Cost-Effectiveness of HIV Screening in Emergency Departments: Results From the Pragmatic Randomized HIV Testing Using Enhanced Screening Techniques in Emergency Departments Trial.

STUDY OBJECTIVE: Identification of HIV remains a critical health priority for which emergency departments (EDs) are a central focus. The comparative cost-effectiveness of various HIV screening strategies in EDs remains largely unknown. The goal of this study was to compare programmatic costs and cost-effectiveness of nontargeted and 2 forms of targeted opt-out HIV screening in EDs using results from a multicenter, pragmatic randomized clinical trial. METHODS: This economic evaluation was nested in the HIV Testing Using Enhanced Screening Techniques in Emergency Departments (TESTED) trial, a multicenter pragmatic clinical trial of different ED-based HIV screening strategies conducted from April 2014 through January 2016. Patients aged 16 years or older, with normal mental status and not critically ill, or not known to be living with HIV were randomized to 1 of 3 HIV opt-out screening approaches, including nontargeted, enhanced targeted, or traditional targeted, across 4 urban EDs in the United States. Each screening method was fully integrated into routine emergency care. Direct programmatic costs were determined using actual trial results, and time-motion assessment was used to estimate personnel activity costs. The primary outcome was newly diagnosed HIV. Total annualized ED programmatic costs by screening approach were calculated using dollars adjusted to 2023 as were costs per patient newly diagnosed with HIV. One-way and multiway sensitivity analyses were performed. RESULTS: The trial randomized 76,561 patient visits, resulting in 14,405 completed HIV tests, and 24 (0.2%) new diagnoses. Total annualized new diagnoses were 12.9, and total annualized costs for nontargeted, enhanced targeted, and traditional targeted screening were $111,861, $88,629, and $70,599, respectively. Within screening methods, costs per new HIV diagnoses were $20,809, $23,554, and $18,762, respectively. Enhanced targeted screening incurred higher costs but with similar annualized new cases detected compared with traditional targeted screening. Nontargeted screening yielded an incremental cost-effectiveness ratio of $25,586 when compared with traditional targeted screening. Results were most sensitive to HIV prevalence and costs of HIV tests. CONCLUSION: Nontargeted HIV screening was more costly than targeted screening largely due to an increased number of HIV tests performed. Each HIV screening strategy had similar within-strategy costs per new HIV diagnosis with traditional targeted screening yielding the lowest cost per new diagnosis. For settings with budget constraints or very low HIV prevalences, the traditional targeted approach may be preferred; however, given only a slightly higher cost per new HIV diagnosis, ED settings looking to detect the most new cases may prefer nontargeted screening.

Communicable Disease Screening and Human Immunodeficiency Virus Prevention in the Emergency Department.

Emergency departments (ED) provide care to populations with high rates of communicable diseases, like HIV, hepatitis C virus, and syphilis. For many patients, the ED is their sole entry point into the healthcare system and they do not routinely access screening and prevention services elsewhere. As such, the ED can serve an important public health role through communicable disease identification, treatment, and prevention. In this article, we examine national recommendations, peer-reviewed literature, and expert consensus to provide cutting edge strategies for implementing communicable infectious disease screening and prevention programs into routine ED care.

A Systematic Review of HIV Pre-exposure Prophylaxis (PrEP) Implementation in U.S. Emergency Departments: Patient Screening, Prescribing, and Linkage to Care.

In the pursuit of ending the HIV epidemic, U.S. emergency departments (EDs) have emerged as a valuable setting to increase HIV testing and linkage to care. There is limited data available, however, describing the incorporation of HIV prevention initiatives in U.S. EDs. Over the last decade, HIV pre-exposure prophylaxis (PrEP) has significantly changed the HIV prevention landscape globally and very little is known about the provision of PrEP in U.S. EDs. To address this gap in the literature, we conducted a systematic review of peer-reviewed quantitative studies and conference abstracts spanning July 2012 - October 2022. Of 433 citations, 11 articles and 13 abstracts meet our inclusion criteria, representing 18 unique studies addressing PrEP screening, prescribing, and/or linkage to PrEP care.Most studies describe screening processes to identify PrEP-eligible patients (n = 17); most studies leveraged a patient's STI history as initial PrEP eligibility screening criteria. Fewer studies describe PrEP prescribing (n = 2) and/or linkage to PrEP care (n = 8).Findings from this systematic review highlight the potential for U.S. EDs to increase PrEP uptake among individuals at risk for HIV infection. Despite a growing number of studies exploring processes for incorporating PrEP into the ED setting, such studies are small-scale and time limited. Models providing prescribing PrEP in the ED show higher initiation rates than post-discharge engagement models. Electronic health record (EHR)-based HIV screening is valuable, but post-ED linkage rates are low. Our findings emphasize the need to establish best practices for initiating and supporting prevention effective PrEP use in the ED setting.

