With this in mind, our group recently developed, validated, and preliminarily tested the comparative effectiveness of enhanced targeted HIV screening using an empirically derived clinical prediction instrument (Denver HIV Risk Score) to nontargeted HIV screening.40,42,43 The preliminary results demonstrate a significantly stronger association between enhanced targeted HIV screening and new HIV diagnoses than to nontargeted HIV screening in an urban emergency department.40 A multicenter clinical trial is currently underway to evaluate the broader comparative effectiveness of structured targeted screening versus nontargeted screening.44 The Denver HIV Risk Score includes only demographics (age, sex, race/ethnicity), 2 risk behaviors (sex with men and injection drug use), and history of HIV testing and has been shown to accurately stratify patients into 5 distinct risk groups from several different clinical settings, including emergency departments and STD clinics.
Although the study by Klein et al. does not provide details related to why HIV testing decreased among high-risk groups, it also raises the question as to whether a more structured risk-based approach would facilitate conversations about HIV testing, thus improving rates of testing and identification of newly diagnosed cases. Such standardized risk-based screening may also improve how clinicians identify patients for repeat screening, as recommended by the CDC for “high-risk” patients.6
Although HIV screening is feasible in clinical venues and will likely be the only way to achieve the goals set forth by the Office of National AIDS Policy, routine screening can take many forms and will likely need to vary depending on the venue. However, nontargeted HIV screening has had little impact even in settings where prevalence is highest. We must continue to work to understand which screening strategies are most effective at identifying patients with HIV infection. High-impact prevention must prioritize effectiveness and costs, feasibility of implementation, and coverage of target populations, and we believe that the study by Klein et al. provides more evidence in support of using more structured approaches to screen for HIV infection in health care settings.
2. Prejean J, Song R, Hernandez A, et al. Estimated HIV Incidence in the United States, 2006–2009. PLoS One 2011; 6: e17502.
3. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365: 493–505.
4. Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy and sexual risk behavior: A meta-analytic review. JAMA 2004; 292: 224–236.
5. Marks G, Crepaz N, Senterfitt JW, et al. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: Implications for HIV prevention programs. J Acquir Immune Defic Syndr 2005; 39: 446–453.
6. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006; 55: 1–17.
7. Bartlett JG, Branson BM, Fenton K, et al. Opt-out testing for human immunodeficiency virus in the United States: Progress and challenges. JAMA 2008; 300: 945–951.
9. Moyer VA, U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2013; 159: 51–60.
10. Haukoos JS. The impact of nontargeted HIV screening in emergency departments and the ongoing need for targeted strategies. Arch Intern Med 2012; 172: 20–22.
11. Klein P, Messer L, Myers E, et al. Impact of a routine, opt-out HIV teseting program on HIV testing and case detection in North Carolina sexually transmitted disease clinics. Sex Transm Dis 2014; 41: 395–402.
12. White DA, Scribner AN, Martin ME, et al. A comparison of patient satisfaction with emergency department opt-in and opt-out rapid HIV screening. AIDS Res Treat 2012; 2012: 904916.
13. Haukoos JS, Hopkins E, Bender B, et al. Use of kiosks and patient understanding of opt-out and opt-in consent for routine rapid human immunodeficiency virus screening in the emergency department. Acad Emerg Med 2012; 19: 287–293.
14. Centers for Disease Control and Prevention. Results of the expanded HIV testing initiative—25 jurisdictions, United States, 2007–2010. MMWR Morb Mortal Wkly Rep 2011; 60: 805–810.
16. Centers for Disease Control and Prevention. HIV testing among men who have sex with men—21 cities, United States, 2008. MMWR Morb Mortal Wkly Rep 2011; 60: 694–699.
17. Centers for Disease Control and Prevention. Expanded HIV testing and trends in diagnoses of HIV infection—District of Columbia, 2004–2008. MMWR Morb Mortal Wkly Rep 2010; 59: 737–741.
