key: cord-0009283-zg3g85cn
authors: Sweeney, M. Monica
title: Perspective from the NYC Assistant Commissioner of the Department of Health
date: 2011-06-17
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2011.03.045
sha: b8925aee9b3f56260288f385f557e37eff0f60e7
doc_id: 9283
cord_uid: zg3g85cn

nan

[Ann Emerg Med. 2011;58:S174-S175.]

With more than 105,000 persons living with HIV/AIDS, New York City has the largest, most complex HIV/AIDS epidemic in the United States. One quarter of individuals who are HIV positive do not know they are infected. Emergency departments (EDs) have become an important venue for HIV testing. In urban areas with higher levels of poverty, a population that is disproportionately affected by HIV commonly uses EDs for primary care. The percentage of patients presenting to the ED in the inner city with undiagnosed HIV, who have no other source of health care, is high. 1 The number of people using EDs as their primary source of medical care continues unchecked for various reasons, ranging from lack of access to primary care, convenient schedules of operation (usually 24 hours), the ability to be treated whether uninsured or underinsured, and, although not often studied, the anonymity often characteristic of ED care.

Why should EDs get involved in HIV screening when riskbased testing proved effective in the 1980s and the 1990s, a time when hundreds of thousands of people infected with HIV were identified? Indeed, this approach helped effectively identify the majority of HIV-infected persons in the United States. Now, the risk-based approach has become a victim of its own success. As efficient as it was in finding persons from traditional risk groups, it ignored those outside this standard Centers for Disease Control and Prevention (CDC)-defined hierarchy of men who have sex with men, needle-sharing partners, and highrisk heterosexuals.

As conscientious practitioners, we understand why people should know their HIV status. But why should EDs (that typically focus on urgent, not preventive, care) be involved in HIV screening? In 2006, the CDC recommended expanding HIV testing to make it a routine part of medical care in all health care settings. The goal of this generalized approach is to help find HIVpositive persons outside the common risk-behavior groups and reduce the stigma associated with HIV testing.

One innovation that should have made voluntary HIV testing routine was the advent of rapid HIV testing technology as an oral (buccal swab) test or as a fingerstick blood or serum test. The most useful and practical aspect of this technology is that test results are available in 20 minutes or less. No ED visit has a cycle time of 30 minutes, or even an hour.

If a hospital decides that counseling and testing with a rapid test interferes with patient flow, one option to consider is a conventional test with a Food and Drug Administration (FDA)approved random access assay. These integrated systems, already in place at many hospitals, allow laboratories to run HIV and other routine tests on a single testing platform. The ADVIA Centaur produces an enzyme immunoassay result in an hour, 2 and a second FDA-approved random-access enzyme immunoassay, the Ortho Vitros, is now available. First, the health care facility has to make the decision that it has a duty to screen for HIV to the patients presenting for care. Then the details will follow.

What are physicians being called on to do? The aphorism "first, do no harm" is not always possible when patients are treated. My preferred physician's oath-I will practice my profession with conscience and dignity; the health of my patient will be my first consideration-is perhaps more realistic. From my years of practicing medicine, including teaching medical students and house staff, I have encountered very few who have not expressed the ideal of placing their patient's health as their first priority. However, the reality of everyday demands prevents too many emergency physicians from adopting evidence-based national guidelines to screen all ED patients for HIV. As one director of a successful ED testing program in a New York Health and Hospitals Corporation facility pointed out, "Emergency physicians always give a tetanus shot after every laceration. Yet, what are the chances of acquiring tetanus in New York City compared to the chance of acquiring HIV?"