The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial: rationale and design of an emergency department-based randomized clinical trial of linkage-to-care strategies for hepatitis C.

BACKGROUND: Hepatitis C (HCV) poses a major public health problem in the USA. While early identification is a critical priority, subsequent linkage to a treatment specialist is a crucial step that bridges diagnosed patients to treatment, cure, and prevention of ongoing transmission. Emergency departments (EDs) serve as an important clinical setting for HCV screening, although optimal methods of linkage-to-care for HCV-diagnosed individuals remain unknown. In this article, we describe the rationale and design of The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Linkage-to-Care Trial. METHODS: The DETECT Hep C Linkage-to-Care Trial will be a single-center prospective comparative effectiveness randomized two-arm parallel-group superiority trial to test the effectiveness of linkage navigation and clinician referral among ED patients identified with untreated HCV with a primary hypothesis that linkage navigation plus clinician referral is superior to clinician referral alone when using treatment initiation as the primary outcome. Participants will be enrolled in the ED at Denver Health Medical Center (Denver, CO), an urban, safety-net hospital with approximately 75,000 annual adult ED visits. This trial was designed to enroll a maximum of 280 HCV RNA-positive participants with one planned interim analysis based on methods by O'Brien and Fleming. This trial will further inform the evaluation of cost effectiveness, disparities, and social determinants of health in linkage-to-care, treatment, and disease progression. DISCUSSION: When complete, the DETECT Hep C Linkage-to-Care Trial will significantly inform how best to perform linkage-to-care among ED patients identified with HCV. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04026867 Original date: July 1, 2019 URL: https://clinicaltrials.gov/ct2/show/NCT04026867.

The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Screening Trial: rationale and design of a multi-center pragmatic randomized clinical trial of hepatitis C screening in emergency departments.

BACKGROUND: Early identification of HCV is a critical health priority, especially now that treatment options are available to limit further transmission and provide cure before long-term sequelae develop. Emergency departments (EDs) are important clinical settings for HCV screening given that EDs serve many at-risk patients who do not access other forms of healthcare. In this article, we describe the rationale and design of The Determining Effective Testing in Emergency Departments and Care Coordination on Treatment Outcomes (DETECT) for Hepatitis C (Hep C) Screening Trial. METHODS: The DETECT Hep C Screening Trial is a multi-center prospective pragmatic randomized two-arm parallel-group superiority trial to test the comparative effectiveness of nontargeted and targeted HCV screening in the ED with a primary hypothesis that nontargeted screening is superior to targeted screening when identifying newly diagnosed HCV. This trial will be performed in the EDs at Denver Health Medical Center (Denver, CO), Johns Hopkins Hospital (Baltimore, MD), and the University of Mississippi Medical Center (Jackson, MS), sites representing approximately 225,000 annual adult visits, and designed using the PRECIS-2 framework for pragmatic trials. When complete, we will have enrolled a minimum of 125,000 randomized patient visits and have performed 13,965 HCV tests. In Denver, the Screening Trial will serve as a conduit for a distinct randomized comparative effectiveness trial to evaluate linkage-to-HCV care strategies. All sites will further contribute to embedded observational studies to assess cost effectiveness, disparities, and social determinants of health in screening, linkage-to-care, and treatment for HCV. DISCUSSION: When complete, The DETECT Hep C Screening Trial will represent the largest ED-based pragmatic clinical trial to date and all studies, in aggregate, will significantly inform how to best perform ED-based HCV screening. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04003454 . Registered on 1 July 2019.

Clinical Utility of the Signal-to-Cutoff Ratio of Reactive HIV Antigen/Antibody Screening Tests in Guiding Emergency Physician Management.

