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Gutman CK, Newton N, Duda E, Alevy R, Palmer K, Wetzel M, Figueroa J, Griffiths M, Koyama A, Middlebrooks L, Camacho-Gonzalez A, Morris CR. Comparison of Targeted and Routine Adolescent HIV Screening in a Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e1613-e1619. [PMID: 35686965 DOI: 10.1097/pec.0000000000002772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of the study were (1) to compare targeted and routine HIV screening in a pediatric emergency department (PED) and (2) to compare provider documented HIV risk assessment with adolescent perception of HIV risk assessment conducted during the PED visit. METHODS This prospective study ran concurrent to a PED routine HIV screening pilot. Adolescents could be tested for HIV by the PED provider per usual care (targeted testing); if not tested, they were approached for the routine screening pilot. A subset of adolescents completed a questionnaire on HIV risk. χ 2 analysis compared adolescents with targeted testing and routine screening. HIV-tested patients were asked if HIV risk was assessed; κ analysis compared this with documentation in the provider note. RESULTS Over 4 months, 107 adolescents received targeted testing and 344 received routine screening. One 14-year-old patient tested positive by routine screening; this adolescent had 2 PED visits without targeted testing within 60 days. Compared with routine screening, adolescents with targeted testing were more likely female (82% vs 57%, P < 0.001), 16 years or older (71% vs 44%, P < 0.001), or had genitourinary/gynecologic concerns (48% vs 6%, P < 0.001). Adolescents with HIV risk factors were missed by targeted testing but received routine screening. Adolescents with documented HIV risk assessment were more likely to receive targeted testing. There was moderate agreement (κ = 0.61) between provider documentation and adolescent perception of HIV risk assessment. CONCLUSIONS There are gaps in PED HIV risk assessment and testing, which may miss opportunities to diagnose adolescent HIV. Routine HIV screening addresses these gaps and expands adolescent HIV testing in the PED.
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Affiliation(s)
| | | | | | | | | | - Martha Wetzel
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Janet Figueroa
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
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Maner M, Omori M, Brinkley-Rubinstein L, Beckwith CG, Nowotny K. Infectious disease surveillance in U.S. jails: Findings from a national survey. PLoS One 2022; 17:e0272374. [PMID: 36006896 PMCID: PMC9409583 DOI: 10.1371/journal.pone.0272374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022] Open
Abstract
While infectious diseases (ID) are a well-documented public health issue in carceral settings, research on ID screening and treatment in jails is lacking. A survey was sent to 1,126 jails in the United States to identify the prevalence of health screenings at intake and characteristics of care for ID; 371 surveys were completed correctly and analyzed. Despite conflicting Centers for Disease Control (CDC) guidance, only seven percent of surveyed jails test individuals for HIV at admission. In 46% of jails, non-healthcare personnel perform ID screenings. Jails in less urban areas were more likely to report healthcare screenings performed by correctional officers. Survey findings indicate that HIV, HCV and TB testing during jail admissions and access to PrEP are severely lacking in less urban jails in particular. Recommendations are provided to improve ID surveillance and address the burden of ID in correctional facilities.
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Affiliation(s)
- Morgan Maner
- Department of Social Medicine, Center for Health Equity Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Marisa Omori
- Department of Criminology and Criminal Justice, University of Missouri, Saint Louis, MO, United States of America
| | - Lauren Brinkley-Rubinstein
- Department of Social Medicine, Center for Health Equity Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Curt G. Beckwith
- Division of Infectious Diseases, Alpert Medical School of Brown University, The Miriam Hospital, Providence, Rhode Island, United States of America
| | - Kathryn Nowotny
- Department of Sociology, University of Miami, Coral Gables, FL, United States of America
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Bi L, Solnick RE, Merchant RC. A systematic review of HIV screening programs conducted in pediatric emergency departments in the United States. BMC Emerg Med 2022; 22:75. [PMID: 35524171 PMCID: PMC9074268 DOI: 10.1186/s12873-022-00633-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/22/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND We conducted a systematic review of studies published in peer-reviewed journals on HIV screening programs conducted in pediatric emergency departments (PEDs) in the United States (US) with the objective of describing the methods, testing yields and challenges in these programs. METHODS We searched for full-text, English-language, original research articles focused on the conduct, development, initiation or implementation of any HIV screening program in a US PED through eight online databases (Pubmed (MEDLINE), Scopus, Embase, Cochrane, Web of Science, CINAHL, PsycInfo and Google Scholar) from their inception through July 2020. We also searched for articles on the websites of thirteen emergency medicine journals, 24 pediatric and adolescent health journals, and ten HIV research journals, and using the references of articles found through these searches. Data on HIV testing program components and yield of testing was extracted by one investigator independently and verified by a second investigator. Each program was summarized and critiqued. RESULTS Of the eight articles that met inclusion criteria, most involved descriptions of their HIV testing program, except for one that was focused on quality improvement of their program. Five described an opt-in and three an opt-out approach to HIV screening. Programs differed greatly by type of HIV test utilized and who initiated or performed testing. There were large variations in the percentage of patients offered (4.0% to 96.7%) and accepting (42.7% to 86.7%) HIV testing, and HIV seropositivity in the studies ranged from 0 to 0.6%. Five of the eight studies reported an HIV seropositivity greater than 0.1%, above Centers for Disease Control and Prevention recommended threshold for testing in a healthcare setting. CONCLUSIONS The studies illustrate opportunities to further optimize the integration of HIV screening programs within US PEDs and reduce barriers to testing, improve efficiency of testing results and increase effectiveness of programs to identify cases. Future research should focus on advancing the methodology of screening programs beyond feasibility studies as well as conducting investigations on their implementation and longer-term sustainability.
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Affiliation(s)
- Lynn Bi
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School , Boston, MA, USA
| | - Rachel E Solnick
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Roland C Merchant
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA.
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Faryar KA, Henderson H, Wilson JW, Hansoti B, May LS, Schechter‐Perkins EM, Waxman MJ, Rothman RE, Haukoos JS, Lyons MS. COVID-19 and beyond: Lessons learned from emergency department HIV screening for population-based screening in healthcare settings. J Am Coll Emerg Physicians Open 2021; 2:e12468. [PMID: 34189516 PMCID: PMC8219288 DOI: 10.1002/emp2.12468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/28/2021] [Accepted: 05/12/2021] [Indexed: 11/24/2022] Open
Abstract
Emergency departments (EDs) have played a major role in the science and practice of HIV population screening. After decades of experience, EDs have demonstrated the capacity to provide testing and linkage to care to large volumes of patients, particularly those who do not otherwise engage the healthcare system. Efforts to expand ED HIV screening in the United States have been accelerated by a collaborative national network of emergency physicians and other stakeholders called EMTIDE (Emergency Medicine Transmissible Infectious Diseases and Epidemics). As the COVID-19 pandemic evolves, EDs nationwide are being tasked with diagnosing and managing COVID-19 in a myriad of capacities, adopting varied approaches based in part on know-how, local disease trends, and the supply chain. The objective of this article is to broadly summarize the lessons learned from decades of ED HIV screening and provide guidance for many analogous issues and challenges in population screening for COVID-19. Over time, and with the accumulated experience from other epidemics, ED screening should develop into an overarching discipline in which the disease in question may vary, but the efficiency of response is increased by prior knowledge and understanding.
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Affiliation(s)
- Kiran A. Faryar
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Heather Henderson
- Division of Emergency Medicine, Department of Internal MedicineMorsani College of Medicine, University of South Florida, Tampa General HospitalTampaFloridaUSA
| | - Jason W. Wilson
- Division of Emergency Medicine, Department of Internal MedicineMorsani College of Medicine, University of South Florida, Tampa General HospitalTampaFloridaUSA
| | - Bhakti Hansoti
- Department of Emergency MedicineThe Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Larissa S. May
- Department of Emergency MedicineUniversity of California DavisSacramentoCaliforniaUSA
| | - Elissa M. Schechter‐Perkins
- Department of Emergency MedicineBoston University School of Medicine/Boston Medical CenterBostonMassachusettsUSA
| | - Michael J. Waxman
- Department of Emergency MedicineAlbany Medical CollegeAlbanyNew YorkUSA
| | - Richard E. Rothman
- Department of Emergency MedicineThe Johns Hopkins UniversityBaltimoreMarylandUSA
| | - Jason S. Haukoos
- Department of Emergency Medicine, Denver Health Medical CenterUniversity of Colorado School of MedicineDenverColoradoUSA
- Department of EpidemiologyColorado School of Public HealthAuroraColoradoUSA
| | - Michael S. Lyons
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Center for Addiction ResearchUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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Nontargeted Hepatitis C Screening in an Urban Emergency Department in New York City. J Emerg Med 2020; 60:299-309. [PMID: 33213988 DOI: 10.1016/j.jemermed.2020.09.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/18/2020] [Accepted: 09/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previously the Centers for Disease Control and Prevention (CDC) recommended targeted hepatitis C virus (HCV) screening for adults born between 1945 and 1965 and individuals with HCV risk factors. In April 2020, the CDC updated their recommendations to now include all individuals 18 years of age and older in settings with HCV prevalence > 0.1%. Few emergency departments (EDs) currently employ this nontargeted screening approach. OBJECTIVES We examined how a shift from targeted to nontargeted screening might affect HCV case identification. We hypothesized that nontargeted screening could improve HCV case identification in our ED. METHODS Retrospective review of prospectively collected nontargeted screening data from June 6, 2018 to June 5, 2019 in a large urban academic ED. Patients 18 years of age and older, triaged to the adult or pediatric ED and able to provide consent for HCV testing, were eligible for study inclusion. RESULTS There were 83,864 ED visits and 40,282 unique patients deemed eligible for HCV testing. Testing occurred in 10,630 (26.4%) patients, of which 638 (6%) had positive HCV antibody (Ab+) tests and 214 (2%) had a positive viral load (VL+). Birth cohort-targeted screening would have identified 48% of the patients with Ab+ tests and 47% of those who were VL+. Risk-based targeted screening would increase the number of Ab+ patients to 67% and VL+ to 72%. CONCLUSIONS Nontargeted ED-based HCV screening can identify a large number of patients with HCV infection. A shift from targeted to nontargeted screening may result in fewer missed infections but requires further study.
