Prevalence of undiagnosed acute and chronic HIV in a lower-prevalence urban emergency department.

OBJECTIVES: We estimated the seroprevalence of both acute and chronic HIV infection by using a random sample of emergency department (ED) patients from a region of the United States with low-to-moderate HIV prevalence. METHODS: This cross-sectional seroprevalence study consecutively enrolled patients aged 18 to 64 years within randomly selected sampling blocks in a Midwestern urban ED in a region of lower HIV prevalence in 2008 to 2009. Participants were compensated for providing a blood sample and health information. After de-identification, we assayed samples for HIV antibody and nucleic acid. RESULTS: There were 926 participants who consented and enrolled. Overall, prevalence of undiagnosed HIV was 0.76% (95% confidence interval [CI] = 0.30%, 1.56%). Three participants (0.32%; 95% CI = 0.09%, 0.86%) were nucleic acid-positive but antibody-negative and 4 (0.43%; 95% CI = 0.15%, 1.02%) were antibody-positive. CONCLUSIONS: Even when the absolute prevalence is low, a considerable proportion of undetected HIV cases in an ED population are acute. Identification of acute HIV in ED settings should receive increased priority.

Effect of an emergency department HIV testing program on the proportion of emergency department patients who have been tested.

OBJECTIVE: The lack of well-described population-level outcome measures for emergency department (ED) HIV testing is one barrier to translation of screening into practice. We demonstrate the impact of an ED diagnostic testing and targeted screening program on the proportion of ED patients ever tested for HIV and explore cumulative effects on testing rates over time. METHODS: Data were extracted from electronic HIV testing program records and administrative hospital databases for January 2003 to December 2008 to obtain the monthly number of ED visits and HIV tests. We calculated the proportions of (1) patients tested in the program who reported a previous HIV test or had been previously tested in the program, and (2) the cumulative number of unique ED patients who were tested in our program. RESULTS: During the study period, 165,665 unique patients made 491,552 ED visits and the program provided 13,509 tests to 11,503 unique patients. From 2003 to 2008, tested patients who reported a history of an HIV test increased by 0.085% per month (95% confidence interval [CI] 0.037% to 0.133%), from 67.7% to 74.4%; the percentage of tested patients who had previous testing in the program increased by 0.277% per month (95% CI 0.245% to 0.308%), from 3.2% to 21.2%; and the percentage of unique ED patients previously tested in the program increased by 0.100% per month (95% CI 0.096% to 0.105%), reaching a cumulative proportion of 6.9%. CONCLUSION: Our HIV testing program increased the proportion of ED patients who have been tested for HIV at least once and repeatedly tested a subset of individuals. HIV screening, even during a minority of ED visits, can have important cumulative effects over time.

Preliminary program evaluation of emergency department HIV prevention counseling.

OBJECTIVE: Controversy surrounds the linkage of prevention counseling with emergency department (ED)-based HIV testing. Further, the effectiveness and feasibility of prevention counseling in the ED setting is unknown. We investigate these issues by conducting a preliminarily exploration of several related aspects of our ED's HIV prevention counseling and testing program. METHODS: Our urban, academic ED provides formal client-centered prevention counseling in conjunction with HIV testing. Five descriptive, exploratory observations were conducted, involving surveys and analysis of electronic medical records and programmatic data focused on (1) patient perception and feasibility of prevention counseling in the ED, (2) patient perceptions of the need to link prevention counseling with testing, and (3) potential effectiveness of providing prevention counseling in conjunction with ED-based HIV testing. RESULTS: Of 110 ED patients surveyed after prevention counseling and testing, 98% believed privacy was adequate, and 97% reported that their questions were answered. Patients stated that counseling would lead to improved health (80%), behavioral changes (72%), follow-up testing (77%), and discussion with partners (74%). However, 89% would accept testing without counseling, 32% were willing to seek counseling elsewhere, and 26% preferred not to receive the counseling. Correct responses to a 16-question knowledge quiz increased by 1.6 after counseling (95% confidence interval 1.3 to 12.0). The program completed counseling for 97% of patients tested; however, 6% of patients had difficulty recalling the encounter and 13% denied received testing. Among patients undergoing repeated testing, there was no consistent change in self-reported risk behaviors. CONCLUSION: Participants in the ED prevention counseling and testing program considered counseling acceptable and useful, though not required. Given adequate resources, prevention counseling can be provided in the ED, but it is unlikely that all patients benefit.