BACKGROUND: The signal-to-cutoff (S/CO) ratio of the HIV antigen/antibody test may help immediately to differentiate true-positive results from false-positive results, which may be particularly useful in time-sensitive circumstances, such as when providing emergency department (ED) care. SETTING: Seven US EDs with HIV screening programs using HIV antigen/antibody assays. METHODS: This cross-sectional study of existing data correlated S/CO ratios with confirmed HIV status. Test characteristics at predetermined S/CO ratios and the S/CO ratio with the best performance by receiver operator characteristic (ROC) curve were calculated. RESULTS: Of 1035 patients with a reactive HIV antigen/antibody test, 232 (22.4%) were confirmed HIV-negative and 803 (77.6%) were confirmed HIV-positive. Of the 803 patients, 713 (88.8%) experienced chronic infections and 90 (11.2%) experienced acute infections. S/CO ratios were greater for HIV-positive (median 539.2) than for HIV-negative patients (median 1.93) (P < 0.001) and lower for acute infection (median 22.8) than for chronic infection (median 605.7) (P < 0.001). All patients with an S/CO ratio < 1.58 (n = 93) were HIV-negative (NPV 100%), and nearly all with an S/CO ≥ 20.7 (n = 760) (optimal level by ROC analysis) were HIV-positive (PPV 98.6%). Of patients with S/CO values between 1.58 and 20.7 (n = 182), 29.7% were HIV-positive. CONCLUSIONS: The S/CO ratio may be used in real time to classify most ED patients as almost certain to be either HIV-positive or HIV-negative long before nucleic acid confirmatory testing is available. When combined with clinical judgment, this could guide preliminary result disclosure and management.

Comparison of HIV Screening Strategies in the Emergency Department: A Randomized Clinical Trial.

Importance: The National HIV Strategic Plan for the US recommends HIV screening in emergency departments (EDs). The most effective approach to ED-based HIV screening remains unknown. Objective: To compare strategies for HIV screening when integrated into usual ED practice. Design, Setting, and Participants: This randomized clinical trial included patients visiting EDs at 4 US urban hospitals between April 2014 and January 2016. Patients included were ages 16 years or older, not critically ill or mentally altered, not known to have an HIV positive status, and with an anticipated length of stay 30 minutes or longer. Data were analyzed through March 2021. Interventions: Consecutive patients underwent concealed randomization to either nontargeted screening, enhanced targeted screening using a quantitative HIV risk prediction tool, or traditional targeted screening as adapted from the Centers for Disease Control and Prevention. Screening was integrated into clinical practice using opt-out consent and fourth-generation antigen-antibody assays. Main Outcomes and Measures: New HIV diagnoses using intention-to-treat analysis, absolute differences, and risk ratios (RRs). Results: A total of 76 561 patient visits were randomized; median (interquartile range) age was 40 (28-54) years, 34 807 patients (51.2%) were women, and 26 776 (39.4%) were Black, 22 131 (32.6%) non-Hispanic White, and 14 542 (21.4%) Hispanic. A total of 25 469 were randomized to nontargeted screening; 25 453, enhanced targeted screening; and 25 639, traditional targeted screening. Of the nontargeted group, 6744 participants (26.5%) completed testing and 10 (0.15%) were newly diagnosed; of the enhanced targeted group, 13 883 participants (54.5%) met risk criteria, 4488 (32.3%) completed testing, and 7 (0.16%) were newly diagnosed; and of the traditional targeted group, 7099 participants (27.7%) met risk criteria, 3173 (44.7%) completed testing, and 7 (0.22%) were newly diagnosed. When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses (enhanced targeted and traditional targeted combined: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.7; 95% CI, 0.30 to 1.56; P = .38; and enhanced targeted only: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.70; 95% CI, 0.27 to 1.84; P = .47). Conclusions and Relevance: Targeted HIV screening was not superior to nontargeted HIV screening in the ED. Nontargeted screening resulted in significantly more tests performed, although all strategies identified relatively low numbers of new HIV diagnoses. Trial Registration: ClinicalTrials.gov Identifier: NCT01781949.

High Prevalence of Hepatitis C Infection Among Adult Patients at Four Urban Emergency Departments - Birmingham, Oakland, Baltimore, and Boston, 2015-2017.