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Haukoos J, Hopkins E. HIV screening in the emergency department: Thoughts on disparities and the next step in ending the epidemic. J Am Coll Emerg Physicians Open 2020; 1:484-486. [PMID: 33000074 PMCID: PMC7493548 DOI: 10.1002/emp2.12226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jason Haukoos
- Department of Emergency MedicineDenver Health Medical CenterDenverColoradoUSA
- Department of EpidemiologyColorado School of Public HealthAuroraColoradoUSA
- University of Colorado School of MedicineAuroraColoradoUSA
| | - Emily Hopkins
- Department of Emergency MedicineDenver Health Medical CenterDenverColoradoUSA
- University of Colorado School of MedicineAuroraColoradoUSA
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Hill MJ, Cardenas-Turanzas M, Prater S, Campbell JW, McNeese M. Racial and sex disparities in HIV screening outcomes within emergency departments of Harris County, Texas. J Am Coll Emerg Physicians Open 2020; 1:476-483. [PMID: 33000073 PMCID: PMC7493530 DOI: 10.1002/emp2.12046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/29/2020] [Accepted: 02/20/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES The emergency department provides opportunities for identifying undiagnosed HIV cases. We sought to describe the racial and sex epidemiology of HIV through ED screening in Harris County, Texas, one of the most diverse and populous metropolitan cities in the Southern United States. METHODS We used a descriptive secondary analysis of a universal HIV screening program (2010-2017) to quantify demographic differences in HIV incidence. We applied a validated codebook to a dataset by the local health department containing 894,387 records of ED visits with 62 variables to assess race/ethnicity and sex differences. RESULTS Of 885,199 (98.9%) patients screened for HIV during an ED visit, 1795 tested positive (incidence rate = 0.2%). Of those tested for HIV, most were White (66.3%), followed by racial minorities (African Americans (29.9%), Asians (3.6%), and American Indian, Alaska Native, Native Hawaiian or Pacific Islanders (natives) (0.1%). Half of those tested were Hispanic. Conversely, of patients testing positive (n = 1782, 99.3% of positive cases), most were African American (52.6%) followed by Whites (46.6%), Asians (0.7%), and natives (0.1%). Less than half (35.5%) of positives were Hispanic. A racial disparity in HIV incidence was discovered among African American females. This group represented 16.8% of the tested population; yet accounted for 65.8% of females who tested positive for HIV and 20.3% of all HIV-positive test results. CONCLUSION Descriptive findings of the racial and sex epidemiology of HIV revealed that African American females had the largest disparity between the population tested and those who tested positive for HIV.
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Affiliation(s)
- Mandy J Hill
- Department of Emergency Medicine, Division of Population Health McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth) Houston Texas
| | - Marylou Cardenas-Turanzas
- Department of Emergency Medicine School of Biomedical Informatics, University of Texas Health Science Center at Houston (UTHealth) Houston Texas
| | - Samuel Prater
- Department of Emergency Medicine McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth) Houston Texas
| | | | - Marlene McNeese
- Houston Health Department Division of Disease Prevention and Control Houston Texas
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Tan R, Hugli O, Cavassini M, Darling K. Non-targeted HIV testing in the emergency department: not just how but where. Expert Rev Anti Infect Ther 2018; 16:893-905. [PMID: 30406726 DOI: 10.1080/14787210.2018.1545575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The emergency department (ED) has the potential to enhance early HIV diagnosis through HIV testing programs. How these are implemented is a subject of debate. Areas covered: We describe the main HIV testing approaches: diagnostic testing, targeted screening, and non-targeted screening, and review ED-based non-targeted HIV screening studies conducted after 2006 among ≥5000 patients. As well as examining how testing is offered, we focus on where it is offered, through the patient's journey from registration, via triage and the waiting room, to the bedside. Barriers to the testing offer, acceptance and performance were examined at each location. While testing offer rates were higher at registration and triage, compared to the waiting room and bedside, this was sometimes at the expense of testing acceptance and performance. Variables affecting testing rates included type of consent, employment of external staff and type of testing: fourth generation serological testing versus rapid testing. Expert commentary: These large studies shed light on the importance of where as well as how HIV testing is performed, and the ways in which the 'where' can influence non-targeted screening yields. This perspective enables testing approaches to be tailored to specific ED settings in order to maximize testing rates.
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Affiliation(s)
- Rainer Tan
- a Infectious Diseases Service , Lausanne University Hospital , Lausanne , Switzerland
| | - Olivier Hugli
- b Emergency Department , Lausanne University Hospital , Lausanne , Switzerland
| | - Matthias Cavassini
- a Infectious Diseases Service , Lausanne University Hospital , Lausanne , Switzerland
| | - Katharine Darling
- a Infectious Diseases Service , Lausanne University Hospital , Lausanne , Switzerland
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White DAE, Todorovic T, Petti ML, Ellis KH, Anderson ES. A Comparative Effectiveness Study of Two Nontargeted HIV and Hepatitis C Virus Screening Algorithms in an Urban Emergency Department. Ann Emerg Med 2018; 72:438-448. [PMID: 29937238 DOI: 10.1016/j.annemergmed.2018.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/16/2018] [Accepted: 05/02/2018] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE We compare the effectiveness of 2 nontargeted HIV and hepatitis C virus screening protocols integrated consecutively into care in an urban emergency department: a nurse-order HIV/hepatitis C virus screening algorithm followed by an automated-laboratory-order HIV/hepatitis C virus screening algorithm programmed into the electronic health record. METHODS This was a before-after comparative effectiveness cohort study. All patients aged 18 to 75 years who received treatment during 5-month periods were eligible for participation. The main outcome measures were the number of patients screened and the number with newly diagnosed HIV and hepatitis C virus infection. RESULTS Of the eligible patients, 6,736 (33.9%) completed HIV screening during the automated-laboratory-order HIV/hepatitis C virus screening algorithm, whereas 4,121 (19.6%) completed HIV screening during the nurse-order HIV/hepatitis C virus screening algorithm (difference 14.3%; 95% confidence interval 13.4% to 15.1%); and 6,972 (35.1%) completed hepatitis C virus screening during the automated-laboratory-order HIV/hepatitis C virus screening algorithm, whereas 2,968 (14.2%) completed hepatitis C virus screening during the nurse-order HIV/hepatitis C virus screening algorithm (difference 20.9%; 95% confidence interval 20.1% to 21.7%). More patients had newly diagnosed HIV (23 versus 17) and hepatitis C virus infection (101 versus 29) during the automated-laboratory-order HIV/hepatitis C virus screening algorithm than the nurse-order HIV/hepatitis C virus screening algorithm. Results were more often available before discharge (HIV 87.2% versus 65.1%; hepatitis C virus 90.0% versus 65.4%) and fewer patients underwent repeated screening (HIV 1.6% versus 5.8%; hepatitis C virus 1.3% versus 4.5%) during the automated-laboratory-order HIV/hepatitis C virus screening algorithm than the nurse-order HIV/hepatitis C virus screening algorithm. CONCLUSION An electronic health record algorithm that automatically links HIV/hepatitis C virus screening to laboratory ordering for adult patients is more effective than a nurse-driven protocol. With widespread use of electronic health record systems, this model can be easily replicated and should be considered the standard for future programs.
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Affiliation(s)
- Douglas A E White
- Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, CA.
| | - Tamara Todorovic
- Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, CA
| | - Mae L Petti
- Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, CA
| | - Kaitlin H Ellis
- Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, CA
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Leblanc J, Hejblum G, Costagliola D, Durand-Zaleski I, Lert F, de Truchis P, Verbeke G, Rousseau A, Piquet H, Simon F, Pateron D, Simon T, Crémieux AC. Targeted HIV Screening in Eight Emergency Departments: The DICI-VIH Cluster-Randomized Two-Period Crossover Trial. Ann Emerg Med 2017; 72:41-53.e9. [PMID: 29092761 DOI: 10.1016/j.annemergmed.2017.09.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/09/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE This study compares the effectiveness and cost-effectiveness of nurse-driven targeted HIV screening alongside physician-directed diagnostic testing (intervention strategy) with diagnostic testing alone (control strategy) in 8 emergency departments. METHODS In this cluster-randomized, 2-period, crossover trial, 18- to 64-year-old patients presenting for reasons other than potential exposure to HIV were included. The strategy applied first was randomly assigned. During both periods, diagnostic testing was prescribed by physicians following usual care. During the intervention periods, patients were asked to complete a self-administered questionnaire. According to their answers, the triage nurse suggested performing a rapid test to patients belonging to a high-risk group. The primary outcome was the proportion of new diagnoses among included patients, which further refers to effectiveness. A secondary outcome was the intervention's incremental cost (health care system perspective) per additional diagnosis. RESULTS During the intervention periods, 74,161 patients were included, 16,468 completed the questionnaire, 4,341 belonged to high-risk groups, and 2,818 were tested by nurses, yielding 13 new diagnoses. Combined with 9 diagnoses confirmed through 97 diagnostic tests, 22 new diagnoses were established. During the control periods, 74,166 patients were included, 92 were tested, and 6 received a new diagnosis. The proportion of new diagnoses among included patients was higher during the intervention than in the control periods (3.0 per 10,000 versus 0.8 per 10,000; difference 2.2 per 10,000, 95% CI 1.3 to 3.6; relative risk 3.7, 95% CI 1.4 to 9.8). The incremental cost was €1,324 per additional new diagnosis. CONCLUSION The combined strategy of targeted screening and diagnostic testing was effective.