We must find the people driving this epidemic. Patient acceptability of HIV testing in the ED was demonstrated by Project B.R.I.E.F., 3 an innovative, award-winning, multimedia HIV testing system in an urban ED, which showed 99% patient satisfaction with HIV testing in the ED. During the past 3.5 years, Project B.R.I.E.F. has tested more than 40,000 people aged 13 to 79 years for HIV while they waited to be treated by a health care provider and has obtained consent for testing from 95% of eligible patients. This example is a model program that can be adopted or modified to make HIV screening a routine part of ED care. The success of Project B.R.I.E.F. can be attributed to having a champion, funding, and established collaboration for immediate linkage to care. S174 Annals of Emergency Medicine Volume , .  : July  Walensky et al 4 clearly demonstrated that, of the 6 chronic disease states described, ranging from comprehensive care after an acute myocardial infarction to antiretroviral therapy for AIDS, the intervention that produced the greatest survival benefit was antiretroviral therapy. But in every ED, a patient presenting with symptoms or signs of an acute myocardial infarction is sent to the head of the line. The comparison of the per-person survival benefit (50 months for comprehensive postmyocardial infarction care) with the survival benefits of antiretroviral therapy treatment (160 months) makes it obvious that missing an opportunity to diagnose HIV may ultimately have more influence than missing the diagnosis of a myocardial infarction, even before consideration of subsequent transmissions averted.

Despite the simplicity and logic of the premise, the articles in this special volume of Annals demonstrate that many obstacles remain that prevent implementation of testing in EDs. The traditional goals of EDs-rapid, intelligent triage and management-do not easily align with the public health ambition of identifying undiagnosed individuals to prevent the subsequent transmission of HIV. Perhaps if the effect were instantaneous, as with the need to identify cases of severe acute respiratory syndrome or influenza, implementation would be easier to accomplish. However, the public health goal of testing of an individual for HIV who has no discernable symptoms of the infection is to prevent a transmission that may occur in a week, a month, or a year. For some physicians, that removes the sense of urgency to screen. So many of our targeted testing efforts are insufficient; testing in jails, prisons, homeless shelters, and drug treatment centers, and testing men who have sex with men all continue to identify cases, but the epidemic continues unchecked. Late testers can transmit HIV for many years before they learn they are infected. Now is the time. Almost 4 years after the most recent CDC guidelines were issued, efforts to mount a broadscale national HIV testing program have yet to succeed.

Provisions to make HIV testing a routine part of medical care in all health care settings must be instituted. First, the culture surrounding HIV/AIDS, making it different from other medical and chronic disease states, must change. Second, many of the laws and regulations that may have been necessary and served us well in the beginning of the epidemic are now barriers to early diagnoses and treatment. Separate written consent laws that still exist in 7 states as this article goes to press serve as one barrier to making HIV testing a routine part of medical care. Mandatory pre-/posttest counseling laws must be eliminated. Many physicians think they need special certification before they can counsel patients or give them their test results. 5 This is not the case. It is no wonder that so many physicians forget to screen for HIV or neglect to include it in their list of differential diagnoses.

Third, but certainly not the least important, is the reimbursement structure. Medicare has now extended coverage for HIV testing to its recipients, and Medicaid pays for testing in many states, as do private insurers. These modifications cover a large number of people presenting to the ED. According to the experience in New York State, funding alone will not change the testing paradigm. In New York, HIV testing in EDs has been adequately reimbursed for many years; still, routine screening has not been widely adopted. For individuals who are uninsured, HIV screening should be covered the same way the rest of their care will be covered: bad debt and charity, grants, etc. In one survey presented in this special supplement, 90.7% of the hospitals with organized testing in the ED had external funding compared with only 14.4% of EDs with no external funding for HIV testing. 6 Funding should be used to establish an organized HIV testing program or to adapt a turnkey testing model that is evidence based, as well as one that has been tested. Once a testing program is established, HIV screening should be billed as a routine part of medical care.

Unless we change the culture of HIV care by changing legislation, modernizing regulations, and providing funding to organize testing programs, we will continue to prolong the longest epidemic in the history of the United States. What ED directors need to realize is that we do not have to build it; they already come.

We just have to screen our patients once they are there.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist.

High-volume rapid HIV testing in an urban emergency department

Behavior Intervention, Rapid HIV Test, Innovative Video, Efficient Cost and Healthcare Savings, and Facilitated Seamless Linkage to Outpatient HIV Care)

The survival benefits of AIDS treatment in the United States

Assessment of emergency department healthcare professionals' behaviors regarding HIV testing and referral for patients with STDs

US emergency department testing practices