OutBox

HIV Testing in the ED

By Gretchen Williams Torres

Emergency departments are fertile ground for testing high volumes of diverse patients

The Centers for Disease Control and Prevention recommends that all health care providers offer voluntary HIV screening for patients 13 to 64 years old. The goal of diagnosing and linking to care the estimated 250,000 to 300,000 people who are unaware of their HIV infection drives this bold recommendation.

People with HIV infection visit health care settings years before receiving a diagnosis, but are not tested for HIV. This is alarming, especially as the demographics of the epidemic change. An increasing number of new HIV infections are among people less 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.

Emergency departments are potentially fertile grounds for testing high volumes of diverse patient populations and reaching those without a regular source of care. Some urban EDs have found HIV in 2 percent to 17 percent of their patient populations and 1 percent to 5 percent undetected infections. Analysts project that widespread HIV screening would be cost-effective in all but the lowest prevalence settings.

Currently, testing for HIV occurs in many EDs but is limited to cases of occupational exposure or at the provider’s discretion based on clinical presentation or other risk factors. To date, programs of widespread screening for HIV in EDs are nonexistent, even for high-risk patients, such as those with sexually transmitted diseases. However, many busy urban EDs have found that HIV testing is feasible.

For example, University Hospital, Cincinnati, and George Washington University Hospital, Washington, D.C., have implemented ED programs to identify HIV-positive patients. Both hospitals work with local health departments, which provide funding, standard and rapid HIV test kits, and train-the-trainer counseling.

Rapid HIV tests, which became available in the last few years, make it possible to perform HIV tests and deliver results within a single medical encounter, eliminating the need for follow-up visits. The expected benefit from HIV testing is large enough that federal and state HIV prevention dollars are seeding testing in many EDs, and some payers are exploring the impact of covering HIV testing as a preventive screening rather than just a diagnostic tool.

But, is there a case to be made for expanded HIV testing in the ED? People unaware of their HIV infection are more likely than those who know to transmit the virus to others—about 3.5 times more likely. This is because people who know their HIV status either change their risky behavior or their highly active antiretroviral therapies keep their viral loads sufficiently low. Early diagnosis of HIV infection can improve quality of life for those infected, link patients with HIV to appropriate preventive and specialty care—thus limiting the number of recurring ED visits to treat undiagnosed, opportunistic infections—and help prevent further transmission. Is there a case to be made for your ED to test patients for HIV?—To access HIV Testing in Emergency Departments: A Practical Guide, go to http://edhivtestguide.org.

Gretchen Williams Torres, M.P.P., is director of research at the Health Research & Educational Trust.

You can contact our guest author at gtorres@aha.org

This article 1st appeared in the March 2008 issue of HHN Magazine.

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