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Affiliation(s)
- Judith Leblanc
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier des Hôpitaux Universitaires Est Parisien, Clinical Research Center of East of Paris, Paris, France; Université Paris Saclay-Université Versailles St Quentin, INSERM UMR 1173, Garches, France.
| | - Gilles Hejblum
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique UMRS 1136, Paris, France
| | - Dominique Costagliola
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique UMRS 1136, Paris, France
| | - Isabelle Durand-Zaleski
- Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel-Dieu, URC Eco Île-de-France, Paris, France, and Université Paris Diderot, Univ Paris 07, INSERM, ECEVE, UMR 1123, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Henri-Mondor, Santé publique, Créteil, France
| | - France Lert
- Université Paris Sud, Univ Paris 11, INSERM, Centre for Research in Epidemiology and Population Health, U 1018, Villejuif, France
| | - Pierre de Truchis
- Assistance Publique-Hôpitaux de Paris, Hôpital Raymond-Poincaré, Infectious Diseases Department, Garches, France
| | - Geert Verbeke
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven, Belgium, and UHasselt, Hasselt, Belgium
| | - Alexandra Rousseau
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier des Hôpitaux Universitaires Est Parisien, Clinical Research Unit of East of Paris, Paris, France
| | - Hélène Piquet
- Assistance Publique-Hôpitaux de Paris, Hôpital St Antoine, Emergency Department, Paris, France
| | - François Simon
- Assistance Publique-Hôpitaux de Paris, Hôpital St Louis, Microbiology Department, INSERM U941, Paris, France
| | - Dominique Pateron
- Assistance Publique-Hôpitaux de Paris, Hôpital St Antoine, Emergency Department, Paris, France
| | - Tabassome Simon
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier des Hôpitaux Universitaires Est Parisien, Clinical Research Center of East of Paris, Paris, France; Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier des Hôpitaux Universitaires Est Parisien, Department of Clinical Pharmacology and Clinical Research Platform of East of Paris, and Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR 1148, Paris, France
| | - Anne-Claude Crémieux
- Université Paris Saclay-Université Versailles St Quentin, INSERM UMR 1173, Garches, France; Assistance Publique-Hôpitaux de Paris, Hôpital Saint Louis, Infectious Diseases Department, Université Paris Diderot, Univ Paris 07, Paris, France
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Menon AA, Nganga-Good C, Martis M, Wicken C, Lobner K, Rothman RE, Hsieh YH. Linkage-to-care Methods and Rates in U.S. Emergency Department-based HIV Testing Programs: A Systematic Literature Review Brief Report. Acad Emerg Med 2016; 23:835-42. [PMID: 27084781 DOI: 10.1111/acem.12987] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 03/18/2016] [Accepted: 04/02/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND An increasing number of U.S. emergency departments (EDs) have implemented ED-based HIV testing programs since the Centers for Disease Control and Prevention issued revised HIV testing recommendations for clinical settings in 2006. In 2010, the National HIV/AIDS Strategy (NHAS) set an linkage-to-care (LTC) rate goal of 85% within 90 days of HIV diagnosis. LTC rates for newly diagnosed HIV-infected patients vary markedly by site, and many are suboptimal. The optimal approach for LTC in the ED setting remains unknown. OBJECTIVE The objective was to perform a brief descriptive analysis of the LTC methods practiced in EDs across the United States to determine the overall linkage rate of ED-based HIV testing programs. METHODS We conducted a systematic review of literature related to U.S. ED HIV testing in the adult population using PubMed, Embase, Web of Science, Scopus, and Cochrane. There were 333 articles were identified; 31 articles were selected after a multiphasic screening process. We analyzed data from the 31 articles to assess LTC methods and rates. LTC methods that involved physical escort of the newly diagnosed patient to an HIV/infectious disease (ID) clinic or interaction with a specialist health care provider at the ED were operationally defined as "intensive" LTC protocol. "Mixed" LTC protocol was defined as a program that employed intensive linkage only part of the coverage hours. All other forms of linkage was defined as "nonintensive" LTC protocol. An LTC rate of ≥85% was used to identify characteristics of ED-based HIV testing program associated with a higher LTC rate. RESULTS There were 37 ED-based HIV testing programs in the 31 articles. The overall LTC rate was 74.4%. Regarding type of protocol, nine (24.3%) employed intensive LTC protocols, 25 (67.6%) nonintensive, two (5.4%) mixed, and one (2.7%) with unclear protocols. LTC rates for programs with intensive and nonintensive LTC protocols were 80.0 and 72.7%, respectively. Four (44.4%) with intensive protocols and nine (36.0%) with the nonintensive protocols had LTC rates > 85%. The linkage staff employed was different between ED programs. Among them, 25 (67.6%) programs used exogenous staff, 10 (27.0%) used the ED staff, and two had no information. All the programs in the nonintensive group utilized drop-in HIV/ID clinic or medical appointments while seven of nine of the programs in the intensive group physically escorted the patients to the initial medical intake appointment. There were no significant differences in characteristics of ED-based HIV testing programs between those with ≥85% LTC rate versus those with <85% within the intensive or nonintensive group. CONCLUSION Intensive LTC protocols had a higher LTC rate and a higher proportion of programs that surpassed the >85% NHAS goal compared to nonintensive methods, suggesting that, when possible, ED-based HIV testing programs should adopt intensive LTC strategies to improve LTC outcomes. However, intensive LTC protocols most often required involvement of multidisciplinary non-ED professionals and external research funding. Our findings provide a foundation for developing best practices for ED-based HIV LTC programs.
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Affiliation(s)
- Aravind A. Menon
- Department of Emergency Medicine; The Johns Hopkins University School of Medicine; Baltimore MD
| | | | - Mikeeo Martis
- Department of Emergency Medicine; The Johns Hopkins University School of Medicine; Baltimore MD
| | - Cassie Wicken
- Department of Emergency Medicine; The Johns Hopkins University School of Medicine; Baltimore MD
| | - Katie Lobner
- The William H. Welch Medical Library; The Johns Hopkins University School of Medicine; Baltimore MD
| | - Richard E. Rothman
- Department of Emergency Medicine; The Johns Hopkins University School of Medicine; Baltimore MD
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine; The Johns Hopkins University School of Medicine; Baltimore MD
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Montoy JCC, Dow WH, Kaplan BC. Patient choice in opt-in, active choice, and opt-out HIV screening: randomized clinical trial. BMJ 2016; 532:h6895. [PMID: 26786744 PMCID: PMC4718971 DOI: 10.1136/bmj.h6895] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
STUDY QUESTION What is the effect of default test offers--opt-in, opt-out, and active choice--on the likelihood of acceptance of an HIV test among patients receiving care in an emergency department? METHODS This was a randomized clinical trial conducted in the emergency department of an urban teaching hospital and regional trauma center. Patients aged 13-64 years were randomized to opt-in, opt-out, and active choice HIV test offers. The primary outcome was HIV test acceptance percentage. The Denver Risk Score was used to categorize patients as being at low, intermediate, or high risk of HIV infection. STUDY ANSWER AND LIMITATIONS 38.0% (611/1607) of patients in the opt-in testing group accepted an HIV test, compared with 51.3% (815/1628) in the active choice arm (difference 13.3%, 95% confidence interval 9.8% to 16.7%) and 65.9% (1031/1565) in the opt-out arm (difference 27.9%, 24.4% to 31.3%). Compared with active choice testing, opt-out testing led to a 14.6 (11.1 to 18.1) percentage point increase in test acceptance. Patients identified as being at intermediate and high risk were more likely to accept testing than were those at low risk in all arms (difference 6.4% (3.4% to 9.3%) for intermediate and 8.3% (3.3% to 13.4%) for high risk). The opt-out effect was significantly smaller among those reporting high risk behaviors, but the active choice effect did not significantly vary by level of reported risk behavior. Patients consented to inclusion in the study after being offered an HIV test, and inclusion varied slightly by treatment assignment. The study took place at a single county hospital in a city that is somewhat unique with respect to HIV testing; although the test acceptance percentages themselves might vary, a different pattern for opt-in versus active choice versus opt-out test schemes would not be expected. WHAT THIS PAPER ADDS Active choice is a distinct test regimen, with test acceptance patterns that may best approximate patients' true preferences. Opt-out regimens can substantially increase HIV testing, and opt-in schemes may reduce testing, compared with active choice testing. FUNDING, COMPETING INTERESTS, DATA SHARING This study was supported by grant NIA 1RC4AG039078 from the National Institute on Aging. The full dataset is available from the corresponding author. Consent for data sharing was not obtained, but the data are anonymized and risk of identification is low.Trial registration Clinical trials NCT01377857.
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Affiliation(s)
- Juan Carlos C Montoy
- Department of Emergency Medicine, University of California, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - William H Dow
- School of Public Health, University of California, 239 University Hall #7360, University of California, Berkeley, CA 94720-7360, USA
| | - Beth C Kaplan
- Department of Emergency Medicine, University of California, 1001 Potrero Ave, San Francisco CA 94143, USA
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Abstract
OBJECTIVE The Johns Hopkins Hospital Emergency Department has served as a window on the HIV epidemic for 25 years, and as a pioneer in emergency department-based screening/linkage-to-care (LTC) programs. We document changes in the burden of HIV and HIV care metrics to the evolving HIV epidemic in inner-city Baltimore. DESIGN/METHODS We analyzed seven serosurveys conducted on 18 ,144 adult Johns Hopkins Hospital Emergency Department patients between 1987 and 2013 as well as our HIV-screening/LTC program (2007, 2013) for trends in HIV prevalence, cross-sectional annual incidence estimates, undiagnosed HIV, LTC, antiretrovirals treatment, and viral suppression. RESULTS HIV prevalence in 1987 was 5.2%, peaked at more than 11% from 1992 to 2003 and declined to 5.6% in 2013. Seroprevalence was highest for black men (initial 8.0%, peak 20.0%, last 9.9%) and lowest for white women. Among HIV-positive individuals, proportion of undiagnosed infection was 77% in 1987, 28% in 1992, and 12% by 2013 (P < 0.001). Cross-sectional annual HIV incidence estimates declined from 2.28% in 2001 to 0.16% in 2013. Thirty-day LTC improved from 32% (2007) to 72% (2013). In 2013, 80% of HIV-positive individuals had antiretrovirals ARVs detected in sera, markedly increased from 2007 (27%) (P < 0.001). Proportion of HIV-positive individuals with viral suppression (<400 copies/ml) increased from 23% (2001) to 59% (2013) (P < 0.001). CONCLUSION Emergency department-based HIV testing has evolved from describing the local epidemic to a strategic interventional role, serving as a model for early HIV detection and LTC. Our contribution to community-based HIV-screening and LTC program parallels declines in undiagnosed HIV infection and incidence, and increases in antiretroviral use with associated viral suppression in the community.