Comparison of missed opportunities for earlier HIV diagnosis in 3 geographically proximate emergency departments.

OBJECTIVE: Differences in the prevalence of undiagnosed HIV between different types of emergency departments (EDs) are not well understood. We seek to define missed opportunities for HIV diagnosis within 3 geographically proximate EDs serving different patient populations in a single metropolitan area. METHODS: For an urban academic, an urban community, and a suburban community ED located within 10 miles of one another, we reviewed visit records for a cohort of patients who received a new diagnosis of HIV between July 1999 and June 2003. Missed opportunities for earlier HIV diagnosis were defined as ED visits in the year before diagnosis, during which there was no documented ED HIV testing offer or test. Outcomes were the number of missed opportunity visits and the number of patients with a missed opportunity for each ED. We secondarily reviewed medical records for missed opportunity encounters, using an extensive list of indications that might conceivably trigger testing. RESULTS: Among 276 patients with a new HIV diagnosis, 123 (44.5%) visited an ED in the year before diagnosis or received a diagnosis in the ED. The urban academic ED HIV testing program diagnosed 23 (8.3%) cases and offered testing to 24 (8.7%) patients who declined. Missed opportunities occurred during 187 visits made by 76 (27.5%) patients. These included 70 patients with 157 visits at the urban academic ED, 9 patients with 24 visits at the urban community ED, and 4 patients with 6 visits at the suburban community ED. Medical records were available for 172 of the 187 missed opportunity visits. Visits were characterized by the following potential testing indicators: HIV risk factors (58; 34%), related diagnosis indicating risk (7; 4%), AIDS-defining illness (8; 5%), physician suspicion of HIV (29; 17%), and nonspecific signs or symptoms of illness potentially consistent with HIV (126; 73%). CONCLUSION: Geographically proximate EDs differ in their opportunities for earlier HIV diagnosis, but all 3 sites had missed opportunities. Many ED patients with undiagnosed HIV have potential indications for testing documented even in the absence of a dedicated risk assessment, although most of these are nonspecific signs or symptoms of illness that may not be clinically useful selection criteria.

Risk, reasons for refusal, and impact of counseling on consent among ED patients declining HIV screening.

Screening for HIV in the emergency department (ED) is recommended by the Centers for Disease Control and Prevention. The relative importance of efforts to increase consent among those who currently decline screening is not well understood. We compared the risk characteristics reported by patients who decline risk-targeted, opt-in ED screening with those who consent. We secondarily recorded reasons for declining testing and reversal of the decision to decline testing after prevention counseling. Of 199 eligible patients, 106 consented to testing and 93 declined. Of those declining, 60 (64.5%) of 93 completed a risk assessment. There were no differences in HIV risk behaviors between groups. Declining patients reported recent testing in 73.3% of cases. After prevention counseling, 4 (6.7%) of 60 who initially declined asked to be tested. Given similarities between those who decline and those who consent to testing, efforts to increase consent may be beneficial. However, this should be tempered by the finding that many declined because of a recent negative test. Emphasizing risk during prevention counseling is not a promising strategy for improving opt-in consent rates.

Comparison of emergency department HIV testing data with visit or patient as the unit of analysis.

