Cost-effectiveness of targeted human immunodeficiency virus screening in an urban emergency department

Cost-effectiveness of internet-based HIV screening among gay, bisexual and other men who have sex with men (GBMSM) in Metro Vancouver, Canada

BACKGROUND

GetCheckedOnline is an internet-based screening service aiming to increase HIV testing among gay, bisexual and other men who have sex with men (GBMSM). We assessed the cost-effectiveness of GetCheckedOnline in its first implementation phase at different uptake scenarios compared to clinic-based screening services alone in Metro Vancouver, Canada.

METHODS

From a healthcare payer's perspective, our cost-utility analysis used an established dynamic GBMSM HIV compartmental model estimating the probability of acquiring HIV, progressing through diagnosis, disease stages and treatment over a 30-year time horizon. The base case scenario assumed 4.7% uptake of GetCheckedOnline in 2016 (remainder using clinic-based services), with 74% of high-risk and 44% of low-risk infrequent testers becoming regular testers in five years. Scenario analyses tested increased GetCheckedOnline uptake to 10% and 15%.

RESULTS

The cost per test for GetCheckedOnline was $29.40 compared to clinic-based services $56.92. Compared with clinic-based screening services, the projected increase in testing frequency with 4.7% uptake of GetCheckedOnline increased the costs by $329,600 (95% Credible Interval: -$498,200, $571,000) and gained 4.53 (95%CrI: 0, 9.20) quality-adjusted life years (QALYs) in a 30-year time horizon. The probability of GetCheckedOnline being cost-effective was 34% at the threshold of $50,000 per QALY, and increased to 73% at the threshold of $100,000 per QALY. The results were consistent in the other uptake scenarios. The probability of GetCheckedOnline being cost-effective became 80% at the threshold of $50,000 per QALY if assuming 5-year time horizon.

CONCLUSIONS

GetCheckedOnline is almost half the cost of clinic-based services on a per-test basis. However, increased access to testing should be balanced with risk profiles of patients to ensure the implementation can be a cost-effective strategy for increasing HIV screening among GBMSM in Metro Vancouver. Additional analyses are needed to understand the impact of internet-based screening including screening for other STIs and in other populations.

Quality of health economic evaluations in emergency medicine journals: a systematic review

OBJECTIVE

Health economic evaluations are used in decision-making regarding resource allocation and it is imperative that they are completed with rigor. The primary objectives were to describe the characteristics and assess the quality of economic evaluations published in emergency medicine journals.

METHODS

Two reviewers independently searched 19 emergency medicine-specific journals via Medline and Embase from inception until March 3, 2022. Quality assessment was completed using the Quality of Health Economic Studies (QHES) tool, and the primary outcome was the QHES score out of 100. Additionally, we identified factors that may contribute to higher-quality publications.

RESULTS

7260 unique articles yielded 48 economic evaluations that met inclusion criteria. Most studies were cost-utility analyses and of high quality, with a median QHES score of 84 (interquartile range, IQR: 72, 90). Studies based on mathematical models and those primarily designed as an economic evaluation were associated with higher quality scores. The most commonly missed QHES items were: (i) providing and justifying the perspective of the analysis, (ii) providing justification for the primary outcome, and (iii) selecting an outcome that was long enough to allow for relevant events to occur.

CONCLUSIONS

The majority of health economic evaluations in the emergency medicine literature are cost-utility analyses and are of high quality. Decision analytic models and studies primarily designed as economic analyses were positively correlated with higher quality. To improve study quality, future EM economic evaluations should justify the choice of the perspective of the analysis and the selection of the primary outcome.

Financing Benefits and Barriers to Routine HIV Screening in Clinical Settings in the United States: A Scoping Review

The Centers for Disease Control and Prevention recommends everyone between 13-64 years be tested for HIV at least once as a routine procedure. Routine HIV screening is reimbursable by Medicare, Medicaid, expanded Medicaid, and most commercial insurance plans. Yet, scaling-up HIV routine screening remains a challenge. We conducted a scoping review for studies on financial benefits and barriers associated with HIV screening in clinical settings in the U.S. to inform an evidence-based strategy to scale-up routine HIV screening. We searched Ovid MEDLINE^®, Cochrane, and Scopus for studies published between 2006-2020 in English. The search identified 383 Citations; we screened 220 and excluded 163 (outside the time limit, irrelevant, or outside the U.S.). Of the 220 screened articles, we included 35 and disqualified 155 (did not meet the eligibility criteria). We organized eligible articles under two themes: financial benefits/barriers of routine HIV screening in healthcare settings (9 articles); and Cost-effectiveness of routine screening in healthcare settings (26 articles). The review concluded drawing recommendations in three areas: (1) Finance: Incentivize healthcare providers/systems for implementing HIV routine screening and/or separate its reimbursement from bundle payments; (2) Personnel: Encourage nurse-initiated HIV screening programs in primary care settings and educate providers on CDC recommendations; and (3) Approach: Use opt-out approach.

