Physician's Weekly Article - Lessons Learned in Implementing HIV Testing in EDs

       Although there is currently no clear guidance on appropriate implementation of HIV testing in EDs, new data provide insights on key strategies that may enable more hospitals to accomplish this feat effectively.

      About 20% of the estimated 1 million people living with HIV infection in the United States are unaware of their diagnosis. In 2006, as a response to these statistics, the CDC recommended that HIV testing be offered to adults aged 13 to 64 in all healthcare settings, including EDs. “The main shift was to go from risk-based HIV testing to routine HIV testing in the ED. The goal was to make HIV screening as routine as standard blood tests,” says Christian Arbelaez, MD, MPH. “Prior to the guidelines, there were, and still are, many missed opportunities to identify HIV-infected patients who had seen providers in primary care and acute care settings because they didn’t have the classic risk factors.”

      The American College of Emergency Physicians responded to the CDC recommendations with an HIV policy statement, which noted that screening must be practical, feasible, not interfere with the primary acute care mission, be based on local prevalence, and be integrated with local healthcare systems. Since then, numerous approaches to HIV testing in the ED have already been implemented as a public health screening service; such programs have had varying degrees of success. “Unfortunately,” says Dr. Arbelaez, “there have been long-standing barriers associated with HIV screening in the ED setting. Specific guidance for EDs on how to successfully and efficiently implement routine HIV screening will facilitate adoption into clinical practice.”

      New Testing Model Assessed

      Dr. Arbelaez, Rochelle P. Walensky, MD, MPH, and colleagues designed and implemented an HIV testing program, initiated in 2006. Findings were published online in the September 3, 2009 International Journal of Emergency Medicine. The study group identified several components to creating a successful HIV testing program in the ED. The framework included identification of a champion; completion of a needs assessment; development of a comprehensive team; selection of an appropriate HIV test; establishment of proper protocols and quality assurance measures; and provision of education and training for providers. “Our objective was to describe the protocol development and implementation strategies that worked for us so that other EDs embarking on such programs may benefit from what we learned,” Dr. Arbelaez explains.

      Collaboration is Critical

      When initiating a program for rapid HIV screening in EDs, Dr. Arbelaez says that a team leader must be evident from the time the program is first launched (Table 1). “The success of any ED-based HIV testing program relies heavily on the investment of designated champions who will lead efforts within the ED community and hospital.” Champions need to consider staff engagement, test selection, protocol development, education and training of personnel, and linkage to care. Dr. Walensky adds that “developing an interdisciplinary team of supportive clinical and administrative staff is a critical step in achieving success with rapid HIV screening programs in EDs. This includes involvement with ED personnel, infectious disease personnel, and laboratory services personnel.”

      In selecting the most appropriate HIV test to use, several factors should be taken into consideration, including the plans/locale for test development, current hospital standards, and costs and available resources. Space available to conduct point-of-care testing, test performance, and turn-around time for results are other important considerations. “Rapid HIV tests have facilitated routine testing; but even among them, there are those that can streamline the process to best suit your intended patient flow,” Dr. Arbelaez says.

      Properly educating and training personnel and other staff on HIV are paramount to successfully integrating a screening program in EDs. Dr. Arbelaez says that buy-in is best achieved if all staff understand the benefits of routine HIV testing (Table 2). “Previous research suggests that ED providers generally feel uninformed about HIV testing,” he says. “They also report that they would welcome more information and resources on the topic. Strategies for education and training to supplement communication efforts may include training sessions for protocols and procedures, HIV-related resources via local testing sites or websites, a program website, bulletin boards, walking rounds, and ‘frequently asked question’ handouts.”

      Another important consideration when designing and implementing HIV screening programs in EDs is spatial constraints. “Many patient care rooms are simply not private,” explains Dr. Arbelaez. “HIV testing is a sensitive issue that should be conducted privately, regardless of the results. Patients who consent for testing may also have questions about whether or not participating in HIV screening will affect their care or if their providers will be notified about their participation. Those establishing the program must consider if, whether, and how the results of an ED-based test will be documented in the medical record; patients will ask.”

      Planning Next Steps

      The development of a framework on appropriate protocols for reactive HIV screening test results is critical (Table 3). “It’s important to remember that positive test results often lead to anxiety for patients and staff,” says Dr. Arbelaez. “Specific plans should be in place to address and alleviate such anxieties for everyone.” The study team created a ‘Reactive (Positive) Result Packet,’ which included mock scripts and other tools to help personnel when delivering results. It also provides resources for follow-up and linkage to care. “Tools like this may help standardize processes, minimize confusion, and simply streamline the process for patients.” Dr. Arbelaez says.

      In settings where rapid tests are used, HIV-preliminary reactive results should be confirmed with a Western Blot, CD4 panel, and an HIV viral load. Once confirmed, resources should be devoted to link newly diagnosed HIV-infected patients to long-term HIV care, says Dr. Arbelaez. “Prescriptive plans should be in place so that ED staff can manage patients appropriately. These plans may include scheduling appointments, arranging transportation and parking, directions or maps to clinics, and having an interpreter available when necessary. Appointments should be made as quickly as possible after the availability of confirmatory results. If appointments aren’t kept, staff should be designated to make repeated attempts to discreetly reach patients in person, by phone, and/or by mail.” He adds that if patients leave without test results, there should be protocols in place to ensure that results are still received quickly and discretely to ensure that follow-up care is pursued.

      With the appropriate infrastructure and with longitudinal and financial support, Dr. Arbelaez says that routine HIV testing in the ED is feasible. “Our hope is that components of our program will serve as a model and preliminary guidance for other EDs so that we can reduce the burden of HIV in the U.S.”

      Christian Arbelaez, MD, MPH, and Rochelle P. Walensky, MD, MPH, have indicated to Physician’s Weekly that they have received grants/research aid from the NIH and have no other financial interests to report.