OBJECTIVES: Outcomes in an episodic care setting like an emergency department (ED) are traditionally evaluated in comparison with the number of visits as opposed to the number of unique patients, although patients commonly present to the ED multiple times. We examined the differences in HIV screening programme outcomes that would occur if the analysis were conducted at the patient-level, rather than the traditional visit-level. We hypothesized that while our ED-based HIV screening programme does test some patients repeatedly, the primary programme outcome of percent positive is not substantially altered by the unit of analysis. METHODS: We reviewed the clinical database of an ED HIV screening programme at a large, urban, teaching hospital in the United States from 2003-2007. Data were analyzed descriptively. The main outcome measure was the rate of positive test results computed with either the visit or the patient as the unit of analysis. RESULTS: HIV testing was provided at 9629 visits, representing 8450 unique patients. For patient-level analysis, the proportion of patients found to be positive was 0.91%. For visit-level analysis, the proportion of tests with positive results was 0.83%. Of the 910 patients with repeat testing, 7 (0.77%) were identified as positive at a repeat test. The median time between tests was 383 days (range 1-1742). CONCLUSIONS: Results changed little regardless of whether unique patients or unique visits were used as the unit of analysis. Any differences in positive rates were mitigated by the contribution of repeat testing to the identification of newly infected patients. Given these findings, and the difficulty of tracking repeat testing over time, visit-level analysis are appropriate for comparing programme outcomes when detailed modeling of epidemiology, cost, and/or outcomes is not required.

Contributions to early HIV diagnosis among patients linked to care vary by testing venue.

OBJECTIVE: Early HIV diagnosis reduces transmission and improves health outcomes; screening in non-traditional settings is increasingly advocated. We compared test venues by the number of new diagnoses successfully linked to the regional HIV treatment center and disease stage at diagnosis. METHODS: We conducted a retrospective cohort study using structured chart review of newly diagnosed HIV patients successfully referred to the region's only HIV treatment center from 1998 to 2003. Demographics, testing indication, risk profile, and initial CD4 count were recorded. RESULTS: There were 277 newly diagnosed patients meeting study criteria. Mean age was 33 years, 77% were male, and 46% were African-American. Median CD4 at diagnosis was 324. Diagnoses were earlier via partner testing at the HIV treatment center (N = 8, median CD4 648, p = 0.008) and with universal screening by the blood bank, military, and insurance companies (N = 13, median CD4 483, p = 0.05) than at other venues. Targeted testing by health care and public health entities based on patient request, risk profile, or patient condition lead to later diagnosis. CONCLUSION: Test venues varied by the number of new diagnoses made and the stage of illness at diagnosis. To improve the rate of early diagnosis, scarce resources should be allocated to maximize the number of new diagnoses at screening venues where diagnoses are more likely to be early or alter testing strategies at test venues where diagnoses are traditionally made late. Efforts to improve early diagnosis should be coordinated longitudinally on a regional basis according to this conceptual paradigm.

A novel emergency department based prevention intervention program for people living with HIV: evaluation of early experiences.

BACKGROUND: HIV prevention is increasingly focused on people living with HIV (PLWH) and the role of healthcare settings in prevention. Emergency Departments (EDs) frequently care for PLWH, but do not typically endorse a prevention mission. We conducted a pilot exploratory evaluation of the first reported ED program to address the prevention needs of PLWH. METHODS: This retrospective observational cohort evaluation reviewed program records to describe the first six months of participants and programmatic operation. Trained counselors provided a risk assessment and counseling intervention combined with three linkage interventions: i) linkage to health care, ii) linkage to case management, and iii) linkage to partner counseling and referral. RESULTS: Of 81 self-identified PLWH who were approached, 55 initially agreed to participate. Of those completing risk assessment, 17/53 (32%, 95 CI 20% to 46%) reported unprotected anal/vaginal intercourse or needle sharing in the past six months with a partner presumed to be HIV negative. Counseling was provided to 52/53 (98%). For those requesting services, 11/15 (73%) were linked to healthcare, 4/23 (17%) were coordinated with case management, and 1/4 (25%) completed partner counseling and referral. CONCLUSION: Given base resources of trained counselors, it was feasible to implement a program to address the prevention needs for persons living with HIV in an urban ED. ED patients with HIV often have unmet needs which might be addressed by improved linkage with existing community resources. Healthcare and prevention barriers for PLWH may be attenuated if EDs were to incorporate CDC recommended prevention measures for healthcare providers.

Emergency department HIV testing and counseling: an ongoing experience in a low-prevalence area.