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Hsieh YH, Kelen GD, Laeyendecker O, Kraus CK, Quinn TC, Rothman RE. HIV Care Continuum for HIV-Infected Emergency Department Patients in an Inner-City Academic Emergency Department. Ann Emerg Med 2015; 66:69-78. [PMID: 25720801 PMCID: PMC4478148 DOI: 10.1016/j.annemergmed.2015.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 12/16/2014] [Accepted: 12/31/2014] [Indexed: 01/11/2023]
Abstract
STUDY OBJECTIVE The recently released HIV Care Continuum Initiative is a cornerstone of the National AIDS Strategy and a model for improving care for those living with HIV. To our knowledge, there are no studies exploring the entirety of the HIV Care Continuum for patients in the emergency department (ED). We determine gaps in the HIV Care Continuum to identify potential opportunities for improved care for HIV-infected ED patients. METHODS A mixed-methods approach was used in 1 inner-city ED in 2007. Data elements were derived from an identity-unlinked HIV seroprevalence study, an ongoing nontargeted HIV screening program, and a structured survey of known HIV-positive ED patients. RESULTS Identity-unlinked testing of 3,417 unique ED patients found that 265 (7.8%) were HIV positive. Of patients testing HIV positive, 73% had received a previous diagnosis (based on self-report, chart review, or presence of antiretrovirals in serum), but only 61% were recognized by the clinician as being HIV infected (based on self-report or chart review). Of patients testing positive, 43% were linked to care, 39% were retained in care, 27% were receiving antiretrovirals, 26% were aware of their receiving antiretroviral treatment, 22% were virally suppressed, and only 9% were self-aware of their viral suppression. CONCLUSION To our knowledge, this study is the first to quantify gaps in HIV care for an ED patient population, with the HIV Care Continuum as a framework. Our findings identified distinct phases (ie, testing, provider awareness of HIV diagnosis, and linkage to care) in which the greatest opportunities for intervention exist, if appropriate resources were allocated. This schema could serve as a model for other indolent treatable diseases frequently observed in EDs, where continuity of care is critical.
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Affiliation(s)
- Yu-Hsiang Hsieh
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Gabor D Kelen
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Oliver Laeyendecker
- Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, MD; Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | | | - Thomas C Quinn
- Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, MD; Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD
| | - Richard E Rothman
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD; Division of Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, MD
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Implementation of a Collaborative HIV Testing Model Between an Emergency Department and Infectious Disease Clinic. J Acquir Immune Defic Syndr 2014; 66:e67-70. [DOI: 10.1097/qai.0000000000000153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lyons MS, Lindsell CJ, Ruffner AH, Wayne DB, Hart KW, Sperling MI, Trott AT, Fichtenbaum CJ. Randomized comparison of universal and targeted HIV screening in the emergency department. J Acquir Immune Defic Syndr 2013; 64:315-23. [PMID: 23846569 PMCID: PMC4241750 DOI: 10.1097/qai.0b013e3182a21611] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Universal HIV screening is recommended but challenging to implement. Selectively targeting those at risk is thought to miss cases, but previous studies are limited by narrow risk criteria, incomplete implementation, and absence of direct comparisons. We hypothesized that targeted HIV screening, when fully implemented and using maximally broad risk criteria, could detect nearly as many cases as universal screening with many fewer tests. METHODS This single-center cluster-randomized trial compared universal and targeted patient selection for HIV screening in a lower prevalence urban emergency department. Patients were excluded for age (<18 and >64 years), known HIV infection, or previous approach for HIV testing that day. Targeted screening was offered for any risk indicator identified from charts, staff referral, or self-disclosure. Universal screening was offered regardless of risk. Baseline seroprevalence was estimated from consecutive deidentified blood samples. RESULTS There were 9572 eligible visits during which the patient was approached. For universal screening, 40.8% (1915/4692) consented with 6 being newly diagnosed [0.31%, 95% confidence interval (CI): 0.13% to 0.65%]. For targeted screening, 37% (1813/4880) had no testing indication. Of the 3067 remaining, 47.4% (1454) consented with 3 being newly diagnosed (0.22%, 95% CI: 0.06% to 0.55%). Estimated seroprevalence was 0.36% (95% CI: 0.16% to 0.70%). Targeted screening had a higher proportion consenting (47.4% vs. 40.8%, P < 0.002), but a lower proportion of ED encounters with testing (29.7% vs. 40.7%, P < 0.002). CONCLUSIONS Targeted screening, even when fully implemented with maximally permissive selection, offered no important increase in positivity rate or decrease in tests performed. Universal screening diagnosed more cases, because more were tested, despite a modestly lower consent rate.
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Affiliation(s)
- Michael S. Lyons
- Department of Emergency Medicine, University of Cincinnati College of Medicine
| | | | - Andrew H. Ruffner
- Department of Emergency Medicine, University of Cincinnati College of Medicine
| | - D. Beth Wayne
- Department of Emergency Medicine, University of Cincinnati College of Medicine
| | - Kimberly W. Hart
- Department of Emergency Medicine, University of Cincinnati College of Medicine
| | - Matthew I. Sperling
- Department of Emergency Medicine, University of Cincinnati College of Medicine
| | - Alexander T. Trott
- Department of Emergency Medicine, University of Cincinnati College of Medicine
| | - Carl J. Fichtenbaum
- Division of Infectious Diseases, University of Cincinnati College of Medicine
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Affiliation(s)
- Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado2Department of Emergency Medicine, University of Colorado School of Medicine, Aurora3Department of Epidemiology, Colorado School of Public Health, Aurora
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Christopoulos KA, Massey AD, Lopez AM, Geng EH, Johnson MO, Pilcher CD, Fielding H, Dawson-Rose C. "Taking a half day at a time:" patient perspectives and the HIV engagement in care continuum. AIDS Patient Care STDS 2013; 27:223-30. [PMID: 23565926 DOI: 10.1089/apc.2012.0418] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The HIV treatment continuum, or "cascade," outlines key benchmarks in the successful treatment of HIV-infected individuals. However, the cascade fails to capture important dimensions of the patient experience in that it has been constructed from a provider point of view. In order to understand meaningful steps in the HIV care cascade for individuals diagnosed with HIV through expanded, more routine testing, we conducted in-depth interviews (n=34) with three groups of individuals: those diagnosed with HIV in the emergency department/urgent care clinic who linked to HIV care and exhibited 100% appointment adherence in the first 6 months of HIV care; those diagnosed in the emergency department/urgent care clinic who linked to HIV care and exhibited sporadic appointment adherence in the first 6 months of HIV care, and; hospitalized patients with no outpatient HIV care for at least 6 months. This last group was chosen to supplement data from in-care patients. The engagement in care process was defined by a changing perspective on HIV, one's HIV identity, and the role of health care. The linkage to care experience laid the groundwork for subsequent retention. Interventions to support engagement in care should acknowledge that patient concerns change over time and focus on promoting shifts in perspective.
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Affiliation(s)
- Katerina A. Christopoulos
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Amina D. Massey
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Andrea M. Lopez
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Elvin H. Geng
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Mallory O. Johnson
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California
| | - Christopher D. Pilcher
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Hegla Fielding
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Carol Dawson-Rose
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California
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Ganguli I, Collins JE, Reichmann WM, Losina E, Katz JN, Arbelaez C, Donnell-Fink LA, Walensky RP. Missed opportunities: refusal to confirm reactive rapid HIV tests in the emergency department. PLoS One 2013; 8:e53408. [PMID: 23308216 PMCID: PMC3540076 DOI: 10.1371/journal.pone.0053408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 11/30/2012] [Indexed: 11/20/2022] Open
Abstract
Background HIV infection remains a major US public health concern. While HIV-infected individuals now benefit from earlier diagnosis and improved treatment options, progress is tempered by large numbers of newly diagnosed patients who are lost to follow-up prior to disease confirmation and linkage to care. Methodology In the randomized, controlled USHER trial, we offered rapid HIV tests to patients presenting to a Boston, MA emergency department. Separate written informed consent was required for confirmatory testing. In a secondary analysis, we compared participants with reactive results who did and did not complete confirmatory testing to identify factors associated with refusal to complete the confirmation protocol. Principal Findings Thirteen of 62 (21.0%, 95% CI (11.7%, 33.2%)) participants with reactive rapid HIV tests refused confirmation; women, younger participants, African Americans, and those with fewer HIV risks, with lower income, and without primary care doctors were more likely to refuse. We projected that up to four true HIV cases were lost at the confirmation stage. Conclusions These findings underscore the need to better understand the factors associated with refusal to confirm reactive HIV testing and to identify interventions that will facilitate confirmatory testing and linkage to care among these populations. Trial Registration ClinicalTrials.gov NCT00502944; NCT01258582.
