exposures that occur with persons of unknown HIV status, no recommendation is made.

The new recommendations are of limited utility for emergency physicians since in the vast majority of cases, the HIV status of the source will be unknown (reference 1). Further, since the source is generally unavailable, rapid testing rarely has direct utility for treatment decisions. In the vast majority of cases decision making will thus be on a case-by-case basis. General consideration regarding initiation of treatment should include the weighing of behavioral factors and the circumstances that led to HIV exposure, the patient's risk of HIV acquisition based on the type of exposure, and the possibility that the source is HIV-infected based on individual risks (if known) and/or risks of the local population.(reference 2)

Emergency physicians have the most experience in nonoccupational PEP in the context of sexual assault victims. Here, PEP decision making should be initiated rapidly in conjunction with rape counselors. The few published studies describing PEP in victims of assault indicate that treatment is not routinely offered and is rarely completed for those seeking care in EDs, indicating a need for further education of both emergency physicians and patients. It remains unclear what the impact of the new CDC guidelines will have on the frequency of patient presentations to the ED, as well as ED physician practice. Again, further education and research are required.

References

  1. Merchant C, Mayer K. Perspectives on new recommendations for nonoccupational HIV postexposure prophylaxis JAMA. 2005;293(19):2407-2409.
  2. New York State Department of Health. HIV prophylaxis following nonoccupational exposure including sexual assault. National Guideline Clearinghouse [Accessed May 15, 2007.]

Resources


Resources

Making the Case

Engaging Essential Players

Measuring Progress

Costs and Funding

Legal Considerations

Operational Flow

Staffing

Choosing a Test

Training Staff

Informed Consent

Delivering Results

Linking to Care

The Clinical Value of HIV Testing in the ED


 
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