key: cord-1003888-4t9wz4x5
authors: Safeek, Rachel; Hill, Tamsey; Hendricks, Arthur; Underwood, David; Washington, Mary; Guidici, Jessica; Wong, Tammy; Gerardo, Charles; Hicks, Charles; McKellar, Mehri
title: Testing for HIV infection in the emergency departments of 2 hospitals in the Southeastern United States
date: 2020-05-26
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12102
sha: 695aaf0053be8d07a51aecb9dec469175824384e
doc_id: 1003888
cord_uid: 4t9wz4x5

BACKGROUND: In 2006, the Centers for Disease Control and Prevention (CDC) recommended non‐targeted, opt‐out HIV screening in all healthcare settings, including emergency departments (EDs). Multiple HIV testing programs have been implemented in EDs across the United States with varying designs and testing platforms. We report findings from a free, non‐targeted, rapid HIV testing program in 2 EDs in the Southeastern United States. METHODS: From 2008 to 2012, adults ≥18 years of age were offered free rapid HIV testing using an oral swab test (OraQuick ADVANCE Rapid HIV‐1/2 antibody test) in the EDs of a large academic medical center and an affiliated community hospital in Durham, North Carolina. RESULTS: In total, 5443 ED patients were offered HIV testing. The overall acceptance rate was 66.9% (3639/5443). Younger persons were significantly more likely to accept testing (78.2% for 18–29 years old vs 67.1% for ≥30 years old; P < 0.001) as were Black participants (72.6% Black vs 66.5% White; P < 0.001). Acceptance rates improved significantly after opt‐out oral consent replaced written consent (71.3% vs 63.1%; P < 0.001). Seven new HIV diagnoses were confirmed during the testing program, resulting in a seropositivity rate of 0.19% (7/3639). There were 8 false–positive rapid oral HIV tests (positive predictive value = 46.7%). CONCLUSIONS: Although the number of new HIV diagnoses was low, implementation of this rapid, non‐targeted ED screening program was feasible with high acceptance rates, particularly after introducing the opt‐out oral consent approach.

Testing for HIV infection in emergency departments appears to be a relatively high yield strategy, in part because the population seen in EDs includes those at higher risk for HIV (racial and ethnic minorities, socio-economically disadvantaged persons, and young people). 1 4, 5 This is largely attributed to enhanced HIV screening programs that have been implemented in various healthcare settings, including EDs. These programs have varied greatly in design and include testing based on risk-assessment versus non-targeted screening, rapid versus conventional assay testing, and HIV antibody testing versus nucleic acid amplification (NAAT) testing. The latter approach offers the advantage of facilitating early diagnosis, as was demonstrated in a review of NAAT HIV testing across 9 EDs in which 15% of all HIV diagnoses were in persons with acute HIV infection. 6 An additional benefit of HIV testing in EDs is the identification of people living with HIV who have been lost to follow-up, providing an opportunity to link them back into care. In a large cohort study, HIV testing in the ED was associated with improved linkage to care, retention, and virologic suppression among persons previously diagnosed with HIV who were "re-diagnosed" as HIV-infected during an ED visit. 7 Published reports of ED HIV testing programs have shown variable test acceptance rates (53%-91%), [8] [9] [10] [11] and rates of new HIV diagnoses have been relatively modest (0.14%-1.7%). 9 replacing it with an opt-out oral consent approach. Test acceptance rates were compared before and after this change occurred.

This was a prospective observational study of a rapid HIV screening program at Duke University Hospital and Duke Regional Hospital EDs, 

Demographics (age, race/ethnicity, and sex) and prior testing history were recorded on all participants providing consent. Reason for ED admission ("chief complaint"), vital signs, and HIV-related symptoms (using a checklist which included recurrent fevers, night sweats, fatigue, rash, sore throat, diarrhea, >10 lb weight loss in last 6 months, and swollen lymph nodes) were obtained and reviewed from both the participant and medical record on all patients at time of testing. If the person declined testing, they were asked why they declined, and the response was categorized into 1 of the following: (1) not interested or scared, (2) not perceived at risk, (3) recently tested, (4) too sick, (5) other, or (6) no reason given. For persons with newly diagnosed HIV infection, ED discharge diagnoses, initial CD4 lymphocyte counts, and baseline HIV RNA levels were collected.

Data were analyzed by using SAS (version 9. The number of participants approached who chose not to enter the study was recorded in order to calculate the overall acceptance rate.

Participants who declined testing could elect or decline to provide their demographic information (age, race/ethnicity, and sex), whether they had ever been previously tested, and reason for declining testing.

Between 2008 and 2012, a total of 5443 ED patients were offered HIV testing (4237 at Duke University Hospital; 1206 at Duke Regional Hospital (67) Other races/ethnicity not included due to low numbers. a Missing includes unknown. P = 0.1052). Acceptance rates improved after written informed consent was replaced with verbal consent (71.3% vs 63.1%; P < 0.001). 