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Affiliation(s)
- Ishani Ganguli
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jamie E. Collins
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - William M. Reichmann
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Elena Losina
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
| | - Jeffrey N. Katz
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Christian Arbelaez
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Laurel A. Donnell-Fink
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Rochelle P. Walensky
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
- Divisions of Infectious Disease and General Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Disease, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- * E-mail:
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Rothman RE, Kelen GD, Harvey L, Shahan JB, Hairston H, Burah A, Moring-Parris D, Hsieh YH. Factors associated with no or delayed linkage to care in newly diagnosed human immunodeficiency virus (HIV)-1-infected patients identified by emergency department-based rapid HIV screening programs in two urban EDs. Acad Emerg Med 2012; 19:497-503. [PMID: 22594352 DOI: 10.1111/j.1553-2712.2012.01351.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to describe the proportions of successful linkage to care (LTC) and identify factors associated with LTC among newly diagnosed human immunodeficiency virus (HIV)-positive patients, from two urban emergency department (ED) rapid HIV screening programs. METHODS This was a retrospective analysis of programmatic data from two established urban ED rapid HIV screening programs between November 2005 and October 2009. Trained HIV program assistants interviewed all patients tested to gather risk behavior data using a structured data collection instrument. Reactive results were confirmed by Western blot testing. Patients were provided with scheduled appointments at HIV specialty clinics at the institutions where they tested positive within 30 days of their ED visit. "Successful" LTC was defined as attendance at the HIV outpatient clinic within 30 days after HIV diagnosis, in accordance with the ED National HIV Testing Consortium metric. "Any" LTC was defined as attendance at the outpatient HIV clinic within 1 year of initial HIV diagnosis. Multivariate logistic regression was performed to determine factors associated with any LTC or successful LTC. RESULTS Of the 15,640 tests administered, 108 (0.7%) were newly identified HIV-positive cases. Nearly half (47.2%) of the patients had been previously tested for HIV. Successful LTC occurred in 54% of cases; any LTC occurred in 83% of cases. In multivariate analysis, having public medical insurance and being self-pay were negatively associated with successful LTC (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.12 to 0.96; OR = 0.34, 95% CI = 0.13 to 0.89, respectively); being female and having previously tested for HIV was negatively associated with any LTC (OR = 0.30, 95% CI = 0.10 to 0.93; OR = 0.23, 95% CI = 0.07 to 0.77, respectively). CONCLUSIONS In spite of dedicated resources for arranging LTC in the ED HIV testing programs, nearly 50% of patients did not have successful LTC (i.e., LTC occurred at >30 days), although >80% of patients were LTC within 1 year of initial diagnosis. Further evaluation of the barriers associated with successful LTC for those with public insurance and self-pay is warranted.
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Affiliation(s)
- Richard E Rothman
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Copeland B, Shah B, Wheatley M, Heilpern K, del Rio C, Houry D. Diagnosing HIV in men who have sex with men: an emergency department's experience. AIDS Patient Care STDS 2012; 26:202-7. [PMID: 22356726 PMCID: PMC3317392 DOI: 10.1089/apc.2011.0303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In the United States, men who have sex with men (MSM) constitute the risk group in which the prevalence of new HIV infection is increasing. The percentage of undiagnosed HIV infection and HIV risk behaviors in MSM and non-MSM participating in an emergency department-based rapid HIV screening program were compared. Medical records of all male patients participating in the program from May 2008 to October 2010 were reviewed. MSM were identified as male or male-to-female patients reporting oral and/or anal sex with a male. Males eligible for testing were aged 18 or older, English-speaking, not known to be HIV infected, and able to decline testing. A total of 6672 males were approached for testing; 5610 (84.1%) accepted, 366 (6.5%) were MSM, and 5244 (93.5%) were non-MSM. A total of 90.7% were black. Median age was 41. Fifty-nine MSM (16.1%) were diagnosed with HIV compared to 81 (1.5%) non-MSM. MSM were 10 times more likely than non-MSM to have undiagnosed HIV infection (odds ratio [OR] 10.4, 95% confidence interval [CI] 7.3, 14.0). HIV-infected MSM (median age, 26) were younger than non-MSM (median age, 41). HIV-infected non-MSM were 2 times more likely than MSM to have CD4 counts less than 200 cells per microliter. MSM were more likely to report previous HIV testing (OR 1.9, 95% CI 1.4, 2.5) and risk behaviors, including sex without a condom (OR 2.0, 95% CI 1.5, 2.6), sex with an HIV-infected partner (OR 14.6, 95% CI 8.3, 25.6) and sex with a known injection drug user (OR 4.1, 95% CI 2.0, 8.4). Further investigation of emergency department-based HIV testing and risk reduction programs targeting MSM is warranted.
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Affiliation(s)
- Brittney Copeland
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia 30303, USA.
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Haukoos JS, Hopkins E, Bender B, Al-Tayyib A, Long J, Harvey J, Irby J, Bakes K. Use of kiosks and patient understanding of opt-out and opt-in consent for routine rapid human immunodeficiency virus screening in the emergency department. Acad Emerg Med 2012; 19:287-93. [PMID: 22435861 DOI: 10.1111/j.1553-2712.2012.01290.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to evaluate patient acceptance and understanding of nontargeted opt-out and opt-in rapid human immunodeficiency virus (HIV) screening using computerized kiosks in the emergency department (ED). METHODS This study was a prospective quasi-experiment in an urban hospital with an annual ED and urgent care census of 120,000 visits. During medical screening, patients 13 years and older were offered rapid HIV screening using kiosks and opt-out consent (October 2009) or opt-in consent (December 2009). Random time blocks were used to administer structured surveys to evaluate patient understanding of the testing process. RESULTS During the opt-out phase, 6,602 were offered testing, and of these 3,993 (61%) did not opt-out and 886 (13%) completed screening. During the opt-in phase, 5,781 were offered testing, and of these 930 (16%) opted-in and 389 (7%) completed screening (absolute difference = 6%, 95% confidence interval [CI] = 5% to 8%). During the opt-out phase, 330 patients completed the survey. Of these, 201 (61%) did not opt-out, but 108 (54%, 95% CI = 47% to 61%) responded that they had not been informed about an HIV test. Of the 84 patients who had been informed, 32 (38%, 95% CI = 28% to 49%) responded that they had not agreed to an HIV test. During the opt-in phase, 416 completed the survey. Of these, 80 (19%) agreed to testing and two (3%, 95% CI = 0.3% to 9%) responded that they had not been informed about an HIV test. Of the 74 patients who had been informed, only two (3%, 95% CI = 0.3% to 9%) responded that they had not agreed to an HIV test. CONCLUSIONS Computerized kiosks can be successfully used to perform nontargeted rapid HIV screening in EDs. However, when using this approach, patient understanding of opt-in consent is significantly better than opt-out consent.
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Affiliation(s)
- Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, CO, USA.
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A Comparison of Patient Satisfaction with Emergency Department Opt-In and Opt-Out Rapid HIV Screening. AIDS Res Treat 2012; 2012:904916. [PMID: 22400107 PMCID: PMC3286895 DOI: 10.1155/2012/904916] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 11/26/2011] [Indexed: 11/25/2022] Open
Abstract
Study objective. To compare patient satisfaction with emergency department (ED) opt-in and opt-out HIV screening.
Methods. We conducted a survey in an urban ED that provided rapid HIV screening using opt-in (February 1, 2007–July 31, 2007) and opt-out (August 1, 2007–January 31, 2008) approaches. We surveyed a convenience sample of patients that completed screening in each phase. The primary outcome was patient satisfaction with HIV screening. Results. There were 207 and 188 completed surveys during the opt-in and opt-out phases, respectively. The majority of patients were satisfied with both opt-in screening (95%, 95% confidence interval [CI] = 92–98) and opt-out screening (94%, 95% CI = 89–97). Satisfaction ratings were similar between opt-in and opt-out phases even after adjusting for age, gender, race/ethnicity, and test result (adjusted odds ratio 1.3, 95% CI = 0.5–3.1).
Conclusions. Emergency department patient satisfaction with opt-in and opt-out HIV screening is similarly high.
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Increased acceptance rates of HIV screening using opt-out consent methods in an urban emergency department. J Acquir Immune Defic Syndr 2011; 58:277-82. [PMID: 21876449 DOI: 10.1097/qai.0b013e318231916d] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal methods for implementing HIV screening in health care settings remain unknown. OBJECTIVE To compare the acceptance rates of emergency department HIV screening when supplemental staff use opt-in and opt-out consent methods. METHODS Experimental equivalent time-sample, conducted in an urban emergency department with an annual census of 80,000 visits. HIV screeners performed nontargeted HIV screening using point-of-care, rapid HIV tests. Eligible patients were medically stable, English or Spanish speaking, ≥13 or ≤64 years, not HIV tested in past 6 months, and not psychiatrically impaired. Screeners offered eligible patients HIV screening using either opt-in or opt-out consent methods on alternate weeks. Main outcome measures were the acceptance rate of HIV screening and the association between opt-out rapid HIV screening and acceptance. RESULTS Of the eligible patients, 2409 were offered HIV screening, with 1209 (50%) on opt-in days and 1200 (50%) on opt-out days. The mean age was 40 years, 52% were male, 45% were Black, 28% Hispanic, and 15% white. The acceptance rate of opt-in HIV screening was 63% [767 of 1209, 95% confidence interval (CI): 61% to 66%] and the acceptance rate of opt-out HIV screening was 78% (931 of 1200, 95% CI: 75% to 80%), absolute difference 14% (95% CI: 11% to 18%). The acceptance rate of opt-out HIV screening remained greater after adjusting for patient demographics, admission status, acuity, treatment area, privacy of encounter, and screening staff identity (adjusted odds ratio: 2.0, 95% CI: 1.7 to 2.4). CONCLUSIONS Opt-out HIV screening using supplemental staff increases patient acceptance and should be considered as the consent methodology of choice.
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Mimiaga MJ, Johnson CV, Reisner SL, Vanderwarker R, Mayer KH. Barriers to routine HIV testing among Massachusetts community health center personnel. Public Health Rep 2011; 126:643-52. [PMID: 21886324 DOI: 10.1177/003335491112600506] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES We assessed the extent to which Centers for Disease Control and Prevention (CDC) recommendations have influenced routine HIV testing among Massachusetts community health center (CHC) personnel, and identified specific barriers and facilitators to routine testing. METHODS Thirty-one CHCs were enrolled in the study. We compared those that did and did not receive funding support from the federal Ryan White HIV/AIDS Program. An anonymous survey was administered to a maximum five personnel from each CHC, including a senior administrator, the medical director, and three medical providers. Overall, 137 participants completed the survey. RESULTS Among all CHCs, 53% of administrators reported having implemented routine HIV testing at their CHCs; however, only 33% of medical directors/providers reported having implemented routine HIV testing in their practices (p<0.05). Among administrators, 60% of those from Ryan White-supported CHCs indicated that both they and their CHCs were aware of CDC's recommendations, compared with 27% of administrators from non-Ryan White-supported CHCs. The five most frequently reported barriers to the implementation of routine HIV testing were (1) constraints on providers' time (68%), (2) time required to administer counseling (65%), (3) time required to administer informed consent (52%), (4) lack of funding (35%), and (5) need for additional training (34%). In a multivariable logistic regression model, the provision of on-site HIV testing by nonmedical staff resulted in increased odds of conducting routine HIV testing (odds ratio [OR] = 9.84, 95% confidence interval [CI] 1.77, 54.70). However, the amount of time needed to administer informed consent was associated with decreased odds of providing routine testing (OR=0.21, 95% CI 0.05, 0.92). CONCLUSIONS Routine HIV testing is not currently being implemented uniformly among Massachusetts CHCs. Future efforts to increase implementation should address personnel concerns regarding time and staff availability.
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Affiliation(s)
- Matthew J Mimiaga
- Harvard Medical School/Massachusetts General Hospital, Department of Psychiatry, Boston, MA, USA.
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Heffelfinger JD, Owen SM, Hendry RM, Lansky A. HIV testing: the cornerstone of HIV prevention efforts in the USA. Future Virol 2011; 6:1299-1317. [PMID: 37965646 PMCID: PMC10644277 DOI: 10.2217/fvl.11.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
An estimated 1.2 million persons in the USA are infected with HIV, of whom approximately 20% are unaware they are infected. HIV testing and knowledge of HIV serostatus have important individual and public health benefits, including reduction of morbidity, mortality and HIV transmission. Although testing is the necessary first step to prevention, more than half of the US adult population has never been tested for HIV. However, this proportion is increasing due to revised national recommendations to make HIV testing a routine part of healthcare, expansion of testing efforts at local, state and national levels, and progress in the development and adoption of new testing technologies. In this article, we describe the essential role of HIV testing as a public health prevention strategy, examine recent advances in HIV testing technologies and testing implementation, and identify future directions for HIV testing in the USA.
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Affiliation(s)
- James D Heffelfinger
- Division of HIV/AIDS Prevention, Centers for Disease Control & Prevention, 1600 Clifton Road, MS: E-46, Atlanta, GA 30333, USA
| | - S Michele Owen
- Division of HIV/AIDS Prevention, Centers for Disease Control & Prevention, 1600 Clifton Road, MS: E-46, Atlanta, GA 30333, USA
| | - R Michael Hendry
- Division of HIV/AIDS Prevention, Centers for Disease Control & Prevention, 1600 Clifton Road, MS: E-46, Atlanta, GA 30333, USA
| | - Amy Lansky
- Division of HIV/AIDS Prevention, Centers for Disease Control & Prevention, 1600 Clifton Road, MS: E-46, Atlanta, GA 30333, USA
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White DAE, Scribner AN, Vahidnia F, Dideum PJ, Gordon DM, Frazee BW, Voetsch AC, Heffelfinger JD. HIV screening in an urban emergency department: comparison of screening using an opt-in versus an opt-out approach. Ann Emerg Med 2011; 58:S89-95. [PMID: 21684416 DOI: 10.1016/j.annemergmed.2011.03.032] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We compare outcomes of opt-in and opt-out HIV screening approaches in an urban emergency department. METHODS This was a 1-year prospective observational study comparing 2 6-month screening approaches. Eligibility for opt-in and opt-out screening was identical: aged 15 years or older, medically stable, and able to complete general consent. During the opt-in phase, triage nurses referred patients to HIV testers stationed at triage, who obtained separate opt-in written consent and performed rapid oral fluid tests. During the opt-out phase, registration staff conducted integrated opt-out consent and then referred patients to HIV testers. We assessed the proportion of potentially eligible patients who were offered screening (screening offer rate), the proportion offered screening who accepted (screening acceptance rate), the proportion who accepted screening and subsequently completed testing (test completion rate), and the proportion of potentially eligible patients who completed testing (overall screening rate) during each phase. RESULTS For the opt-in versus the opt-out phases, respectively, there were 23,236 potentially eligible patients versus 26,757, screening offer rate was 27.9% versus 75.8% (P<.001), screening acceptance rate was 62.7% versus 30.9% (P<.001), test completion rate was 99.8% versus 74.6% (P<.001), and overall screening rate was 17.4% versus 17.5% (P = .90). CONCLUSION A significantly higher proportion of patients were offered HIV screening with an opt-out approach at registration. However, this was offset by much higher screening acceptance and test completion rates with the opt-in approach at triage. Overall screening rates with the 2 approaches were nearly identical.
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Affiliation(s)
- Douglas A E White
- Department of Emergency Medicine, Alameda County Medical Center, Highland Hospital, Oakland, CA 94602, USA.
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Rothman RE, Hsieh YH, Harvey L, Connell S, Lindsell CJ, Haukoos J, White DAE, Kecojevic A, Lyons MS. 2009 US emergency department HIV testing practices. Ann Emerg Med 2011; 58:S3-9.e1-4. [PMID: 21684405 DOI: 10.1016/j.annemergmed.2011.03.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We characterize HIV testing practices and programs in US emergency departments (EDs) in 2009. METHODS A national Web-based survey of members of the National ED HIV Testing Consortium, participants in the 2007 Centers for Disease Control and Prevention (CDC)-sponsored ED HIV Testing Workshops, all US academic EDs, and a weighted random sample of US community EDs with snowball sampling to recruit additional testing sites was conducted. Data collected included geographic location, estimated seroprevalence, indications for testing, method of consent, weekly number of tests, funding, and costs. RESULTS Of 619 sites surveyed, 338 (54.6%) responded. A total of 277 (82.0%) reported conducting any HIV testing, and 75 (22.2%) reported systematic HIV testing programs, operationally defined as having testing or screening organized at the departmental or institutional level. systematic HIV testing programs were concentrated in the Northeast, at high-volume urban EDs, and in regions with higher HIV/AIDS prevalence. Most systematic HIV testing programs had existed for less than or equal to 3 years, and nearly one third reported using an opt-out approach for consent. Among systematic HIV testing programs, the number of patients tested ranged from less than 1 to 2,100 tests per week. Overall, universal screening was the most commonly reported screening method reported overall, and rates of HIV positivity were consistently above the CDC threshold of 0.1%. CONCLUSION The number of EDs conducting HIV testing has grown substantially since release of the 2006 CDC HIV testing recommendations. Although many EDs have systematic HIV testing programs, the majority do not. Ongoing surveillance will be required to quantify the evolution of ED-based HIV testing and the factors that facilitate or impede expanded translation.
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Affiliation(s)
- Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21209, USA.
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Hsieh YH, Jung JJ, Shahan JB, Pollack HA, Hairston HS, Moring-Parris D, Kelen GD, Rothman RE. Outcomes and cost analysis of 3 operational models for rapid HIV testing services in an academic inner-city emergency department. Ann Emerg Med 2011; 58:S133-9. [PMID: 21684392 DOI: 10.1016/j.annemergmed.2011.03.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We compare the outcomes and costs of alternative staffing models for an emergency department (ED) rapid HIV testing program. METHODS A rapid oral-fluid HIV testing program was instituted in an inner-city ED in 2005. Three staffing models were compared during 24.5 months: indigenous medical staff only, exogenous staff only, or exogenous staff plus medical staff (hybrid). Personnel obtained written consent and provided brief pretest counseling, obtained kits, collected specimens, returned specimens to the ED satellite laboratory, and performed posttest counseling and referral to care. Cost analysis was performed to estimate cost per patient tested and cost per patient linked to care. RESULTS Overall, 44 of 2,958 (1.5%) patients tested received confirmed positive results and 30 (68%) were linked to care. The exogenous staff only model yielded the highest number tested per month (587), and indigenous medical staff only yielded the lowest (57). Significantly higher positivity rates were found in both indigenous medical staff only (2.2%) and hybrid (2.0%) models versus the exogenous staff only model (0.6%) (prevalence rate ratio: 3.7 [95% confidence interval {CI}1.5 to 9.3] versus 3.4 [95% CI 1.5 to 7.8], respectively). All patients with confirmed positive results were linked to care in the indigenous medical staff only model but only approximately 60% were linked to care in the 2 other models (linked to care rate ratio versus exogenous staff only: 1.8 [95% CI 1.1 to 4.4]; versus hybrid: 1.7 [95% CI 1.2 to 2.5]). The indigenous medical staff only model had the highest cost ($109) per patient tested, followed by the hybrid ($87) and the exogenous staff only ($39). However, the indigenous medical staff only model had the lowest cost ($4,937) per patient linked to care, followed by the hybrid ($7,213) and exogenous staff only ($11,454). CONCLUSION The exogenous staff only model tested the most patients at the least cost per patient tested. The indigenous medical staff only model identified the fewest patients with unrecognized HIV infection and had the highest cost per patient tested but the lowest cost per patient linked to care.
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Affiliation(s)
- Yu-Hsiang Hsieh
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21209, USA.
