EDs Reluctant to Grow Routine HIV Testing Programs

EDs Reluctant to Grow Routine HIV Testing Programs But Some Successes Taking Root

by PAIGE HEWITT Special Contributor to Annals News & Perspective

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hen the CDC in 2006 recommended that emergency departments (EDs) across America routinely test for HIV, EDs— on board in spirit—responded with a firm pause. Emergency medicine of course supported the ideal of diagnosing HIV patients and linking them to care and counseling as early as possible. After all, as the HIV epidemic marches, the ED— seen by some advocates as a perfect touch point for early detection— has a front-row seat in caring for many of the nation’s 1 million HIV patients, an estimated 250,000 of whom don’t know they’re infected and thus are at greater risk to themselves and others. “The initial reaction was relatively positive. Provider groups were supportive of the proposal and intent. But there were concerns about some logistics,” said Bernard Branson, MD, associate director for laboratory diagnostics for the CDC’s Division of HIV/AIDS Prevention. The American College of Emergency Physicians’ board of directors in April 2007 endorsed ED-based screening, as long as it’s practical and doesn’t interfere with the primary acute care mission of the ED. “Early diagnosis and treatment for [HIV] can prolong life, reduce transmis16A Annals of Emergency Medicine

sion, and has been demonstrated to be a cost-effective public health intervention,” the board said. However, EDs across the nation— overburdened, underfunded—flatly ignored the guidelines initially, arguing on legitimate

grounds and noting the CDC’s recommendation was not accompanied with a how-to guide to address critical issues. What kind

of testing should be done? Which patients should be tested? How do you address confidentiality, ethics? Who has the time or staff to conduct all those tests? Should HIV screening get financial priority over other types of screening? And, of course, who would pay? The barriers turned up in a national survey of preventive services in US EDs, published in Annals of Emergency Medicine in February 2011. It found that only 19% of ED directors reported that their institution offered HIV screening (it didn’t establish how widespread the screening was, or to whom the test was offered). Only 2% wanted to implement HIV screening, meaning they were far less enthusiastic about ED-based HIV testing than the 10 other public health interventions in the survey. “Proponents of ED HIV screenings, such as the CDC, will need to demonstrate that HIV screening is not just a worthy priority among the competing priorities for acute care but also a priority among the other preventive services that ED directors appear to prefer,” the authors wrote. Although the CDC’s recommendation is still met with reluctance—and a slew of logistics and sustainability concerns still linger—many EDs nonetheless are stepping up their HIV testing, and a few have adopted substantive components of the guidelines during the last year or two, emerging as models for an increasing number of providers exploring how it might be done, said Michael S. Lyons, MD, Department of Emergency Medicine, University of Cincinnati College of Medicine. (See related story on HIV testing experience in Washington, DC.) Advocates for routine HIV testing in the ED, who say testing is prevention, point to such indicators as a suggestion that a shift of sorts may be under way. Volume , .  : April 

Dr. Lyons said CDC’s 2006 guidelines— which recommended broader HIV testing, including at such nontraditional sites at EDs—have provoked more dialogue, more dollars, and more study on testing for HIV in the ED. Dr. Branson, with CDC, observed the same. “I think we will see continuation of a lot of programs, and potentially expansion. People have gained more experience in doing this kind of screening, and their approaches have evolved into being potentially more feasible and cost effective,” he said.

lion. The number of jurisdictions also was increased, to 35, Dr. Branson said. Dr. Lyons said EDs around the nation are implementing various components of CDC’s guidelines, and in different ways. He emphasized that each ED is unique and has its own needs and priorities, which may not necessarily include routine HIV testing or screening. Some sites test routinely; others don’t. Some EDs use opt-in testing, in which testing is conducted only when a patient requests it. Some sites administer opt-out testing—passing the burden to patients to say no—to all patients or only to high-risk

FINDING FUNDING

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DC launched the HIV initiative—recommending that EDs administer such screening unless undiagnosed infection fell below 0.1%—with $35 million in supplemental funding, distributing the money through health departments to 25 jurisdictions with large numbers of AIDS cases among blacks, disproportionately affected by the epidemic, Dr. Branson said. “That fostered implementation and relieved concerns,” Dr. Branson said. “It made it affordable. The CDC funding is made available to the health departments, which sort of decide and negotiate who gets it, exactly how they will do testing, and which people get tested.” Funding was not strictly earmarked for EDs, but most of it went to EDs in the first 3 years, Dr. Branson said. “Given the substantial benefits of treatment and very likely high benefit for prevention . . . the goal was to ensure that people who were HIV infected did not go through the health care system without finding out,” he said. “HIV is treatable, like any other chronic condition, like diabetes. If they are diagnosed early and treated, they can achieve normal life expectancy. The earlier you find someone, the more effective you can be in preserving their immune system.” Secondary goals included making HIV testing more feasible and less stigmatizing, he said. The CDC renewed that 3-year funding for 2010, increasing it to $47 mil-

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patients. EDs in Houston, Dallas, San Francisco, Washington, DC, and Denver, for instance, have opt-out HIV testing.

