Routine Opt-out Screening in Emergency Rooms Identifies Few Additional People with HIV

Routine opt-out HIV screening in an urban emergency department -- testing not targeted specifically to people thought to be at risk -- identified only a "modest" number of additional cases compared with standard diagnostic testing, according to a U.S. study reported in the July 21, 2010 Journal of the American Medical Association (JAMA) HIV/AIDS theme issue, released to coincide with the XVIII International AIDS Conference (AIDS 2010) last month in Vienna. Most of the additional people found to be infected had late-stage disease, suggesting that a better method is needed to identify HIV positive individuals sooner so they can benefit from timely care.

Below is a media advisory from JAMA and Archives Journals describing the research.

Routine Emergency Department HIV Screening Associated With Only Small Increase in Number of Patients Newly Diagnosed With HIV

Vienna -- July 18, 2010 -- The use of routine HIV screening in a hospital emergency department, which patients had the option to decline, was associated with only a modest increase in the number of patients with newly diagnosed HIV infection, compared to physician-directed diagnostic rapid HIV testing, according to a study in the July 21 issue of JAMA, a theme issue on HIV/AIDS.

Jason S. Haukoos, MD, of the Denver Health Medical Center, Denver, presented the findings of the study at a JAMA media briefing at the International AIDS conference in Vienna.

Infection with the human immunodeficiency virus (HIV) remains an important public health problem in the United States, with more than 1 million people estimated to be infected, and approximately 230,000 infections being undiagnosed. Additionally, approximately 56,000 people are newly infected each year, according to background information in the article. Testing for HIV infection remains an important preventive strategy, and in 2006, the Centers for Disease Control and Prevention (CDC) published revised guidelines for performing HIV testing in health care settings, recommending widespread routine (non-targeted) opt-out (the option to decline) HIV screening in settings where the prevalence of undiagnosed infection was 0.1 percent or greater.

Emergency departments (EDs) have been an important focus for HIV prevention efforts, including testing and screening initiatives, and since 2006, efforts to integrate non-targeted HIV screening into EDs have increased, although limited research supports this practice, and it remains unknown if non-targeted opt-out HIV screening, when incorporated into an ED setting, is associated with the identification of patients with HIV infection as a prevention strategy, the authors write.

Dr. Haukoos and colleagues conducted a study to determine whether non-targeted opt-out rapid HIV screening in a high-volume ED was associated with identification of more patients with newly diagnosed HIV infection than physician-directed diagnostic rapid HIV testing. The study included an urban hospital with an approximate annual ED census of 55,000 patient visits. Patients were 16 years or older and capable of providing consent for rapid HIV testing. The interventions included non-targeted opt-out rapid HIV screening and physician-directed diagnostic rapid HIV testing alternated in sequential 4-month time intervals between April 2007 and April 2009.

Of the 28,043 eligible patients included in the opt-out phase, 6,933 patients (25 percent) completed HIV testing (6,702 patients were screened; 231 patients were diagnostically tested). Of the 6,702 patients screened, 10 patients (0.15 percent) had new HIV diagnoses. Of the remaining 21,281 patients who opted out or were opted out by registration personnel, 231 (1 percent) subsequently underwent diagnostic testing and 5 patients (2.2 percent) had new diagnoses.

Of the 29,925 eligible patients included in the diagnostic phase, 243 patients (0.8 percent) underwent testing and 4 patients (1.6 percent) had new diagnoses. The overall prevalence of newly detected HIV infection during the opt-out phase (including those diagnostically tested) and during the diagnostic phase was 15 in 28,043 (0.05 percent) and 4 in 29,925 (0.01 percent), respectively.

The authors found that non-targeted opt-out screening was associated with newly identified HIV-infected patients. Most of these patients were identified late in the course of disease and met serological criteria for acquired immunodeficiency syndrome (AIDS) at the time of their diagnoses.

"Non-targeted opt-out rapid HIV screening in conjunction with diagnostic testing was associated with approximately 30 times the number of rapid HIV tests performed, yet only a few more patients were newly identified with HIV infection when compared with diagnostic testing alone," the authors write.

Editorial: HIV Screening in Health Care Settings -- Some Progress, Even More Questions

Roland C. Merchant, MD, MPH, ScD, and Michael J. Waxman, MD, of the Warren Alpert Medical School of Brown University, Providence, RI, write in an accompanying editorial that "the optimal models for HIV screening in health care settings are not yet known and most likely will not be a one-size-fits-all approach."

"Research is needed to determine who should initiate screening, as well as how, and when screening should be conducted during medical care. The current CDC recommendations might not be the optimal methods for all settings, but they offer suggestions from which models can be tailored to a setting's and patients' needs. New tools are available for HIV testing; it is up to clinicians to use them and find those that work best. The next greatest challenge will be to identify which HIV screening models are most effective and efficient and can be self-sustaining after research funding has been removed."

Investigators affiliations: Departments of Emergency Medicine, Clinical Social Work, Health Services Research, and Pathology, Denver Health Medical Center, Denver, CO; University of Colorado School of Medicine, Aurora, CO; Departments of Epidemiology and Health Systems Management and Policy, Colorado School of Public Health, Aurora, CO; Department of Health and Behavioral Sciences, University of Colorado, Denver, CO; Denver Public Health, Denver, CO; Division of HIV/AIDS Prevention, CDC, Atlanta, GA; Children's Immunodeficiency Program, Children's Hospital, Aurora, CO; University of Colorado HIV/AIDS Clinical Program, University of Colorado Hospital, Aurora, CO.

8/10/10

References

JS Haukoos, E Hopkins, AA Conroy, and others (Denver Emergency Department HIV Opt-Out Study Group). Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients. JAMA 304(3): 284-292 (Abstract). July 21, 2010.

RC Merchant and MJ Waxman. HIV screening in health care settings: some progress, even more questions. JAMA 304(3): 348-349. July 21, 2010.

Other Source
JAMA and Archives Journals. Routine Emergency Department HIV Screening Associated With Only Small Increase in Number of Patients Newly Diagnosed With HIV. Media advisory. July 18, 2010.