18. Centers for Disease Control and Prevention. Rapid HIV testing in emergency departments—Three U.S. sites, January 2005–March 2006. MMWR Morb Mortal Wkly Rep 2007; 56: 597–601.
19. Silva A, Glick NR, Lyss SB, et al. Implementing an HIV and sexually transmitted disease screening program in an emergency department. Ann Emerg Med 2007; 49: 564–572.
20. Mehta SD, Hall J, Lyss SB, et al. Adult and pediatric emergency department sexually transmitted disease and HIV screening: programmatic overview and outcomes. Acad Emerg Med 2007; 14: 250–258.
21. Brown J, Shesser R, Simon G, et al. Routine HIV screening in the emergency department using the new US Centers for Disease Control and Prevention Guidelines: results from a high-prevalence area. J Acquir Immune Defic Syndr 2007; 46: 395–401.
22. Walensky RP, Arbelaez C, Reichmann WM, et al. Revising Expectations from Rapid HIV Tests in the Emergency Department. Ann Intern Med 2008; 149: 153–160.
23. White DA, Scribner AN, Schulden JD, et al. Results of a Rapid HIV Screening and Diagnostic Testing Program in an Urban Emergency Department. Ann Emerg Med 2009; 54: 56–64.
24. Haukoos JS, Hopkins E, Conroy AA, et al. Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients. JAMA 2010; 304: 284–292.
25. Sattin RW, Wilde JA, Freeman AE, et al. Rapid HIV Testing in a Southeastern Emergency Department Serving a Semiurban-Semirural Adolescent and Adult Population. Ann Emerg Med 2011; 58 Suppl 1: S60–S64.
26. Wheatley MA, Copeland B, Shah B, et al. Efficacy of an Emergency Department-Based HIV Screening Program in the Deep South. J Urban Health 2011; 88: 1015–1019.
27. White DA, Scribner AN, Vahidnia F, et al. HIV Screening in an Urban Emergency Department: Comparison of Screening Using an Opt-In Versus an Opt-Out Approach. Ann Emerg Med 2011; 58 Suppl 1: S89–S95.
28. Hoxhaj S, Davila JA, Modi P, et al. Using nonrapid HIV technology for routine, opt-out HIV screening in a high-volume urban emergency department. Ann Emerg Med 2011; 58: S79–S84.
29. d’Almeida KW, Kierzek G, de Truchis P, et al. Modest Public Health Impact of Nontargeted Human Immunodeficiency Virus Screening in 29 Emergency Departments. Arch Intern Med 2012; 172: 12–20.
30. Wilbur L, Huffman G, Lofton S, et al. The Use of a Computer Reminder System in an Emergency Department Universal HIV Screening Program. Ann Emerg Med 2011; 58 Suppl 1: S71–S3 e1.
31. Casalino E, Bernot B, Bouchaud O, et al. Twelve months of routine HIV screening in 6 emergency departments in the Paris area: results from the ANRS URDEP study. PLoS One 2012; 7: e46437.
32. Haukoos JS, Hopkins E, Bender B, et al. Use of kiosks and patient understanding of opt-out and opt-in consent for routine rapid human immunodeficiency virus screening in the emergency department. Acad Emerg Med 2012; 19: 287–293.
33. Hack CM, Scarfi CA, Sivitz AB, et al. Implementing routine HIV screening in an urban pediatric emergency department. Pediatr Emerg Care 2013; 29: 319–323.
34. Haukoos JS, Hopkins E, Bender B, et al. Thrun MW. Comparison of enhanced targeted rapid HIV screening using the Denver HIV risk score to nontargeted rapid HIV screening in the emergency department. Ann Emerg Med 2013; 61: 353–361.
35. Lyons MS, Lindsell CJ, Ruffner AH, et al. Randomized Comparison of Universal and Targeted HIV Screening in the Emergency Department. J Acquir Immune Defic Syndr 2013; 64: 315–323.
36. Freeman AE, