"There remain substantial differences related to HIV testing between academic and community institutions, and a substantial proportion of institutions still do not provide some form of HIV testing," the authors said.
Staffing for Testing Programs
Having enough personnel with the right training is the key to implementing any HIV testing program in the ED. The Universal Screening for HIV Infection in the Emergency Room (USHER) trial compared HIV testing offered by supplemental HIV counselors to testing offered by ED providers. The objective of the trial was to determine whether testing rates were higher when offered by existing ED providers or by additional staff such as counselors and social workers (Ann. Emerg. Med. 2011;58[suppl]:S126-132).
"Routine, voluntary HIV testing was completed more than twice as frequently when personnel were dedicated specifically to this task," reported Dr. Rochelle P. Walensky of Massachusetts General Hospital, Boston, and her colleagues.
In this 2007-2008 randomized controlled trial, 2,446 ED patients were randomized to the counselor arm and 2,409 to the ED provider arm. A total of 80% of patients in the counselor arm were offered testing vs. 36% of those in the provider arm. In the provider arm, the offer rate declined with increasing age of the patient and declined over the course of the study (from 76% at 2 months to 25% at 17 months). "Testing attrition over time [in the provider arm] may be due to waning enthusiasm for the program in the face of patient acuity and other clinical duties," Dr. Walensky and her coauthors suggested.
A comparable proportion of patients accepted testing when it was offered (71% in the counselor arm and 75% in the provider arm), for an overall testing rate of 57% in the counselor arm and 27% in the provider arm.
"Although HIV counselor time certainly costs less than that of ED providers, the cost of additional trained personnel is not trivial." However, "without such resources, rapid HIV testing in this setting is most likely diagnostic and not truly routine," they concluded.
In another 2007-2008 study of six EDs that had HIV screening programs in place for at least 6 months, Gretchen Williams Torres and her coinvestigators found that "several sites had 1 or more staff individuals, generally an emergency physician or nurse, who took ownership of the screening program" (Ann. Emerg. Med. 2011;58[suppl]:S104-13).
Testing was done by supplemental staff at four hospitals and by existing ED staff at two. Costs were higher at the two EDs in which supplemental staff was used to implement the programs, at $10,200-$12,300, compared with $3,400-$8,600 when ED providers added it to their tasks, wrote Ms. Torres of the University of Chicago and her coauthors.
The six study institutions were a public hospital and a for-profit hospital in the South, two nonprofits in the Midwest, a public hospital in the West, and a public hospital in the Northeast. All were teaching hospitals, with a median of 37.5 ED beds. Two of the EDs did targeted screening of higher-risk patients, three screened some patients regardless of risk, and one screened all patients (universal screening).
Yet "none of the EDs were able to test more than 10% of the patients presenting for care," with a median of 4.7% of patients tested. EDs with targeted programs tested 2%-3% of their patients, those with nontargeted programs tested 5%-8%, and the hospital with universal screening tested 7% (while that institution offered screening to 97% of its patients, most declined the test).
In a report of a 2009 pilot program at an urban academic ED, the investigators found that the success of the program was dependent on "a core group of coordinators, involvement and support from administration, and broad buy-in from faculty and staff," including "ED technicians, nurses, and physician extenders and emergency physicians" (Ann. Emerg. Med. 2011;58[suppl]:S44-8).
The program required a commitment from staff to perform the tasks necessary "for patient recruitment, specimen collection and processing, result notification, posttest counseling, and data entry," said Dr. Bryn E. Mumma of the University of Pittsburgh and her colleagues.
"Finding someone with time to enroll patients and collect the OraSure specimen without compromising patient care or ED flow was the most significant barrier to universal screening in our pilot program," they said.
Providing HIV screening in the ED setting serves a hard-to-reach population, and much progress has been made in adding routine HIV testing to ED visits. However, the lack of available dedicated staff, inadequate funding, and other obstacles will continue to hamper future efforts.
Mr. Kecojevic had no disclosures. Dr. Rothman received funding from the Maryland Department of Health and Mental Hygiene. Dr. Haukoos received an award from the Agency for Healthcare Research and Quality, support from the CDC, and an unrestricted grant from Abbott Laboratories. Dr. Walensky received the Doris Duke Charitable Foundation Clinical Scientist Development Award, and her study had support from the National Institute of Mental Health. Ms. Torres’ study was funding by the CDC and the Health Research and Educational Trust of the American Hospital Association. The Allegheny County Health Department provided the OraSure tests and processing for Dr. Mumma’s study.