The human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) together remain one of the leading causes of illness and death in the United States. The United Nations Report on the Global AIDS Epidemic estimates more than 1.5 million Americans were living with HIV in 2009. Even more staggering, there were more than 34 million people infected worldwide at the end of 2010. (www.unaids.org.)
The AIDS pandemic prompted the Centers for Disease Control and Prevention to recommend in 2006 that all U.S. health care settings, including emergency departments, conduct HIV screening of patients 13 to 64 seeking medical care regardless of their risks for HIV infection. (MMWR Recomm Rep 2006;55[RR-14]:1.) In an effort to better support and implement these recommendations, the National Emergency Department HIV Testing Consortium convened in November 2007 to consider all aspects of ED-based HIV screening.
A primary argument for increased HIV screening is that it serves a greater good. Those previously unaware of their HIV-positive status would presumably be more likely to decrease risky behavior. According to the article, 25 percent of HIV infections are found in “people who do not perceive themselves to be at risk and have no identified risk factors.” Now more than ever, effective antiviral therapy can halt the progression of HIV-related disease. Advocates maintain than HIV screening can be accomplished even in large-volume EDs with minimal financial impact and minimal resources. (Ann Emerg Med 2011;58[1 Suppl 1]:S79.) As failures of the primary care system continue to encroach on our EDs, perhaps it has become our duty to identify patients unknowingly carrying this deadly virus.
On the other hand, the ED is usually a pretty busy place that routinely struggles with another deadly health problem — emergencies. Without additional provisions, any resources shifted away from emergency care threatens the ability to fulfill that vital role. HIV testing also carries with it a lot of baggage — test-related counseling, mandatory reporting, partner notification, referral to follow-up, and uncertain reimbursement, not to mention potential ethical and legal ramifications from reporting false-positive tests or not providing positive test results at all. In the Annals study, 25 percent of patients newly diagnosed with HIV were not notified before they left the ED. These cases were referred to local public health authorities, with an unknown rate of successful contact. (Ann Emerg Med 2011;58[1 Suppl 1]:S79).
The bottom line is that a simple but loaded question needs to be answered. Should we universally screen for HIV in the emergency department?
A national survey recently reported that 22 percent of EDs had systematic HIV screening programs in place in 2009, and concluded that ED-based HIV testing has grown substantially since the release of the 2006 CDC recommendations. (Ann Emerg Med 2011;58[1 Suppl 1]:S3.) This figure is likely to be highly inflated. In the study, only 54.6 percent of surveyed EDs actually responded, and EDs targeted in the survey were highly selected from a group that previously showed interest in HIV screening. Bear in mind, too, that more than 90 percent of sites that performed systematic screening in their EDs reported receiving external funding for it.
If financial obstacles weren't enough, Mumma and Suffoletto reported on a pilot program of HIV screening in an urban ED where they encountered numerous barriers categorized as departmental, public health, legal, institutional, test-related, and infrastructural. Ultimately, they discovered two HIV-positive patients in 395 screened (0.5%). They concluded that successful ED-based screening would depend on fundamental changes in resource availability, public health culture, institutional requirements, and HIV-testing law. (Ann Emerg Med 2011;58[1 Suppl 1]:S44.)
Emergency departments best serve the public good by excelling at their primary directive: ruling out and treating emergencies. In our health system, no other venue is willing or able to fill that role. The ED serves as a safety net for the uninsured in our community, the one health care door that by law remains open to all comers, at least until an emergency is ruled out. Without appropriate provisions, these CDC recommendations have the potential to interfere with this primary directive, especially if regulatory agencies choose to make them mandates.
Universal ED-based HIV screening is an admirable goal, but at this time remains an unreasonable burden for most EDs. If it is ultimately determined that the ED is going to be delegated this task, it will have to come with substantial legislative change to support the effort adequately. Perhaps a better idea is to allow EDs to remain focused on their primary directive and bolster resources in areas where HIV screening might be better accepted, more easily administered, and offer higher yield: primary care offices, mobile clinics, pharmacies, needle exchange programs, methadone clinics, marijuana dispensaries, homeless shelters, massage parlors, strip clubs, casinos, urban sidewalks, or local malls.
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Dr. Cha is a senior resident in the University of California Los Angeles (UCLA)-Olive View Emergency Medicine Residency Program. Dr. Lovato is an associate professor at the David Geffen School of Medicine at UCLA, the director of critical care in emergency medicine at Olive View-UCLA Medical Center, the co-chair for the Emergency Medicine Best Practices Committee for the Los Angeles County Department of Health Services, and an instructor for the National MegaLLSA Review Course (www.megallsa.com).
C. difficile common in Chicago
An outbreak strain of Clostridium difficile, a bacterium that causes diarrhea and sometimes life-threatening inflammation of the colon, is frequently found in Chicago-area acute care hospitals, according to a study at the Chicago and Cook County health departments published in the September issue of Infection Control and Hospital Epidemiology. (Infect Control Hosp Epidemiol 2011;32:897.)
The health departments surveyed 25 Chicago-area hospitals over one month in 2009, and identified 263 cases of C. difficile as a discharge diagnosis. Of those cases, 61 percent were the strain known as BI/NAPI, which is recognized to cause more serious illness.
“Our findings highlight the need for effective interventions aimed at reducing the risk of C. difficile infection,” said Stephanie Black, MD, of the Chicago Department of Public Health and the investigation's lead author.
The study found that the transfer of patients from one facility to another helped spread the BI strain. Half of the patients with the BI strain in the study were transferred from one health care facility to another. C. difficile is most common in elderly patients and those receiving treatment with antibiotics.