The Cost-Effectiveness of HIV/STI Prevention in High-Income Countries with Concentrated Epidemic Settings: A Scoping Review

The purpose of this scoping review is to establish the state of the art on economic evaluations in the field of HIV/STI prevention in high-income countries with concentrated epidemic settings and to assess what we know about the cost-effectiveness of different measures. We reviewed economic evaluations of HIV/STI prevention measures published in the Web of Science and Cost-Effectiveness Registry databases. We included a total of 157 studies focusing on structural, behavioural, and biomedical interventions, covering a variety of contexts, target populations and approaches. The majority of studies are based on mathematical modelling and demonstrate that the preventive measures under scrutiny are cost-effective. Interventions targeted at high-risk populations yield the most favourable results. The generalisability and transferability of the study results are limited due to the heterogeneity of the populations, settings and methods involved. Furthermore, the results depend heavily on modelling assumptions. Since evidence is unequally distributed, we discuss implications for future research.

Risk-Based Screening Tools to Optimise HIV Testing Services: a Systematic Review

PURPOSE OF REVIEW

Effective ways to diagnose the remaining people living with HIV who do not know their status are a global priority. We reviewed the use of risk-based tools, a set of criteria to identify individuals who would not otherwise be tested (screen in) or excluded people from testing (screen out).

RECENT FINDINGS

Recent studies suggest that there may be value in risk-based tools to improve testing efficiency (i.e. identifying those who need to be tested). However, there has not been any systematic reviews to synthesize these studies. We identified 18,238 citations, and 71 were included. The risk-based tools identified were most commonly from high-income (51%) and low HIV (<5%) prevalence countries (73%). The majority were for "screening in" (70%), with the highest performance tools related to identifying MSM with acute HIV. Screening in tools may be helpful in settings where it is not feasible or recommended to offer testing routinely. Caution is needed for screening out tools, where there is a trade-off between reducing costs of testing with missing cases of people living with HIV.

Targeted HIV screening in the emergency department

Despite considerable improvement in human immunodeficiency virus (HIV) knowledge and treatment in the last 3 decades, the overall number of people living with HIV (PLHIV) is still rising with up to one quarter being unaware of their HIV status. Early HIV diagnosis and treatment prolongs life, reduces transmission, improves quality of life, and is a cost-effective public health intervention. The emergency department (ED) sees a large number of patients from marginalized and traditionally underserved populations in whom HIV is known to be more prevalent and who may not attend traditional services because of either cultural reasons or because of a chaotic lifestyle. This article discusses the two main approaches to screening; 'Opt-out' screening offers testing routinely in all clinical settings, and 'Targeted' screening offers testing to individuals presenting with indicator conditions. There are many studies of 'Opt-out' ED HIV screening in urban areas of high-HIV prevalence. However, little is known about the effectiveness of 'targeted' HIV screening, especially in areas of low prevalence. This review discusses the background to HIV screening in the ED and reviews the evidence around 'targeted' HIV screening in adult EDs in different HIV prevalence settings, concluding that targeted HIV screening at the ED can be impactful, cost-effective, and well accepted in the ED population, but its long-term implementation requires extra funding and increased staffing resource limiting its application in low resource setting. Despite most evidence being from areas of high-HIV prevalence, targeted screening might also be appropriate in low-HIV prevalence areas.

Economic evaluation of HIV testing options for low-prevalence high-income countries: a systematic review

INTRODUCTION

This study reviewed the economic evidence of rapid HIV testing versus conventional HIV testing in low-prevalence high-income countries; evaluated the methodological quality of existing economic evaluations of HIV testing studies; and made recommendations on future economic evaluation directions of HIV testing approaches.