Identifying persons with hepatitis C virus (HCV) infection has become an urgent public health challenge because of increasing HCV-related morbidity and mortality, low rates of awareness among infected persons, and the advent of curative therapies (1). Since 2012, CDC has recommended testing of all persons born during 1945-1965 (baby boomers) for identification of chronic HCV infection (1); urban emergency departments (EDs) are well positioned venues for detecting HCV infection among these persons. The United States has witnessed an unprecedented opioid overdose epidemic since 2013 that derives primarily from commonly injected illicit opioids (e.g., heroin and fentanyl) (2). This injection drug use behavior has led to an increase in HCV infections among persons who inject drugs and heightened concern about increases in human immunodeficiency virus (HIV) and HCV infection within communities disproportionately affected by the opioid crisis (3,4). However, targeted strategies for identifying HCV infection among persons who inject drugs is challenging (5,6). During 2015-2016, EDs at the University of Alabama at Birmingham; Highland Hospital, Oakland, California; Johns Hopkins Hospital, Baltimore, Maryland; and Boston University Medical Center, Massachusetts, adopted opt-out (i.e., patients can implicitly accept or explicitly decline testing), universal hepatitis C screening for all adult patients. ED staff members offered HCV antibody (anti-HCV) screening to patients who were unaware of their status.* During similar observation periods at each site, ED staff members tested 14,252 patients and identified an overall 9.2% prevalence of positive results for anti-HCV among the adult patient population. Among the 1945-1965 birth cohort, prevalence of positive results for anti-HCV (13.9%) was significantly higher among non-Hispanic blacks (blacks) (16.0%) than among non-Hispanic whites (whites) (12.2%) (p<0.001). Among persons born after 1965, overall prevalence of positive results for anti-HCV was 6.7% and was significantly higher among whites (15.3%) than among blacks (3.2%) (p<0.001). These findings highlight age-associated differences in racial/ethnic prevalences and the potential for ED venues and opt-out, universal testing strategies to improve HCV infection awareness and surveillance for hard-to-reach populations. This opt-out, universal testing approach is supported by new recommendations for hepatitis C screening at least once in a lifetime for all adults aged ≥18 years, except in settings where the prevalence of positive results for HCV infection is <0.1% (7).

Continuum of Care for Hepatitis C Virus Among Patients Diagnosed in the Emergency Department Setting.

BACKGROUND.: Urban emergency departments (EDs) seem to be able to detect new hepatitis C virus (HCV) infections at a high rate, but it is unknown the extent to which individuals screened in the ED can progress to treatment and cure. We evaluate the HCV Continuum of Care for patients identified with HCV in 2 urban EDs, and consider the results in the context of outcomes from ambulatory screening venues where 2%-10% of chronically infected patients are treated. METHODS.: This is a multicenter, retrospective cohort study of 2 ED HCV screening programs. Patients who screened HCV antibody reactive between 1 May and 31 October 2014 were followed for up to 18 months. The main outcome was the absolute number and proportion of eligible patients who completed each stage of the HCV Continuum of Care. RESULTS.: A total of 3704 ED patients were estimated to have undiagnosed HCV infection, and screening identified 532 (14.4%) HCV antibody-reactive patients. Of the 532 HCV antibody-reactive patients, 435 completed viral load testing (82%), of whom 301 (69%) were chronically infected. Of the 301 chronically infected patients, 158 had follow-up arranged (52%), of whom 97 attended their appointment (61%). Of these 97, 24 began treatment (25%), and 19 of these 24 achieved sustained virological response (79%). CONCLUSIONS.: Urban EDs serve patients with poor access to preventive care services who have a high prevalence of HCV infection. Because ED patients identified with HCV infection can progress to treatment and cure with rates comparable to ambulatory care settings, implementation of ED HCV screening should be expanded.

Hepatitis C Virus Screening and Emergency Department Length of Stay.

BACKGROUND: Recent studies demonstrate high rates of previously undiagnosed hepatitis C virus (HCV) infection among patients screened in urban emergency departments (ED). Experts caution, however, that public health interventions, such as screening for infectious diseases, must not interfere with the primary mission of EDs to provide timely acute care. Increases in ED length of stay (LOS) have been associated with decreased quality of ED care. OBJECTIVE: In this study, we assess the influence of an integrated HCV screening protocol on ED LOS. METHODS: This was a retrospective cohort study analyzing timestamp data for all discharged patients over a 1-year period. The primary outcome compared the median LOS in minutes between patients who completed HCV screening and those who did not. Further analysis compared LOS for HCV screening by whether or not complete blood count (CBC) testing was conducted. RESULTS: Of 69,639 visits, 2,864 (4%) had HCV screening tests completed and 272 (9.5%) were antibody positive. The median LOS for visits that included HCV screening was greater than visits that did not include screening (151 versus 119 minutes, P < 0.001). Among the subset of visits in which CBC testing was conducted, there was no significant difference in median LOS between visits that also included HCV screening and those that did not (240 versus 242 minutes, P = 0.68). CONCLUSION: Integrated HCV screening modestly prolongs ED LOS. However, among patients undergoing other blood tests, screening had no effect on LOS. Programs may consider routinely offering HCV screening to patients who are undergoing laboratory testing.