STUDY OBJECTIVE: Despite recommendations, emergency department (ED)-based HIV screening is not widespread, and feasibility studies are generally limited to settings with high HIV prevalence (>1%). This investigation was to evaluate an ongoing, publicly funded, ED-based HIV counseling and testing program in a low-prevalence area. METHODS: We reviewed a database of patients treated by an ED-based HIV counseling and testing program at a large, urban, teaching hospital for 1998 to 2002. ED patients at risk for HIV were targeted for standard serologic testing and counseling. Data were collected prospectively using standardized forms as part of clinical operations rather than in the context of rigorous research methodology; patient-oriented outcomes were not assessed. Counselors were trained according to Centers for Disease Control and Prevention guidelines, and health department guidelines for counseling and testing centers were followed. The main outcome measure was the number and proportion of patients newly diagnosed with HIV. RESULTS: Eight thousand five hundred seventy-four patients were approached; 5,504 consented to HIV testing. Mean age was 29 years (SD 9.4 years), 76% were black, and 50% were men. Five thousand three hundred seventy-four (97.6%) patients tested negative and 39 (0.7%) patients tested positive. Seventy-five percent of negative-test patients and 79% of positive-test patients were notified of test results. Information for seropositive patients not notified of results was forwarded to the health department. All notified HIV-positive patients entered treatment. Risk factors included sexually transmitted disease (47%), multiple sexual partners (40%), unprotected sex while using drugs or alcohol (30%), men having sex with men (5%), and intravenous drug use (4%). CONCLUSION: Identification of HIV-positive patients is possible in low-prevalence ED settings. In this instance, it was possible to perpetuate an ED-based HIV intervention program during an extended time. Although our work expands the profile of ED-based HIV counseling and testing beyond previous reports, the results should not be overgeneralized.

Health department collaboration with emergency departments as a model for public health programs among at-risk populations.

OBJECTIVES: Accessing at-risk and underserved populations for intervention remains a major obstacle for public health programs. Emergency departments (EDs) care for patients not otherwise interacting with the health care system, and represent a venue for such programs. A variety of perceived and actual barriers inhibit widespread implementation of ED-based public health programs. Collaboration between local health departments and EDs may overcome such barriers. The goal of this study was to assess the effectiveness of a health department-funded, ED-based public health program in comparison with other similar community-based programs through analysis of data reported by health department-funded HIV counseling and testing centers in one Ohio county. METHOD: Data for HIV counseling and testing at publicly funded sites in southwestern Ohio from January 1999 through December 2002 were obtained from the Ohio Department of Health. Demographic and risk-factor profiles were compared between the counseling and testing program located in the ED of a large, urban teaching hospital and the other publicly funded centers in the same county. RESULTS: A total of 26,382 patients were counseled and tested; 5,232 were ED patients, and 21,150 were from community sites. HIV positivity was 0.86% (95% confidence interval [CI] 0.64%, 1.15%) in the ED and 0.65% (95% CI 0.55%, 0.77%) elsewhere. The ED program accounted for 19.8% of all tests and 24.7% of all positive results. The ED notified 77.3% of individuals testing positive and 84.4% of individuals testing negative. At community program centers, 88.3% of patients testing positive and 63.8% of patients testing negative were notified of results. All ED patients notified of positive status were successfully referred to infectious disease specialists. CONCLUSIONS: Public health programs can operate effectively in the ED. EDs should have a rapidly expanding role in the national public health system.

Emergency department pelvic examination and Pap testing: addressing patient misperceptions.