METHODS

A systematic search of selected databases for relevant English language studies published between Jan 1, 2001, and Jan 30, 2019, was conducted. The methodological design quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) and the Drummond tool. We reported the systematic review according to the PRISMA guidelines.

RESULTS

Five economic evaluations met the eligibility criteria but varied in comparators, evaluation type, perspective, and design. The methodologic quality of the included studies ranged from medium to high. We found evidence to support the cost-effectiveness of rapid HIV testing approaches in low-prevalence high-income countries. Rapid HIV testing was associated with cost per adjusted life year (QALY), ranging from $42,768 to $90,498. Additionally, regardless of HIV prevalence, rapid HIV testing approaches were the most cost-effective option.

CONCLUSIONS

There is evidence for the cost-effectiveness of rapid HIV testing, including the use of saliva-based testing compared to usual care or hospital-based serum testing. Further studies are needed to draw evidence on the relative cost-effectiveness of the distinct options and contexts of rapid HIV testing.

The Role of Targeted HIV Screening in the Emergency Department: A Scoping Review

BACKGROUND

Human immunodeficiency virus (HIV) infection continues to expand worldwide, and a significant proportion of infection is still undiagnosed. Recent studies have addressed the impact and feasibility of 'opt-out' HIV screening in Emergency Departments (EDs) in urban settings at high HIV prevalence, whereas little is known about the yield of implementing 'targeted' HIV testing, especially in low-prevalence areas.

OBJECTIVE

The present study undertakes a scoping review of research carried out on the implementation of targeted HIV screening of adult in EDs to determine the impact, feasibility and acceptability of HIV testing in different HIV prevalence settings.

DESIGN

Online databases (EMBASE, MEDLINE) were used to identify papers published between 2000 to 2020. A three-concept search was employed with HIV (HIV, Human immunodeficiency virus infection, HIV infections), targeted testing (Target, screening or testing) and emergency medicine (Emergency Service, emergency ward, A&E, accident and emergency or Emergency Department) (28^th February 2020). Only full-text articles written in English, French, Spanish or Italian and using impact and/or feasibility and/or acceptability of the program as primary or secondary outcomes were analysed.

RESULTS

The search provided 416 articles. Of these, 12 met inclusion criteria and were included in the final review. Most of the included studies were carried out in the United States (n=8; 67%) and in areas of high HIV prevalence (n=11; 92%). Three (20%) were randomized control studies. While the rate of newly diagnosed HIV cases varied widely (0.03-2.2%), likely due to methodological heterogeneity between studies, the linkage of new HIV diagnosis was often high (80-100%) and median CD4+ cell count was always greater than 200 cells per microliter. Targeted HIV screening was found to be cost-effective (out of 2 studies) and well accepted by participants (out 2 studies).

CONCLUSIONS

Targeted HIV screening at the ED can be impactful, feasible and well accepted, but often requires extra funding and staff. Most previous work has focused on areas of high disease prevalence.

Cost-effectiveness of HIV screening in emergency departments: a systematic review

In 2016 worldwide, 1.8 million people were newly infected with HIV. About 36.7 million had HIV but 14 million were unaware, did not seek treatment and were likely to infect others. Undiagnosed HIV infection is a major contributor to transmission. Therefore, screening is critical to prevention. Although CDC recommends routine screening in the emergency department (ED), implementation is not universal or sustained. Cost-effectiveness of ED-based screening could enhance implementation. We address the question: Is HIV screening in the ED cost-effective? Using the Joanna Briggs Institute guidelines, we conducted a systematic review of economic evaluations of ED-based HIV screening. We found 311 studies with 12 duplicates. We excluded 276 studies that did not conduct economic evaluations and another three for lack of quantitative data, leaving 20 articles for the full review. We reviewed cost-effectiveness ratios (CER), incremental cost-effectiveness ratios (ICER), and average costs per diagnosis, quality-adjusted life years, averted transmissions and per patient linked to care. CER and ICER were below CDC thresholds indicating that HIV screening in the ED is cost-effective. Therefore, ED-based HIV screening should be widely implemented, supported and sustained as a cost-effective tool for combating HIV/AIDS.

"That Can't Be!": Perceptions of HIV and Hepatitis C Screening during Admission to an Acute Care Surgery Service

Background:

A large number of patients live with undiagnosed HIV and/or hepatitis C despite broadened national screening guidelines. European studies, however, suggest many patients falsely believe they have been screened during a prior hospitalization. This study aims to define current perceptions among trauma and emergency general surgery (EGS) patients regarding HIV and hepatitis C screening practices.

Methods:

Prospective survey administered to adult (>18 years old) acute care surgery service (trauma and EGS) patients at a Level 1 academic trauma center. The survey consisted of 13 multiple choice questions: demographics, whether admission tests included HIV and hepatitis C at index and prior hospital visits and whether receiving no result indicated a negative result, prior primary care screening. Response percentages calculated in standard fashion.

Results:

One hundred and twenty-five patients were surveyed: 80 trauma and 45 EGS patients. Overall, 32% and 29.6% of patients believed they were screened for HIV and hepatitis C at admission. There was no significant difference in beliefs between trauma and EGS. Sixty-eight percent of patients had a hospital visit within 10 years of these, 49.3% and 44.1% believe they had been screened for HIV and hepatitis C. More EGS patients believed they had a prior screen for both conditions. Among patients who believed they had a prior screen and did not receive any results, 75.9% (HIV) and 80.8% (hepatitis C) believed a lack of results meant they were negative. Only 28.9% and 23.6% of patients had ever been offered outpatient HIV and hepatitis C screening.

Conclusions:

A large portion of patients believe they received admission or prior hospitalization HIV and/or hepatitis C screening and the majority interpreted a lack of results as a negative diagnosis. Due to these factors, routine screening of trauma/EGS patients should be considered to conform to patient expectations and national guidelines, increase diagnosis and referral for medical management, and decrease disease transmission.

A different form of injury prevention: Successful screening and referral for human immunodeficiency virus and hepatitis C virus in a trauma population

BACKGROUND

In the United States, millions of patients are living with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) (0.44% and 1.5%) and many are currently undiagnosed. Because highly effective treatments are now available, early identification of these patients is extremely important to achieve improved clinical outcomes. Prior data and trauma-associated risk factors suggest a higher prevalence of both diseases in the trauma population. We hypothesized that a screening program could be successfully initiated among trauma activation patients and that a referral and linkage-to-care program could be developed.

METHODS

Hepatitis C virus and HIV screening tests were added to standard trauma activation laboratory orders at an academic Level I Trauma Center. Confirmatory viral load was sent when indicated. Patients with positive results were educated about their disease and referred to disease-specific follow-up. Data were collected prospectively from January 1, 2016, until June 30, 2017. Total and new diagnosis, referral rates, and linkage-to-care rates were analyzed.

RESULTS

One thousand eight hundred ninety-eight patients arrived as trauma activations. One thousand two hundred seventeen (64.1%) patients were screened (Level A, 75.6%; Level B, 60.2%). Seven percent of the screened patients were initially positive, and 5.5% were confirmed positive. Rates of both HIV (1.1%) and HCV (4.4%) were almost triple the national average. Overall, 3.3% screened positive for a new diagnosis. For HCV, the rate of new diagnosis was twice the national average (3%). Over 85% of all cases were referred for follow-up, and the combined linkage-to-care rate was 43.3%.

CONCLUSION

The majority of patients were screened and referred for follow-up, indicating successful implementation of our trauma screening program. Routine screening of trauma patients should be considered to increase diagnosis rate, increase linkage-to-care rates, and decrease disease transmission. These screening efforts would help bridge the health care gap that exists in the trauma population due to lower insurance rates and limited access to primary care.

LEVEL OF EVIDENCE

Therapeutic/Care management, level III.

Cost-effectiveness of HIV screening in high-income countries: A systematic review

INTRODUCTION

Over 2 million people in high-income countries live with HIV. Early diagnosis and treatment present benefits for infected subjects and reduce secondary transmissions. Cost-effectiveness analyses are important to effectively inform policy makers and consequently implement the most cost-effective programmes. Therefore, we conducted a systematic review regarding the cost-effectiveness of HIV screening in high-income countries.

METHODS

We followed PRISMA statements and included all papers evaluating the cost-effectiveness of HIV screening in the general population or in specific subgroups.

RESULTS

Thirteen studies considered routine HIV testing in the general population. The most cost-effective option appeared to be associating one-time testing of the general population with annual screening of high-risk groups, such as injecting-drug users. Thirteen studies assessed the cost-effectiveness of HIV screening in specific settings, outlining the attractiveness of similar programmes in emergency departments, primary care, sexually transmitted disease clinics and substance abuse treatment programmes.

DISCUSSION

Evidence regarding the health benefits and cost-effectiveness of HIV screening is growing, even in low-prevalence countries. One-time screenings offered to the adult population appear to be a valuable choice, associated with repeated testing in high-risk populations. The evidence regarding the benefits of using a rapid test, even in terms of cost-effectiveness, is growing. Finally, HIV screening seems useful in specific settings, such as emergency departments and STD clinics.

Costs of Expanded Rapid HIV Testing in Four Emergency Departments

OBJECTIVE

The HIV Prevention Trials Network (HPTN) 065 trial sought to expand HIV screening of emergency department (ED) patients in Bronx, New York, and Washington, D.C. This study assessed the testing costs associated with different expansion processes and compared them with costs of a hypothetical optimized process.

METHODS

Micro-costing studies were conducted in two participating EDs in each city that switched from point-of-care (POC) to rapid-result laboratory testing. In three EDs, laboratory HIV testing was only conducted for patients having blood drawn for clinical reasons; in the other ED, all HIV testing was conducted with laboratory testing. Costs were estimated through direct observation and interviews to document process flows, time estimates, and labor and materials costs. A hypothetical optimized process flow used minimum time estimates for each process step. National wage and fringe rates and local reagent costs were used to determine the average cost (excluding overhead) per completed nonreactive and reactive test in 2013 U.S. dollars.

RESULTS

Laboratory HIV testing costs in the EDs ranged from $17.00 to $23.83 per completed nonreactive test, and POC testing costs ranged from $17.64 to $37.60; cost per completed reactive test ranged from $89.29 to $123.17. Costs of hypothetical optimized HIV testing with automated process steps were approximately 45% lower for nonreactive tests and 20% lower for reactive tests. The cost per ED visit to conduct expanded HIV testing in each hospital ranged from $1.21 to $3.96.

CONCLUSION

An optimized process could achieve additional cost savings but would require an investment in electronic system interfaces to further automate testing processes.

Novel emergency department registration kiosk for HIV screening is cost-effective

High operating costs challenge sustainability of successful US emergency department (ED) HIV screening programs. Free-standing registration kiosks could potentially reduce the marginal costs of ED HIV screening. We investigated incremental cost-effectiveness ratio (CER) per new HIV diagnosis for a kiosk-based approach for offering screening at ED registration versus a testing staff-based approach to offer testing at the bedside. A rapid oral-fluid HIV screening program, instituted in a US ED since 2005, had a rate of new HIV diagnosis 0.16% in 2012. A two-phase quasi experimental design, including a testing staff-based approach to offer testing at the bedside (Phase I, August and September 2011) and a kiosk-based approach to offer testing at ED registration (Phase II, December 2011 and January 2012), was performed. CER per new HIV diagnosis was defined as total cost of the screening program divided by number of newly diagnosed cases. Costs included screening program personnel (study coordinator, testing staff, and kiosk helpers), diagnostic assays (rapid and confirmatory tests), and kiosks (2 kiosks, software, and IT consulting fees). Sensitivity analyses were performed. Data from our dedicated testing staff (DTS) program (Phase I) resulted in an estimated 5434 patients tested in one year and 9 newly diagnosed HIV-infected patients (95% CI: 3, 18). Data from the kiosk program (Phase II), resulted in a projected 4571 ED patients tested in one year and 21 newly diagnosed HIV-infected patients (95% CI: 4, 70). The overall cost was $ 201,433 for the DTS program, versus $292,008 for the kiosk program. Incremental CER per new HIV diagnosis for kiosk-based approach was $7523 (range: $1780-90,025 by sensitivity analysis). Our pilot data demonstrated that the use of kiosks for HIV screening was potentially more cost-effective than a testing staff-based bedside approach.

Prevalence of Heavy Drinking and Risky Sexual Behaviors in Adult Emergency Department Patients

BACKGROUND

The study aim was to assess the prevalence and co-occurrence of alcohol and sexual risk behaviors among emergency department (ED) patients in community hospitals.

METHODS

Systematic screening of ED patients (N = 6,486; 56.5% female) was conducted in 2 community hospitals in the northeast during times with high patient volume, generally between the hours of 10 AM to 8 PM, Monday through Saturday. Screening occurred from May 2011 through November 2013. Assessment included validated measures of alcohol use and sexual risk behavior.