Patient Understanding of HIV and Hepatitis C Testing in an Emergency Department with an Integrated Program.

INTRODUCTION: We implemented triage nurse rapid HIV and hepatitis C virus (HCV) screening, in parallel with physician diagnostic testing, in our urban emergency department (ED). METHODS: A 2-month cross-sectional survey was performed to determine the proportion of patients who correctly reported being tested for HIV and HCV. RESULTS: A total of 492 patients were surveyed. Fifty-one (70%) of the 73 patients who reported being HIV tested and 372 (89%) of the 419 patients who reported not being HIV tested were correct. Thirty (60%) of the 50 patients who reported being HCV tested and 416 (94%) of the 442 patients who reported not being HCV tested were correct. CONCLUSION: Although most ED patients correctly reported whether testing was performed, there were many who did not. Although ED screening programs for HIV and HCV serve as an important venue for screening, strategies to improve communication require attention.

Results of a Rapid Hepatitis C Virus Screening and Diagnostic Testing Program in an Urban Emergency Department.

STUDY OBJECTIVE: We describe the results of an emergency department (ED) hepatitis C virus testing program that integrated birth cohort screening and screening of patients with a history of injection drug use, as well as physician diagnostic testing, according to national guidelines. METHODS: We conducted a retrospective cohort study using data collected as part of clinical care. The primary outcome was the hepatitis C virus prevalence among tested patients. We evaluated factors associated with testing positive with logistic regression. RESULTS: Of the 26,639 unique adults aged 18 years or older and presenting to the ED during the 6-month study, 2,581 (9.7%) completed hepatitis C virus screening (2,028) or diagnostic testing (553), of whom 267 were antibody positive (10.3% prevalence). Factors associated with testing positive for hepatitis C virus included injection drug use (38.4% prevalence; odds ratio [OR] 10.8; 95% confidence interval [CI] 7.5 to 15.5), homeless (25.5% prevalence; OR 3.1; 95% CI 1.5 to 6.8), diagnostic testing (14.8% prevalence; OR 2.6; 95% CI 1.7 to 3.9), birth cohort (13.7% prevalence; OR 3.6; 95% CI 2.4 to 5.3), and male sex (12.4% prevalence; OR 1.4; 95% CI 1.0 to 2.0). Of the 267 patients testing positive for hepatitis C virus antibody, 137 (51%) had documentation of result disclosure and 180 (67%) had confirmatory ribonucleic acid testing performed, of whom 126 (70%) had a positive result. Follow-up appointments at the hepatitis C virus clinic were arranged for 57 of the 126 (45%) patients with confirmed positive results, of which 30 attended. CONCLUSION: This ED screening and diagnostic testing program found a high prevalence of hepatitis C virus antibody positivity across all groups. Challenges encountered with hepatitis C virus screening included result disclosure, confirmatory testing, and linkage to care. Our results warrant continued efforts to develop and evaluate policies for ED-based hepatitis C virus screening.

Low rate of syphilis screening among high-risk emergency department patients tested for gonorrhea and chlamydia infections.