OPT OUT

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Ds have various approaches in place, but all of course are subject to state consent laws, which vary widely across the country, Dr. Lyons said. But

for sites that meet the CDC’s benchmark—in which undiagnosed infection has not dropped below 0.1%—a key element in opt-out testing is commitment, Dr. Lyons said. In other words, if there is a will to make it work, it just might. He said there is indeed such will at Ben Taub General Hospital in Houston, where HIV long has been at a crisis point. Ben Taub’s new HIV cases represent a 0.65 positive rate, more than 6 times higher than the CDC’s standard. Among the CDC’s original 25 sites in the initiative, Ben Taub is part of the Harris County Hospital District and a Level I trauma center whose ED treats about 300 patients per day. Ben Taub, implementing opt-out HIV testing, “has come the closest” to adopting the substance of what the CDC recommended 4 years ago, Dr. Lyons said. Its ED links with the hospital district’s freestanding HIV/AIDS treatment operation, Thomas Street Health Center, with a focus on early detection. “It’s terribly exciting, what’s been going on in Houston,” Dr. Lyons said. “There’s a lot to learn from them.” Ben Taub, which receives 2 or 3 visits/inquiries monthly about its opt-out testing from other EDs around the nation, started its Universal Screening for HIV program in August 2008, operating on about $1.2 million since its inception, the hospital said. All patients aged 18 to 64 years and requiring blood tests during their visit to Ben Taub’s ED, as well as the other county hospital, LBJ, are routinely tested also for HIV unless they opt out of the testing. Blood is processed in fewer than 2 hours; counselors meet with patients who receive positive test results. Patients are alerted about the op-out testing by signs posted about the ED; staff inform them verbally and privately during admission. Such opt-out testing—avoiding singling out patients— further helps to “de-stigmatize the topic of HIV, which even in the health care world is unfortunately often treated as Annals of Emergency Medicine 17A

taboo,” said Shkelzen Hoxhaj, MD, MPH, MBA, Emergency Services, Ben Taub General Hospital, and Emergency Medicine, Baylor College of Medicine. “For us it’s no different than testing for diabetes,” said Dr. Hoxhaj, who has been credited by others for being a key driver behind Ben Taub’s mission to diagnose, especially patients unaware they are infected. Ben Taub tests with rapid blood draws, costing $4 each, compared with oral swab tests, which are more time consuming and cost the ED $10. Testing there is paid for with federal monies and local funds. Medicare and Medicaid do not cover routine testing, and it’s too soon to know if and how the nation’s new health care measure will affect routine HIV screening, Dr. Hoxhaj said. “The greatest success is identifying patients who would have never been tested and catching them early in the disease process when they are healthier and have better outcomes,” Dr. Hoxhaj said. “Additionally—those who knew they had tested HIV positive in the past but never sought care due to any number of reasons, including denial—this gives us an opportunity to intervene and link these patients into appropriate HIV care.”

PROMISING RESULTS

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esults: Ben Taub and LBJ have screened about 80,000 patients since starting the program in Au-

gust 2008. Among those cases, 459 people who did not know they were infected learned they had HIV. There were another 950 reconfirmed cases in which patients had not sought medical care. Ben Taub is pleased with their results, but there have been obstacles along the way, and challenges remain, Dr. Hoxhaj said. Early on, some staff were reluctant. “The biggest challenge was getting nursing and physician buy-in that this was an important issue in the emergency center and getting everyone on board with a true opt-out HIV testing,” he said. “We overcame this by sharing the staggering prevalence in our community and the benefits of early detection and treatment to the patient and slowing the spread of the disease in the community.” Another problem has been training because Ben Taub is a teaching hospital. “The turnover is great, and residents go through the areas regularly,” said Ken Malone, HIV testing project coordinator for the county’s HIV/AIDS clinic. “It is a challenge to monitor the results and finetune problem areas, but overall, it has worked well.” Another relatively smaller challenge was the availability of counselors on weekends and nights, so physicians and nurses were educated on that issue, and the ED developed education and follow-up materials for patients, Dr. Hoxhaj said. Linkage— ensuring patients return to clinics for definitive HIV care—is still

Routine HIV Testing in the ED The Experience in the Nation’s Capital

by JOANNE KENEN Special Contributor to Annals News & Perspective

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n estimated 3.2% of Washington, DC’s, population—and more than 7% of its black men—are infected with HIV/AIDS. That’s triple the overall 18A Annals of Emergency Medicine

US rate and as severe as in some parts of Africa. Those rates constitute an emergency, and local emergency departments (EDs) have responded with initiatives to screen patients and direct those who receive positive test results to clinics where they can receive life-prolonging care. They are trying to make HIV testing as routine—and as free of stigma—as other

the system’s greatest challenge. “Oftentimes our patients do not give us accurate contact information, or it changes frequently,” Dr. Hoxhaj said. “This has become better as our staff has been trained in behavior-based interviewing and intervention.” Those approaches have shown some promise. Ben Taub’s linkage-to-care rate has increased to 80% in recent months compared with less than 40% when its opt-out testing was started, Dr. Hoxhaj said. Dr. Lyons said that although testing is prevention, he acknowledged the nation cannot test its way out of an epidemic, marked and holding steady with 56,000 new cases annually. “But I think we’ve reached a tipping point. It’s not going to go away,” he said. Section editor: Truman J. Milling, Jr, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. doi:10.1016/j.annemergmed.2011.02.007

common tests and screenings and in the process challenge common misconceptions about how HIV testing will increase crowding, add to length of stay, and burden an already burdened staff. Not every hospital in DC has yet gone full speed ahead on testing, despite the encouragement of the city’s Department of Health, which has observed progress in expanding free testing and getting people into care before the disease progresses. But those EDs that have embarked on ED-based testing, largely using free test kits supplied by the city, have found that it’s workable and worthwhile. “The argument is made that the ED is not a public health intervention kind of place,” said Jeremy Brown, MD, research director and director of ED HIV screening, Department of Emergency Medicine Volume , .  : April 