RESULTS

Overall results identified high rates of alcohol use, sexual risk behaviors, and their co-occurrence in this sample of ED patients. Specifically, ED patients in between the ages of 18 and 35 were consistently highest in hazardous alcohol use (positive on the Alcohol Use Disorders Identification Test or endorsing heavy episodic drinking [HED]), sexual risk behaviors, and the co-occurrence of alcohol and sex-risk behaviors.

CONCLUSIONS

Findings show a high co-occurrence of hazardous drinking and unprotected sex among ED patients and highlight the role of HED as a factor associated with sexual risk behavior. Efforts to integrate universal screening for the co-occurrence of alcohol and sexual risk behavior in ED settings are warranted; brief interventions delivered to ED patients addressing the co-occurrence of alcohol and sexual risk behaviors have the potential to decrease the risk of sexually transmitted infections and HIV among a large number of patients.

Level of impact on the public health of universal human immunodeficiency virus screening in an Emergency Department

INTRODUCTION

The aim of this study was to determine the prevalence of HIV and the acceptability of rapid testing in an emergency department (ED), Barcelona (6/07/2011 to 8/03/2013).

METHOD

A convenience sample was used, depending on nurse availability in the ED. Participants signed an informed consent. Results were confirmed by conventional methods.

RESULT

A total of 2,140 individuals were offered testing, and 5% rejected taking part (107/2,140). Three subjects (3/2,033 [0.15%]) had confirmed reactive test. Individuals with a higher education were more likely to perform a rapid HIV test in ED (P<.005).

CONCLUSION

A low prevalence of new HIV diagnoses was found among participants, although there was a high acceptability rate to perform rapid testing in the ED.

Cost-effectiveness analysis along the continuum of HIV care: how can we optimize the effect of HIV treatment as prevention programs?

The cascade of HIV care has been proposed as a useful tool to monitor health system performance across the key stages of HIV care delivery to reduce morbidity, mortality, and HIV transmission, the focal points of HIV Treatment as Prevention campaigns. Interventions to improve the cascade at its various stages may vary substantially in their ability to deliver health value per amount expended. In order to meet global antiretroviral treatment access targets, there is an urgent need to maximize the value of health spending by prioritizing cost-effective interventions. We executed a literature review on economic evaluations of interventions to improve specific stages of the cascade of HIV care. In total, 33 articles met the criteria for inclusion in the review, 22 (67 %) of which were published within the last 5 years. Nonetheless, substantial gaps in our knowledge remain, particularly for interventions to improve linkage and retention in HIV care in developed and developing-world settings and generalized and concentrated epidemics. We make the case here that the attention of scientists and policymakers needs to turn to the development, implementation, and rigorous evaluation of interventions to improve the various stages of the cascade of HIV care.

Characteristics of U.S. emergency departments that offer routine human immunodeficiency virus screening

OBJECTIVES

The association between emergency department (ED) characteristics, ED director's perceptions of preventive services, and the availability of human immunodeficiency virus (HIV) screening are unknown. The authors hypothesized that, after adjusting for ED operational and demographic characteristics, teaching hospital status would be associated with increased availability, and ED crowding and ED director agreement with barriers to screening would be associated with decreased availability.

METHODS

This was a secondary, cross-sectional analysis on previously collected data from 2008 to 2009 regarding availability of ED preventive services. Data were obtained from a random sample of 277 EDs in which ED directors provided information on ED characteristics and availability of HIV screening and rated five barriers to providing preventive services. The association between the availability of HIV screening and teaching hospital and crowding status, ED volume, urban-rural location, ownership, geographic region, patient demographics, state HIV testing consent laws, and ED director opinions on barriers to providing preventive services were determined in univariate analyses and a multivariate logistic regression model.

RESULTS

Nineteen percent of the sampled EDs offer HIV screening. Teaching hospitals offer HIV screening more frequently than nonteaching hospitals (38% vs. 18%; p = 0.03), but after adjusting for other characteristics in a multivariate model, this association was not significant (relative risk ratio [RR] = 2.07, 95% confidence interval [CI] = 0.91 to 3.59). ED crowding also was not significantly associated with screening availability (RR = 0.66, 95% CI = 0.34 to 1.21). However, public ownership (RR = 2.13, 95% CI = 1.28 to 3.14), 24-hour social work (RR = 1.87, 95% CI = 1.02 to 2.99), uninsured population ≥35% (RR = 2.48, 95% CI = 1.39 to 3.69), increased local nonwhite minority population percentage (RR = 1.14 per 10%, 95% CI = 1.02 to 1.26), and state laws allowing opt-out consent for testing (RR = 1.76, 95% CI = 1.01 to 2.74) were associated with increased availability of screening in multivariable analysis. EDs whose directors were concerned about added costs were associated with decreased availability of screening (RR = 0.45, 95% CI = 0.23 to 0.85).