BACKGROUND: Implementing national recommendations for syphilis screening is not feasible in the emergency department (ED) setting. The purpose of this study was to determine the syphilis screening rate among ED patients tested for gonorrhea and chlamydia (GC/CT) and the syphilis prevalence among those who were tested. METHODS: A 1-year retrospective cohort study in an urban ED. At the time of this study, there were no explicit syphilis screening guidelines and testing was at the discretion of the treating physician. We determined the proportion of all GC/CT-tested patients who also underwent syphilis screening and the prevalence of syphilis among this group. Predictors of syphilis screening among patients tested for GC/CT were identified. RESULTS: GC/CT tests were performed in 3951 (4.7%) of the 83,988 ED visits, of which 332 (8.4%) were reactive. The mean age of GC/CT-tested patients was 22.6 ± 12 years, most were female (67%), black (47%), and English speaking (74%). Syphilis screening was completed in 1218 (31%) of the GC/CT-tested patients, 17 tests (1.4%) were reactive, which included 8 (0.7%) unique patients with newly diagnosed syphilis. In multivariable analysis, the following variables were predictive of syphilis screening: empirical GC/CT treatment (odds ratio [OR]: 1.9, 95% confidence interval [CI]: 1.6-2.3), evaluation in the low acuity section of the ED (OR: 1.8, 95% CI: 1.4-2.3), a reactive GC/CT test (OR: 1.3, 95% CI: 1.0-1.6), and age ≤25 years (OR: 1.2, 95% CI: 1.0-1.4). CONCLUSION: Among ED patients tested for GC/CT, less than one-third were screened for syphilis. Failure to screen these patients likely resulted in missed opportunities for syphilis diagnosis.

Understanding patient acceptance and refusal of HIV testing in the emergency department.

BACKGROUND: Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing. METHODS: In-depth interviews with fifty ED patients (28 accepters and 22 decliners of HIV testing) in three ED HIV testing programs that serve vulnerable urban populations in northern California. RESULTS: Many factors influenced the decision to accept ED HIV testing, including curiosity, reassurance of negative status, convenience, and opportunity. Similarly, a number of factors influenced the decision to decline HIV testing, including having been tested recently, the perception of being at low risk for HIV infection due to monogamy, abstinence or condom use, and wanting to focus on the medical reason for the ED visit. Both accepters and decliners viewed ED HIV testing favorably and nearly all participants felt comfortable with the testing experience, including the absence of counseling. While many participants who declined an ED HIV test had logical reasons, some participants also made clear that they would prefer not to know their HIV status rather than face psychosocial consequences such as loss of trust in a relationship or disclosure of status in hospital or public health records. CONCLUSIONS: Testing for HIV in the ED as for any other health problem reduces barriers to testing for some but not all patients. Patients who decline ED HIV testing may have rational reasons, but there are some patients who avoid HIV testing because of psychosocial ramifications. While ED HIV testing is generally acceptable, more targeted approaches to testing are necessary for this subgroup.

Increased acceptance rates of HIV screening using opt-out consent methods in an urban emergency department.

BACKGROUND: Optimal methods for implementing HIV screening in health care settings remain unknown. OBJECTIVE: To compare the acceptance rates of emergency department HIV screening when supplemental staff use opt-in and opt-out consent methods. METHODS: Experimental equivalent time-sample, conducted in an urban emergency department with an annual census of 80,000 visits. HIV screeners performed nontargeted HIV screening using point-of-care, rapid HIV tests. Eligible patients were medically stable, English or Spanish speaking, ≥13 or ≤64 years, not HIV tested in past 6 months, and not psychiatrically impaired. Screeners offered eligible patients HIV screening using either opt-in or opt-out consent methods on alternate weeks. Main outcome measures were the acceptance rate of HIV screening and the association between opt-out rapid HIV screening and acceptance. RESULTS: Of the eligible patients, 2409 were offered HIV screening, with 1209 (50%) on opt-in days and 1200 (50%) on opt-out days. The mean age was 40 years, 52% were male, 45% were Black, 28% Hispanic, and 15% white. The acceptance rate of opt-in HIV screening was 63% [767 of 1209, 95% confidence interval (CI): 61% to 66%] and the acceptance rate of opt-out HIV screening was 78% (931 of 1200, 95% CI: 75% to 80%), absolute difference 14% (95% CI: 11% to 18%). The acceptance rate of opt-out HIV screening remained greater after adjusting for patient demographics, admission status, acuity, treatment area, privacy of encounter, and screening staff identity (adjusted odds ratio: 2.0, 95% CI: 1.7 to 2.4). CONCLUSIONS: Opt-out HIV screening using supplemental staff increases patient acceptance and should be considered as the consent methodology of choice.