OBJECTIVES: Failure to obtain cervical cancer screening can be precipitated by limited knowledge. This study describes understanding of Papanicolaou (Pap) smear testing among women undergoing emergency department (ED) pelvic examination and tests the feasibility of educating patients in the ED. METHODS: Patients undergoing pelvic examination in an urban, tertiary care ED were surveyed about Pap smear screening. Among the initial cohort, no education was provided prior to survey administration. Subsequently, a pilot study of scripted information provided by physicians alone or both physicians and counselors was conducted. RESULTS: There were 81 patients in the non-intervention cohort and 32 patients in the intervention cohort. Of the 32 intervention patients, 16 received physician-administered intervention, and 16 received reinforced counseling (physician + counselor). Of 113 total patients, 90 (82%) were African American; mean age was 26 years (SD +/- 7.7 years). Of the 81 non-intervention patients, six (7%; 95% CI = 3% to 15%) said they were told that a Pap test was not done, and 60 (74%; 95% CI = 64% to 82%) mistakenly believed they had a Pap test. Sixty-six (81.5%; 95% CI = 72% to 88%) patients stated they knew the purpose of a Pap test; only 17 (26%; 95% CI = 17% to 37%) of these correctly identified the Pap test as a test for cervical cancer. All 32 intervention patients were surveyed after physician counseling. Compared with the non-intervention group, fewer (56%; 95% CI = 39% to 72%) thought they had a Pap test, and more (31%; 95% CI = 18% to 49%) said they were told they did not receive a Pap test. All 16 reinforced intervention patients correctly denied receiving a Pap test after counselor education. CONCLUSIONS: Knowledge of Pap testing among women undergoing ED pelvic examination is poor; most mistakenly believe they receive a Pap test during ED evaluation. Educating patients may be feasible and effective in the ED setting.

Randomized comparison of universal and targeted HIV screening in the emergency department.

OBJECTIVE: Universal HIV screening is recommended but challenging to implement. Selectively targeting those at risk is thought to miss cases, but previous studies are limited by narrow risk criteria, incomplete implementation, and absence of direct comparisons. We hypothesized that targeted HIV screening, when fully implemented and using maximally broad risk criteria, could detect nearly as many cases as universal screening with many fewer tests. METHODS: This single-center cluster-randomized trial compared universal and targeted patient selection for HIV screening in a lower prevalence urban emergency department. Patients were excluded for age (<18 and >64 years), known HIV infection, or previous approach for HIV testing that day. Targeted screening was offered for any risk indicator identified from charts, staff referral, or self-disclosure. Universal screening was offered regardless of risk. Baseline seroprevalence was estimated from consecutive deidentified blood samples. RESULTS: There were 9572 eligible visits during which the patient was approached. For universal screening, 40.8% (1915/4692) consented with 6 being newly diagnosed [0.31%, 95% confidence interval (CI): 0.13% to 0.65%]. For targeted screening, 37% (1813/4880) had no testing indication. Of the 3067 remaining, 47.4% (1454) consented with 3 being newly diagnosed (0.22%, 95% CI: 0.06% to 0.55%). Estimated seroprevalence was 0.36% (95% CI: 0.16% to 0.70%). Targeted screening had a higher proportion consenting (47.4% vs. 40.8%, P < 0.002), but a lower proportion of ED encounters with testing (29.7% vs. 40.7%, P < 0.002). CONCLUSIONS: Targeted screening, even when fully implemented with maximally permissive selection, offered no important increase in positivity rate or decrease in tests performed. Universal screening diagnosed more cases, because more were tested, despite a modestly lower consent rate.

Relationship of self-reported prior testing history to undiagnosed HIV positivity and HIV risk.

Screening everyone for HIV at least once is estimated to be cost-effective. Screening in health care settings is recommended to help achieve that goal. Health care settings often encounter the same patient repeatedly, and it is unknown if limited resources are better allocated to conduct repeat screening, or to screen patients not yet tested. We reviewed data for a targeted ED based HIV screening program for 2003-2007. The role of prior testing history as a predictor of undiagnosed HIV positivity was assessed using a negative binomial model adjusted for demographics and risk behaviors. HIV testing was provided to 8,450 unique patients. There were 5,781 (70%) self-reporting a prior HIV test. Compared with patients reporting no prior test, the relative risk of HIV positivity for those reporting a test within the prior year was 0.90 (95%CI 0.48-1.66), and for those reporting a prior test more than a year previously the relative risk was 0.91 (95%CI 0.48-1.73). Among patients testing positive, those who did not report a prior test had a median CD4 count that was 228 cells/mm(3) lower than those with a prior test (CI(95) of the difference in medians 20-436 cells/mm(3)). Diagnosis of prevalent HIV among those who are at risk but have never been tested should be a priority. However, repeat screening of target populations for incident infection remains important and results in earlier diagnosis. Recent self-reported testing history is not associated with undiagnosed positivity among targeted patients irrespective of the timing of the prior test.