Reasons for declining HIV testing included having had "recent testing" (43%), being "not perceived at risk" (20%), being "not interested/scared" (19%), "too sick" (14%), or offering "other or no reason" (4%). Younger persons (aged 18-44 years) were more likely to decline due to recent testing than were older persons (≥45 years) (46% vs 23%; P < 0.001). Compared to the younger group, older persons were more likely to decline testing due to being "not interested/scared" (30% vs 19%; P < 0.001) or not perceiving themselves to be at risk (29% vs 18%; P < 0.001).

Reasons for declining testing varied by race (Figure 1 ). Black participants were significantly more likely to decline testing due to recent testing than were White participants (44% vs 30%; P < 0.001 accepted testing the second time they were approached ( Figure 2 ). with serious illness or injury, a group that may represent a higher risk population. Another potential factor may be the timing during which the majority of testing was offered (daytime hours during weekdays). Although rates of new HIV diagnoses have been similarly modest in other ED testing programs, 9, 10, [13] [14] [15] 23 all these rates are consistently above the CDC threshold of 0.1% for instituting routine HIV screening. 3 Notably, seroprevalence rates among persons who decline testing have been found to be 1.4-18 times higher than those who accept testing, even when reporting similar risk. 12, [24] [25] [26] [27] The most common reason for declining testing in this study was due to ED patients reporting having been previously tested, which may be a reasonable reason for not being tested based on the CDC rec-

ommendations that persons should be tested at least once as adults.

Although we were unable to verify prior testing unless the testing had been done during this study, patient reliability has been demonstrated in both self-reported testing history and behavioral risk factors. 27, 28 However, many people declined testing due to disinterest/fear and/or not perceiving themselves to be at risk. Current public awareness of HIV testing recommendations remains quite low. 29 Scaling up public health education efforts about the realities of today's HIV epidemic may improve public awareness of the importance of getting tested and the need for routine HIV testing programs.

Reasons for declining testing in this program differed by age and race. Older persons were significantly more likely to perceive themselves "not at risk" for having HIV infection. However, in 2016, persons aged 50 and older accounted for 17% of all new diagnoses and 47% of all persons living with HIV. 30 These rising numbers may reflect changing attitudes regarding sexuality in older populations, misinformation or lack of knowledge of risky sexual behaviors among seniors and the inattention of healthcare providers regarding sexual health in their older patients. [31] [32] [33] [34] Although some of the increase of identified HIV infections among older persons may be due to expanded HIV testing programs, the median CD4 count at initial presentation among persons aged >50 years old is consistently lower than that seen in younger adults, with a greater proportion diagnosed with AIDS at the time of or within 3 months of initial presentation, indicative of late diagnosis. 35 White participants were also more likely to decline testing due to not perceiving themselves to be at risk for HIV infection. The incidence and prevalence of HIV infection is lower among Whites, 36 According to the data we collected, one effective way to encourage more people to test may be to increase the number of times that persons are asked to test. We found that participants who initially declined and were approached a second time had a higher acceptance rate, suggesting that frequent approach can be effective. By reapproaching patients and reinforcing the universal nature of our testing program, the testing seems normative rather than selective. Stigma associated with being asked to be tested is decreased considerably with repeated approaches, and refusing the test, rather than accepting, adopts the stigma of appearing to possess heightened risk-factors for HIV infection. 38 Our results and others have shown that even being approached only 2 times may be sufficient enough to reduce stigma or encourage testing acceptance for a significant number of people. 39 More false-positive tests were observed in this study than truepositive tests, yielding a positive predictive value (PPV) of ∼47%. This was much lower than the performance characteristics reported by the manufacturer and others including in low-risk populations. 10, 40, 41 However, multiple "real-world" settings have experienced similar issues with false-positives while using the oral version of the OraQuick test. 42, 43 It is notable that since this study was concluded, the NC DHHS no longer recommends use of oral swab testing for HIV screening programs in North Carolina (personal correspondence). 

Incorporating HIV testing into the workflow of EDs offers significant health benefits to persons seeking care who are unaware of their HIV diagnosis, but ED HIV testing programs may need to be suspended when circumstances demand a different focus. For example, the current COVID-19 pandemic has tasked EDs with enormous patient care responsibilities, requiring strict attention to infection control measures including minimizing non-essential contact between health care personnel and potentially infected persons. Obviously, this necessitates deferral of population-based HIV screening, as ED resources must be concentrated on managing the pandemic. Flexibility with regard to testing strategies will allow EDs to maximize the benefits of HIV screening over time while ensuring that EDs focus on critical needs during mass casualties, natural disasters, and epidemics.

The authors declare no conflict of interest.

MM takes responsibility of the final manuscript.

Safeek MPH https://orcid.org/0000-0002-1746-3306

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