Of the more than 1 million HIV-positive patients in the United States, approximately 21% are undiagnosed, as more than 50,000 new infections occur annually. The emergency department is recognized as an important point of access to HIV testing for many patients.
In 2006, the Centers for Disease Control and Prevention recommended that HIV testing be incorporated into routine medical care, including emergency care and, in 2007, the American College of Emergency Physicians agreed, saying in a policy statement that HIV testing in the emergency department "should be available in an expeditious and efficient fashion similar to testing and results for other conditions."
Although HIV testing in EDs has become more common since the CDC and ACEP recommendations were made, controversies about and obstacles to such testing remain.
Perceptions of Testing
In a 2007 study of the perceived benefits and disadvantages of HIV testing in the ED, researchers did a structured evaluation of opinions gathered from 98 experts from 42 institutions who attended the 2007 conference of the National Emergency Department HIV Testing Consortium in Baltimore (Ann. Emerg. Med. 2011;58:S151-9).
The expert opinions were organized using a subjective analytic planning tool called SWOT (strengths, weaknesses, opportunities, threats) by the researchers, led by Aleksandar Kecojevic of Johns Hopkins University, Baltimore.
The identified strengths of HIV testing in the ED were the high volume of ED visits (110 million annually) and the high prevalence of HIV in the ED patient population (cited by 19.6% of the experts). Access to an underserved patient population was cited by 16.1%. Other strengths included the availability of testing around the clock (11.7%) and the chance for earlier diagnosis (8.1%).
A total of 23.2% of the experts identified the additional strain on ED staff and resources as the biggest weakness of the approach. Inadequate privacy for testing in the ED was mentioned by 13%.
The opportunity to reduce the stigma of HIV was cited by 26.8% of the experts and better surveillance of disease rates and transmission networks by 18.4%. The threat category included lack of funding and other resources (44%), and diversion of resources and staff from the emergency department’s primary mission of acute care (13.4%).
Increasing Rates of Testing
Despite the barriers to HIV testing in EDs, the rates have increased substantially since the testing recommendations were published.
A 1996 survey found that about 50% of academic EDs tested for HIV after suspected exposure. In 2006, a survey found that a similar 57% of academic EDs did some rapid HIV testing, but only 4% did so routinely. Only 3 years later, in 2009, a cross-sectional survey of medical providers by Dr. Richard E. Rothman and his colleagues found that 82% of EDs conducted HIV testing (Ann. Emerg. Med. 2011;58[suppl]:S3-9).
However, only 22% did so as part of a routine HIV testing program, and 18% did no testing at all, according to Dr. Rothman of Johns Hopkins University, Baltimore, and his coinvestigators.
The survey included 338 academic, nonacademic, and community hospitals from urban and rural areas across the country. Survey respondents included ED directors and chairs, HIV program directors, nurses, and ED social workers.
Of the 22% of EDs that reported routine HIV screening, 85% were in urban areas and 65% were in academic hospitals. Most of the 18% that did no testing were small community hospitals. Of large hospitals with more than 100,000 visits a year, 91% offered HIV testing and more than half had routine HIV testing programs. More than 80% of the screening programs had been in place for less than 3 years, and about a third had existed for less than a year.
"These results represent a recent increase in the availability of HIV testing in U.S. EDs and a steady increase in HIV screening," Dr. Rothman and his colleagues concluded.
Overall, EDs in academic hospitals implement HIV testing at a higher rate than do those in community hospitals, according to a 2007 cross-sectional survey by Dr. Jason S. Haukoos and his colleagues, which found significant differences in testing rates (Ann. Emerg. Med. 2011;58[suppl]:S10-16).
Their survey included ED administrators, emergency physicians, and other health care staff at 99 academic EDs and 150 community institutions. They found that 65% of academic EDs offered testing, compared with 50% of community hospitals; more academic institutions tested without charging patients (34% vs. 7%) and received funding for testing (15% vs. 2%), said Dr. Haukoos of Denver Health Medical Center and his colleagues.
Diagnostic testing was offered most widely (73% of academic EDs, 63% of community EDs). Nontargeted screening was performed at 16% of academic institutions, compared with only 5% of community EDs.