2009 US emergency department HIV testing practices.

OBJECTIVES: We characterize HIV testing practices and programs in US emergency departments (EDs) in 2009. METHODS: A national Web-based survey of members of the National ED HIV Testing Consortium, participants in the 2007 Centers for Disease Control and Prevention (CDC)-sponsored ED HIV Testing Workshops, all US academic EDs, and a weighted random sample of US community EDs with snowball sampling to recruit additional testing sites was conducted. Data collected included geographic location, estimated seroprevalence, indications for testing, method of consent, weekly number of tests, funding, and costs. RESULTS: Of 619 sites surveyed, 338 (54.6%) responded. A total of 277 (82.0%) reported conducting any HIV testing, and 75 (22.2%) reported systematic HIV testing programs, operationally defined as having testing or screening organized at the departmental or institutional level. systematic HIV testing programs were concentrated in the Northeast, at high-volume urban EDs, and in regions with higher HIV/AIDS prevalence. Most systematic HIV testing programs had existed for less than or equal to 3 years, and nearly one third reported using an opt-out approach for consent. Among systematic HIV testing programs, the number of patients tested ranged from less than 1 to 2,100 tests per week. Overall, universal screening was the most commonly reported screening method reported overall, and rates of HIV positivity were consistently above the CDC threshold of 0.1%. CONCLUSION: The number of EDs conducting HIV testing has grown substantially since release of the 2006 CDC HIV testing recommendations. Although many EDs have systematic HIV testing programs, the majority do not. Ongoing surveillance will be required to quantify the evolution of ED-based HIV testing and the factors that facilitate or impede expanded translation.

HIV screening in an urban emergency department: comparison of screening using an opt-in versus an opt-out approach.

OBJECTIVE: We compare outcomes of opt-in and opt-out HIV screening approaches in an urban emergency department. METHODS: This was a 1-year prospective observational study comparing 2 6-month screening approaches. Eligibility for opt-in and opt-out screening was identical: aged 15 years or older, medically stable, and able to complete general consent. During the opt-in phase, triage nurses referred patients to HIV testers stationed at triage, who obtained separate opt-in written consent and performed rapid oral fluid tests. During the opt-out phase, registration staff conducted integrated opt-out consent and then referred patients to HIV testers. We assessed the proportion of potentially eligible patients who were offered screening (screening offer rate), the proportion offered screening who accepted (screening acceptance rate), the proportion who accepted screening and subsequently completed testing (test completion rate), and the proportion of potentially eligible patients who completed testing (overall screening rate) during each phase. RESULTS: For the opt-in versus the opt-out phases, respectively, there were 23,236 potentially eligible patients versus 26,757, screening offer rate was 27.9% versus 75.8% (P<.001), screening acceptance rate was 62.7% versus 30.9% (P<.001), test completion rate was 99.8% versus 74.6% (P<.001), and overall screening rate was 17.4% versus 17.5% (P = .90). CONCLUSION: A significantly higher proportion of patients were offered HIV screening with an opt-out approach at registration. However, this was offset by much higher screening acceptance and test completion rates with the opt-in approach at triage. Overall screening rates with the 2 approaches were nearly identical.

Operational methods of HIV testing in emergency departments: a systematic review.

OBJECTIVES: Casual review of existing literature reveals a multitude of individualized approaches to emergency department (ED) HIV testing. Cataloging the operational options of each approach could assist translation by disseminating existing knowledge, endorsing variability as a means to address testing barriers, and laying a foundation for future work in the area of operational models and outcomes investigation. The objective of this study is to provide a detailed account of the various models and operational constructs that have been described for performing HIV testing in EDs. METHODS: Systematic review of PUBMED, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Web of Science through February 6, 2009 was performed. Three investigators independently reviewed all potential abstracts and identified all studies that met the following criteria for inclusion: original research, performance of HIV testing in an ED in the United States, description of operational methods, and reporting of specific testing outcomes. Each study was independently assessed and data from each were abstracted with standardized instruments. Summary and pooled descriptive statistics were reported by using recently published nomenclature and definitions for ED HIV testing. RESULTS: The primary search yielded 947 potential studies, of which 25 (3%) were included in the final analysis. Of the 25 included studies, 13 (52%) reported results using nontargeted screening as the only patient selection method. Most programs reported using voluntary, opt-in consent and separate, signed consent forms. A variety of assays and communication methods were used, but relatively limited outcomes data were reported. CONCLUSION: Currently, limited evidence exists to inform HIV testing practices in EDs. There appears to be recent progression toward the use of rapid assays and nontargeted patient selection methods, with the rate at which reports are published in the peer-reviewed literature increasing. Additional research will be required, including controlled clinical trials, more structured program evaluation, and a focus on an expanded profile of outcome measures, to further improve our understanding of which HIV testing methods are most effective in the ED.