Studies show new progress in HIV testing in emergency departments

Special supplement published in the Annals of Emergency Medicine

Emergency departments are increasingly offering HIV testing to patients, but many face serious challenges as they work to integrate testing into emergency care protocols, a series of studies on routine HIV testing in emergency departments has found.

The findings were published in a special supplement to the Annals of Emergency Medicine. The supplement was sponsored by the Centers for Disease Control and Prevention with funding from the agency’s “HIV Screening. Standard Care.” campaign for health care providers. Since 2006, CDC has recommended that all adults, adolescents, and pregnant women be offered an HIV test as a routine part of medical care, including emergency department visits.

“Ensuring that all Americans know their HIV status is vital to ending the U.S. HIV epidemic,” said Jonathan Mermin, M.D., director of CDC’s Division of HIV/AIDS Prevention. “Emergency departments play a critical role in helping people learn their HIV status, connecting them to life-prolonging care, and helping them avoid transmitting the virus to others.”

Approximately 240,000 Americans who are living with HIV are unaware of their infection. Helping more Americans get tested is a key goal of the National HIV/AIDS Strategy, which calls for increasing the proportion of people with HIV who know they are infected from 79 percent to 90 percent. Emergency departments reach many individuals at higher risk for HIV, including people who may rely on the local emergency department for primary care. For example, in CDC’s Expanded HIV Testing Initiative, emergency departments accounted for 8 percent of all testing venues, but 32 percent of all previously undiagnosed HIV infections.

The 25 articles in the supplement report new data on the scope of HIV testing in emergency departments across the United States, and provide insights into how emergency departments can create and sustain protocols allowing for routine HIV testing.

Findings include:

• The number of institutions providing HIV testing in emergency departments has grown substantially in recent years. A national survey of emergency departments in 2009 found that 22 percent had routine HIV testing programs, with more than 90 percent of these started between 2004 and 2009.
• However, the same survey revealed that despite this progress, 78 percent of emergency departments did not have systematic HIV testing programs in 2009. Of those that did, only one-third used the opt-out approach recommended by CDC, in which all patients are screened unless they decline after being notified that testing will be performed.
• A separate national survey of academic- and community-based emergency departments indicated greater education efforts are needed to reach emergency physicians and administrators. According to the survey, 60 percent of non-academic emergency departments were not aware of CDC’s HIV testing recommendations.
• Routine opt-out HIV screening programs can lead to high levels of HIV testing among emergency department patients. One program in Augusta, Ga., found that 91 percent of patients accepted HIV tests when offered on an opt-out basis.

Other supplement articles include cost-effectiveness studies, outcome-based comparisons of different program approaches, and case studies of HIV testing programs from diverse emergency department settings.

“While recent progress is very encouraging, emergency departments still face a number of obstacles as they try to develop sustainable approaches to routine opt-out HIV testing,” said Richard Rothman, M.D., Ph.D., director of research at the Department of Emergency Medicine, Johns Hopkins University School of Medicine and co-editor of the supplement. “Funding to support and sustain HIV screening in emergency departments is limited, and very few state Medicaid networks provide reimbursement for broadly testing in this setting. I hope that administrators and policymakers will take steps to address these challenges.”

Better education of health care providers about the national HIV testing recommendations is crucial to the success of any testing program. CDC’s “HIV Screening. Standard Care.” campaign seeks to improve knowledge of the recommendations by providing clinicians and other health care workers with educational tools and guidance for implementing HIV testing in clinical settings. “HIV Screening. Standard Care.” is part of Act Against AIDS, CDC’s five-year multi-faceted national communication campaign designed to refocus national attention on the HIV epidemic in America by increasing awareness of HIV and the importance of prevention and testing.

For additional information about the testing campaign, see www.actagainstaids.org/provider/hssc/.

See HIV Testing in Emergency Departments supplement (Annals of Emergency Medicine).

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES