Emergency Medicine

Routine opt-out HIV emergency department screening only slightly improves identification of patients with HIV infection

Infection with the human immunodeficiency virus (HIV) remains an important public health problem. Approximately 230,000 infections remain undiagnosed, with about 56,000 people newly infected each year. In 2006, the Centers for Disease Control and Prevention (CDC) revised their testing guidelines to expand the scope of HIV testing by recommending routine (nontargeted) opt-out HIV screening in health care settings, including emergency departments (EDs) where the prevalence of undiagnosed infection is 0.1 percent or greater. This nontargeted approach only marginally improved HIV diagnoses over physician-directed rapid HIV screening of at-risk ED patients, according to a new study.

The researchers compared newly diagnosed HIV infection using the two approaches on patients at a high-volume urban ED. Under the new recommendation, patients arriving at the ED were informed that rapid HIV testing would be conducted unless the person declined it. The researchers compared this approach with physician-directed diagnostic testing of patients considered to be at increased risk for HIV infection based on clinical characteristics or actual or perceived behavioral characteristics ascertained during the patient's evaluation. The researchers enrolled more than 60,000 ED patients over a 2-year period. Of the 28,043 patients included in the opt-out phase, 6,702 were screened, of whom 16 were confirmed with HIV infection, and 10 patients had new diagnoses (most of whom were identified late in the course of the disease). Of the 29,925 patients included in the physician-directed phase, 243 underwent testing, of whom 5 were confirmed with HIV infection, and 4 patients had new diagnoses.

The nontargeted screening was associated with around 30 times more rapid HIV tests than the diagnostic testing, yet only a few more patients with newly identified HIV infection were found. This study was supported in part by the Agency for Healthcare Research and Quality (HS17526).

See "Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients," by Jason S. Haukoos, M.D., M.Sc., Emily Hopkins, M.S.P.H., Amy A. Conroy, M.P.H., and others in the July 21, 2010, Journal of the American Medical Association 304(3), pp. 284-292.

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