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 six 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.
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.top of this page
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.
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:
Men who have sex with men (MSM)
Heterosexual with multiple partners
Exchange of sex for drugs or money
History of sexually transmitted disease
Unprotected sex with a partner who is HIV-infected or has risk factors for HIV
Spent time in prison
Sexually transmitted diseases
Abdominal pain and vaginal discharge and/or dysuria in women
Testicular pain, dysuria, and/or discharge in men
Severe gingivitis or peridonitis
Persistent oral candidiasis (thrush)
Unexplained chronic diarrhea (greater than one month)
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
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
- Ensure that patients receive the results of their tests and are linked to care.
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.top of this page
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