CONCLUSIONS

After adjusting for other ED operational and demographic characteristics, ED crowding and teaching hospital affiliation were not independently associated with the availability of HIV screening. EDs whose directors were concerned about the cost of preventive services were less likely to provide routine HIV screening. Addressing ED director's concerns about the added costs of ED preventive services, increasing social work availability, and implementing testing laws consistent with Centers for Disease Control and Prevention (CDC) recommendations may facilitate increased adoption of ED HIV screening.

Long-term follow-up after voluntary human immunodeficiency virus/sexually transmitted infection counseling, point-of-service testing, and referral to substance abuse treatment from the emergency department

OBJECTIVES

Public health initiatives have lowered human immunodeficiency virus (HIV) transmission risk associated with injection drug use in the United States, making sexual risk behaviors a greater source of transmission. Strategies are therefore needed to reduce these risk behaviors among all emergency department (ED) patients who use drugs, regardless of route of administration. Although recent articles have focused on the opportunity for early HIV detection and treatment through an array of ED screening and testing strategies, the effect of voluntary HIV testing and brief counseling (VT/C) on the sexual behaviors of out-of-treatment drug users over time has not yet been reported.

METHODS

From November 2004 to May 2008, the study screened 46,208 urban ED patients aged 18 to 54 years; 2,148 (4.6%) reported cocaine or heroin use within 30 days, 1,538 met eligibility criteria (Drug Abuse Severity Test [DAST] scores ≥3 and were either English- or Spanish-speaking), and 1,030 were enrolled. These data were obtained in the course of a randomized, controlled trial (Project SAFE) of a brief motivational intervention focused on reducing risky sexual behaviors. Although the intervention itself did not demonstrate any differential effect on the number or percentage of unprotected sexual acts, both control and intervention group participants received baseline VT/C and referral for drug treatment as part of the study protocol. This study is a report of a secondary analysis of cohort data to describe changes in sexual behaviors over time among drug users after the VT/C and referral.

RESULTS

The mean (±SD) age of enrollees was 35.8 (±8.4) years; 67% were male, 39% were non-Hispanic black or African American, 41% were white non-Hispanic, and 19% were Hispanic. Half injected drugs, and 53% met criteria for posttraumatic stress disorder (PTSD). At baseline testing, 8.8% were HIV-positive on enzyme-linked immunosorbent assay. Follow-ups were conducted at 6 and 12 months, with an attrition rate of 22%. Known HIV-positive patients accounted for 84 of 1,030 cases (8.1%), and 13 new cases were discovered: 7 of 946 at were discovered at the baseline contact (0.74%), 2 of 655 were discovered at 6 months (0.3%), and 4 of 706 (0.57%) were discovered at the 12-month contact. Twelve of the 13 returned for confirmatory testing and were actively enrolled in our infectious disease clinic. For all partners, there was a reduction in the percentage of unprotected sex acts over time (p < 0.0001), with decreases at 6 months versus baseline (odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.60 to 0.83), sustained at 12 months versus baseline (OR = 0.69, 95% CI = 0.58 to 0.82). For the outcome of percentage of sex acts while high, there was also a significant reduction over time (p < 0.0001), with a drop-off at 6 months versus baseline (OR = 0.31, 95% CI = 0.25 to 0.37) that was sustained at 12 months (OR vs. baseline 0.25, 95% CI = 0.20 to 0.30). In an adjusted model, male sex, older age, and HIV positivity predicted significant declines over time in the likelihood of unprotected sexual acts. Older age and higher baseline drug severity predicted significant decreases over time in the likelihood of sex acts while high.

CONCLUSIONS

Voluntary testing and counseling for HIV or sexually transmitted infections, accompanied by referral to drug treatment, for this population of ED cocaine and heroin users was associated with reduction in unprotected sex acts and fewer sex acts while high.

Testing and linkage to care outcomes for a clinician-initiated rapid HIV testing program in an urban emergency department

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.