Background: Undiagnosed HIV infection is prevalent among patients who present to urban emergency departments (EDs). Providing appropriate counseling, testing, and follow-up in the ED is difficult. The aim of this study was to evaluate the effectiveness of a referral-based outpatient HIV testing system for patients referred from the ED.
Methods: This was a prospective cohort study performed at an urban teaching hospital. Consecutive patients referred from the emergency department (ED) for outpatient HIV testing were enrolled. Data were collected from each patient's ED record and HIV clinic record, if applicable.
Results: Of the 586 referrals made from our ED, 494 (84%) met inclusion criteria. Only 56 patients (11%, 95% CI: 9-15%) arrived at the HIV clinic and completed pretest counseling. Of these, 51 (91%, 95% CI: 80-97%) tested negative for HIV, 4 (7%, 95% CI: 2-17%) tested positive for HIV, and 1 (2%, 95% CI: 0-10%) refused the test.
Conclusions: This referral system was ineffective at identifying unrecognized HIV infection due to poor adherence. Changes in the structure of the referral system or the use of point-of-care testing in the ED may improve the ability to detect HIV infection in this setting.
The Centers for Disease Control and Prevention (CDC) estimates that 900,000 individuals are infected with HIV in the United States, and the number of new infections is growing by approximately 40,000 per year. 1 The incidence has increased most dramatically over the past several years among racial and ethnic minorities, heterosexual men, and women. 2 In addition, it is estimated that 200,000 Americans currently have unrecognized infection, largely due to its long asymptomatic period and because many of those at risk have never been tested. 1
The introduction of highly active antiretroviral therapy has led to a significant reduction in HIV-related morbidity and mortality. 3 Thus, early identification and initiation of therapy, especially during the asymptomatic period, may delay disease progression and limit opportunistic infections. In addition, HIV counseling and testing, and the knowledge of one's HIV status, may allow for reduction in risk behaviors and prevention of secondary transmission. 4
Estimates of the prevalence of HIV infection among emergency department (ED) patients range from 0-14%. 5-7 The highest prevalence generally occurs in urban inner-city EDs, 5 where a large proportion of these patients have unrecognized HIV infection. 5 The CDC recommends testing all individuals in settings where the HIV prevalence is ≥1%. 8 Indeed, a recent review of the appropriateness of offering HIV screening to ED patients identified the ED as an important place to screen for HIV infection and recommended that EDs offer screening to high-risk patients. 9 However, current CDC guidelines for HIV counseling and testing recommend that information about HIV and personalized risk reduction counseling accompany the testing process during pretest and posttest interviews. 8 This is often impractical in the ED setting, despite the high prevalence of HIV in this setting. As a result, emergency physicians usually refer patients suspected of being either infected with, or at risk for, HIV to an outpatient HIV counseling and testing center.
Our institution currently provides a referral-based outpatient HIV counseling and testing system for those patients who present to our ED and who are identified as being at risk for or suspected of being infected with HIV. The purpose of this study was to determine the effectiveness of this system in identifying patients with previously undiagnosed HIV infection.