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Haukoos JS, White DAE, Lyons MS, Hopkins E, Calderon Y, Kalish B, Rothman RE. Operational methods of HIV testing in emergency departments: a systematic review. Ann Emerg Med 2011; 58:S96-103. [PMID: 21684417 DOI: 10.1016/j.annemergmed.2011.03.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Casual review of existing literature reveals a multitude of individualized approaches to emergency department (ED) HIV testing. Cataloging the operational options of each approach could assist translation by disseminating existing knowledge, endorsing variability as a means to address testing barriers, and laying a foundation for future work in the area of operational models and outcomes investigation. The objective of this study is to provide a detailed account of the various models and operational constructs that have been described for performing HIV testing in EDs. METHODS Systematic review of PUBMED, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Web of Science through February 6, 2009 was performed. Three investigators independently reviewed all potential abstracts and identified all studies that met the following criteria for inclusion: original research, performance of HIV testing in an ED in the United States, description of operational methods, and reporting of specific testing outcomes. Each study was independently assessed and data from each were abstracted with standardized instruments. Summary and pooled descriptive statistics were reported by using recently published nomenclature and definitions for ED HIV testing. RESULTS The primary search yielded 947 potential studies, of which 25 (3%) were included in the final analysis. Of the 25 included studies, 13 (52%) reported results using nontargeted screening as the only patient selection method. Most programs reported using voluntary, opt-in consent and separate, signed consent forms. A variety of assays and communication methods were used, but relatively limited outcomes data were reported. CONCLUSION Currently, limited evidence exists to inform HIV testing practices in EDs. There appears to be recent progression toward the use of rapid assays and nontargeted patient selection methods, with the rate at which reports are published in the peer-reviewed literature increasing. Additional research will be required, including controlled clinical trials, more structured program evaluation, and a focus on an expanded profile of outcome measures, to further improve our understanding of which HIV testing methods are most effective in the ED.
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Affiliation(s)
- Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO 80204, USA.
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Sitlinger AP, Lindsell CJ, Ruffner AH, Wayne DB, Hart KW, Trott AT, Fichtenbaum CJ, Lyons MS. Preliminary program evaluation of emergency department HIV prevention counseling. Ann Emerg Med 2011; 58:S120-5.e1-3. [PMID: 21684390 DOI: 10.1016/j.annemergmed.2011.03.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Controversy surrounds the linkage of prevention counseling with emergency department (ED)-based HIV testing. Further, the effectiveness and feasibility of prevention counseling in the ED setting is unknown. We investigate these issues by conducting a preliminarily exploration of several related aspects of our ED's HIV prevention counseling and testing program. METHODS Our urban, academic ED provides formal client-centered prevention counseling in conjunction with HIV testing. Five descriptive, exploratory observations were conducted, involving surveys and analysis of electronic medical records and programmatic data focused on (1) patient perception and feasibility of prevention counseling in the ED, (2) patient perceptions of the need to link prevention counseling with testing, and (3) potential effectiveness of providing prevention counseling in conjunction with ED-based HIV testing. RESULTS Of 110 ED patients surveyed after prevention counseling and testing, 98% believed privacy was adequate, and 97% reported that their questions were answered. Patients stated that counseling would lead to improved health (80%), behavioral changes (72%), follow-up testing (77%), and discussion with partners (74%). However, 89% would accept testing without counseling, 32% were willing to seek counseling elsewhere, and 26% preferred not to receive the counseling. Correct responses to a 16-question knowledge quiz increased by 1.6 after counseling (95% confidence interval 1.3 to 12.0). The program completed counseling for 97% of patients tested; however, 6% of patients had difficulty recalling the encounter and 13% denied received testing. Among patients undergoing repeated testing, there was no consistent change in self-reported risk behaviors. CONCLUSION Participants in the ED prevention counseling and testing program considered counseling acceptable and useful, though not required. Given adequate resources, prevention counseling can be provided in the ED, but it is unlikely that all patients benefit.
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Affiliation(s)
- Andrea P Sitlinger
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0769, USA
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Affiliation(s)
- G D Kelen
- Department of Emergency Medicine, The Johns Hopkins University, Baltimore, MD 21205, USA.
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Abstract
OBJECTIVE We identify undiagnosed HIV among adult emergency department (ED) patients awaiting medicine admission through rapid testing, expedite their redirection to the inpatient HIV service, and improve linkage to ambulatory HIV care. METHODS Two ED health educators offered rapid testing to patients aged 18 to 64 years from the high-acuity ED area from which most medicine admissions originate. Heath educators obtained consent, obtained fingerstick blood, and performed point-of-care testing. Patients with reactive results received counseling, confirmatory testing, and appointments at the affiliated HIV clinic. RESULTS Between March 1, 2008, and February 28, 2009, 4,755 patients received testing. Thirty patients (0.6%) had received a new diagnosis of HIV; 26 were admitted and redirected to the HIV service. Characteristics of HIV positive patients were mean age 38 years, 87% men, 64% black, and 33% Hispanic; 76% had CD4 counts less than 200 cells/mm(3); 67% had HIV-related diagnoses; and 93% reported for ambulatory HIV care in a median of 10 days. During 2 preceding years, these patients had a mean of 3 previous health system visits without testing. During a 6-month quality assurance interval of the 5,340 ED medicine admissions, 31% of patients were eligible for testing, of whom 88% received testing (1% positive) and 12% declined; 29% of the 5,340 were not approached for testing; and 40% were deemed ineligible. Common reasons for ineligibility included older age, recent previous test, and known HIV-positive status. CONCLUSION Patients who receive a diagnosis of HIV in our ED before admission are extremely ill, most having AIDS. Targeted HIV screening of ED patients awaiting hospital admission facilitated timely diagnosis and reliable linkage to inpatient and outpatient HIV care.
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Public health and clinical impact of increasing emergency department-based HIV testing: perspectives from the 2007 conference of the National Emergency Department HIV Testing Consortium. Ann Emerg Med 2011; 58:S151-9.e1. [PMID: 21684395 DOI: 10.1016/j.annemergmed.2011.03.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Understanding perceived benefits and disadvantages of HIV testing in emergency departments (EDs) is imperative to overcoming barriers to implementation. We codify those domains of public health and clinical care most affected by implementing HIV testing in EDs, as determined by expert opinion. METHODS Opinions were systematically collected from attendees of the 2007 National ED HIV Testing Consortium meeting. Structured evaluation of strengths, weaknesses, opportunities, and threats analysis was conducted to assess the impact of ED-based HIV testing on public health. A modified Delphi method was used to assess the impact of ED-based HIV testing on clinical care from both individual patient and individual provider perspectives. RESULTS Opinions were provided by 98 experts representing 42 academic and nonacademic institutions. Factors most frequently perceived to affect public health were (strengths) high volume of ED visits and high prevalence of HIV, (weaknesses) undue burden on EDs, (opportunities) reduction of HIV stigma, and (threats) lack of resources in EDs. Diagnostic testing and screening for HIV were considered to have a favorable impact on ED clinical care from both individual patient and individual provider perspectives; however, negative test results were not perceived to have any benefit from the provider's perspective. The need for HIV counseling in the ED was considered to have a negative impact on clinical care from the provider's perspective. CONCLUSION Experts in ED-based HIV testing perceived expanded ED HIV testing to have beneficial impacts for both the public health and individual clinical care; however, limited resources were frequently cited as a possible impediment. Many issues must be resolved through further study, education, and policy changes if the full potential of HIV testing in EDs is to be realized.
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Torres GW, Heffelfinger JD, Pollack HA, Barrera SG, Rothman RE. HIV Screening Programs in US Emergency Departments: A Cross-Site Comparison of Structure, Process, and Outcomes. Ann Emerg Med 2011; 58:S104-13. [DOI: 10.1016/j.annemergmed.2011.03.034] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Waxman MJ, Popick RS, Merchant RC, Rothman RE, Shahan JB, Almond G. Ethical, Financial, and Legal Considerations to Implementing Emergency Department HIV Screening: A Report From the 2007 Conference of the National Emergency Department HIV Testing Consortium. Ann Emerg Med 2011; 58:S33-43. [DOI: 10.1016/j.annemergmed.2011.03.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Christopoulos KA, Kaplan B, Dowdy D, Haller B, Nassos P, Roemer M, Dowling T, Jones D, Hare CB. Testing and linkage to care outcomes for a clinician-initiated rapid HIV testing program in an urban emergency department. AIDS Patient Care STDS 2011; 25:439-44. [PMID: 21545296 DOI: 10.1089/apc.2011.0041] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The urban emergency department is an important site for the detection of HIV infection. Current research has focused on strategies to increase HIV testing in the emergency department. As more emergency department HIV cases are identified, there need to be well-defined systems for linkage to care. We conducted a retrospective study of rapid HIV testing in an urban public emergency department and level I trauma center from June 1, 2008, to March 31, 2010. The objectives of this study were to evaluate the increase in the number of tests and new HIV diagnoses resulting from the addition of targeted testing to clinician-initiated diagnostic testing, describe the demographic and clinical characteristics of patients with newly diagnosed HIV infection, and assess the effectiveness of an HIV clinic based linkage to care team. Of 96,711 emergency department visits, there were 5340 (5.5%) rapid HIV tests performed, representing 4827 (91.3%) unique testers, of whom 62.4% were male and 60.8% were from racial/ethnic minority groups. After the change in testing strategy, the median number of tests per month increased from 114 to 273 (p=0.004), and the median number of new diagnoses per month increased from 1.5 to 4 (p=0.01). From all tests conducted, there were 65 new diagnoses of HIV infection (1.2%, 95% confidence interval [CI] 0.9%, 1.5%). The linkage team connected over 90% of newly diagnosed and out-of-care HIV-infected patients to care. In summary, the addition of targeted testing to diagnostic testing increased new HIV case identification, and an HIV clinic-based team was effective at linkage to care.
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Affiliation(s)
- Katerina A. Christopoulos
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - Beth Kaplan
- Department of Emergency Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - David Dowdy
- Department of Internal Medicine, University of California San Francisco, San Francisco, California
| | - Barbara Haller
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California
| | - Patricia Nassos
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California
| | - Marguerite Roemer
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California
| | - Teri Dowling
- HIV Prevention Section, San Francisco Department of Public Health, San Francisco, California
| | - Diane Jones
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
| | - C. Bradley Hare
- HIV/AIDS Division, San Francisco General Hospital, University of California San Francisco, San Francisco, California
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Physician-Initiated Rapid HIV Testing in an Urban Emergency Department: Comparison of Testing Using a Point-of-Care Versus a Laboratory Model. Ann Emerg Med 2011; 58:S53-9. [DOI: 10.1016/j.annemergmed.2011.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Spielberg F, Kurth AE, Severynen A, Hsieh YH, Moring-Parris D, Mackenzie S, Rothman R. Computer-facilitated rapid HIV testing in emergency care settings: provider and patient usability and acceptability. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2011; 23:206-221. [PMID: 21696240 DOI: 10.1521/aeap.2011.23.3.206] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Providers in emergency care settings (ECSs) often face barriers to expanded HIV testing. We undertook formative research to understand the potential utility of a computer tool, "CARE," to facilitate rapid HIV testing in ECSs. Computer tool usability and acceptability were assessed among 35 adult patients, and provider focus groups were held, in two ECSs in Washington State and Maryland. The computer tool was usable by patients of varying computer literacy. Patients appreciated the tool's privacy and lack of judgment and their ability to reflect on HIV risks and create risk reduction plans. Staff voiced concerns regarding ECS-based HIV testing generally, including resources for follow-up of newly diagnosed people. Computer-delivered HIV testing support was acceptable and usable among low-literacy populations in two ECSs. Such tools may help circumvent some practical barriers associated with routine HIV testing in busy settings though linkages to care will still be needed.
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Christopoulos KA, Koester K, Weiser S, Lane T, Myers JJ, Morin SF. A comparative evaluation of the process of developing and implementing an emergency department HIV testing program. Implement Sci 2011; 6:30. [PMID: 21450053 PMCID: PMC3073926 DOI: 10.1186/1748-5908-6-30] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 03/30/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The 2006 Centers for Disease Control and Prevention (CDC) HIV testing guidelines recommend screening for HIV infection in all healthcare settings, including the emergency department (ED). In urban areas with a high background prevalence of HIV, the ED has become an increasingly important site for identifying HIV infection. However, this public health policy has been operationalized using different models. We sought to describe the development and implementation of HIV testing programs in three EDs, assess factors shaping the adoption and evolution of specific program elements, and identify barriers and facilitators to testing. METHODS We performed a qualitative evaluation using in-depth interviews with fifteen 'key informants' involved in the development and implementation of HIV testing in three urban EDs serving sizable racial/ethnic minority and socioeconomically disadvantaged populations. Testing program HIV prevalence ranged from 0.4% to 3.0%. RESULTS Three testing models were identified, reflecting differences in the use of existing ED staff to offer and perform the test and disclose results. Factors influencing the adoption of a particular model included: whether program developers were ED providers, HIV providers, or both; whether programs took a targeted or non-targeted approach to patient selection; and the extent to which linkage to care was viewed as the responsibility of the ED. A common barrier was discomfort among ED providers about disclosing a positive HIV test result. Common facilitators were a commitment to underserved populations, the perception that testing was an opportunity to re-engage previously HIV-infected patients in care, and the support and resources offered by the medical setting for HIV-infected patients. CONCLUSIONS ED HIV testing is occurring under a range of models that emerge from local realities and are tailored to institutional strengths to optimize implementation and overcome provider barriers.
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Affiliation(s)
- Katerina A Christopoulos
- San Francisco General Hospital HIV/AIDS Division, University of California San Francisco, San Francisco, CA, USA.
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Leider J, Fettig J, Calderon Y. Engaging HIV-positive individuals in specialized care from an urban emergency department. AIDS Patient Care STDS 2011; 25:89-93. [PMID: 21247337 DOI: 10.1089/apc.2010.0205] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Linking patients who test positive for HIV in an emergency department (ED) setting to HIV care can be challenging. The aim of this study was to assess whether a multimedia HIV testing model utilized in an inner-city ED can effectively link HIV-positive individuals into specialized medical care. A prospective cohort study was performed from October 2005 to January 2009 at an urban academic hospital with a Level 1 trauma center and in-house specialized HIV clinic. Patients were HIV tested in the ED using a multimedia video counseling program which included computer-assisted data collection. Patients who tested positive were linked to care by the same counselor who gave the test result. Linkage was immediate for discharged patients during clinic hours and patients tested during off-hours were scheduled a visit on the next business day. All follow-up was conducted through chart review. The public health advocates (PHAs) tested 24,495 patients over the course of the study, of whom 116 (0.47%) were HIV positive and 93 were newly diagnosed. A total of 83.6% (97/116) of HIV-positive individuals were linked into specialized care, defined here as an outpatient clinic visit within 30 days of diagnosis in the ED. The findings suggest that a multimedia testing model that includes a counselor who acts as tester and navigator can successfully link a high percentage of patients into specialized care.
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Affiliation(s)
- Jason Leider
- Jacobi Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | | | - Yvette Calderon
- Jacobi Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
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Results from a New York City emergency department rapid HIV testing program. J Acquir Immune Defic Syndr 2010; 53:420-2. [PMID: 20190591 DOI: 10.1097/qai.0b013e3181b7220f] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Haukoos JS, Lyons MS. Idealized models or incremental program evaluation: translating emergency department HIV testing into practice. Acad Emerg Med 2009; 16:1044-8. [PMID: 20053220 DOI: 10.1111/j.1553-2712.2009.00556.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Haukoos JS, Mehta SD, Harvey L, Calderon Y, Rothman RE. Research priorities for human immunodeficiency virus and sexually transmitted infections surveillance, screening, and intervention in emergency departments: consensus-based recommendations. Acad Emerg Med 2009; 16:1096-102. [PMID: 20053228 DOI: 10.1111/j.1553-2712.2009.00546.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article describes the results of the human immunodeficiency virus (HIV) and sexually transmitted infections (STI) prevention in the emergency department (ED) component of the 2009 Academic Emergency Medicine Consensus Conference entitled "Public Health in the ED: Surveillance, Screening, and Intervention." The objectives were to use experts to define knowledge gaps and priority research questions related to the performance of HIV and STI surveillance, screening, and intervention in the ED. A four-step nominal group technique was applied using national and international experts in HIV and STI prevention. Using electronic mail, an in-person meeting, and a Web-based survey, specific knowledge gaps and research questions were identified and prioritized. Through two rounds of nomination and refinement, followed by two rounds of election, consensus was achieved for 11 knowledge gaps and 14 research questions related to HIV and STI prevention in EDs. The overarching themes of the research priority questions were related to effectiveness, sustainability, and integration. While the knowledge gaps appear disparate from one another, they are related to the research priority questions identified. Using a consensus approach, we developed a set of priorities for future research related to HIV and STI prevention in the ED. These priorities have the potential to improve future clinical and health services research and extramural funding in this important public health sector.
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Affiliation(s)
- Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA.
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Broderick KB, Ranney ML, Vaca FE, D'Onofrio G, Rothman RE, Rhodes KV, Becker B, Haukoos JS. Study designs and evaluation models for emergency department public health research. Acad Emerg Med 2009; 16:1124-31. [PMID: 20053232 DOI: 10.1111/j.1553-2712.2009.00557.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract Public health research requires sound design and thoughtful consideration of potential biases that may influence the validity of results. It also requires careful implementation of protocols and procedures that are likely to translate from the research environment to actual clinical practice. This article is the product of a breakout session from the 2009 Academic Emergency Medicine consensus conference entitled "Public Health in the ED: Screening, Surveillance, and Intervention" and serves to describe in detail aspects of performing emergency department (ED)-based public health research, while serving as a resource for current and future researchers. In doing so, the authors describe methodologic features of study design, participant selection and retention, and measurements and analyses pertinent to public health research. In addition, a number of recommendations related to research methods and future investigations related to public health work in the ED are provided. Public health investigators are poised to make substantial contributions to this important area of research, but this will only be accomplished by employing sound research methodology in the context of rigorous program evaluation.
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Affiliation(s)
- Kerry B Broderick
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA.
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Haukoos JS, Hopkins E, Byyny RL, Conroy AA, Silverman M, Eisert S, Thrun M, Wilson M, Boyett B, Heffelfinger JD. Design and implementation of a controlled clinical trial to evaluate the effectiveness and efficiency of routine opt-out rapid human immunodeficiency virus screening in the emergency department. Acad Emerg Med 2009; 16:800-8. [PMID: 19673717 DOI: 10.1111/j.1553-2712.2009.00477.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In 2006, the Centers for Disease Control and Prevention (CDC) released revised recommendations for performing human immunodeficiency virus (HIV) testing in health care settings, including implementing routine rapid HIV screening, the use of an integrated opt-out consent, and limited prevention counseling. Emergency departments (EDs) have been a primary focus of these efforts. These revised CDC recommendations were primarily based on feasibility studies and have not been evaluated through the application of rigorous research methods. This article describes the design and implementation of a large prospective controlled clinical trial to evaluate the CDC's recommendations in an ED setting. From April 15, 2007, through April 15, 2009, a prospective quasi-experimental equivalent time-samples clinical trial was performed to compare the clinical effectiveness and efficiency of routine (nontargeted) opt-out rapid HIV screening (intervention) to physician-directed diagnostic rapid HIV testing (control) in a high-volume urban ED. In addition, three nested observational studies were performed to evaluate the cost-effectiveness and patient and staff acceptance of the two rapid HIV testing methods. This article describes the rationale, methodologies, and study design features of this program evaluation clinical trial. It also provides details regarding the integration of the principal clinical trial and its nested observational studies. Such ED-based trials are rare, but serve to provide valid comparisons between testing approaches. Investigators should consider similar methodology when performing future ED-based health services research.
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Affiliation(s)
- Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA.
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Kelen GD, Rothman RE. Emergency department-based HIV testing: too little, but not too late. Ann Emerg Med 2009; 54:65-71. [PMID: 19398241 DOI: 10.1016/j.annemergmed.2009.03.027] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 03/26/2009] [Accepted: 03/30/2009] [Indexed: 11/19/2022]
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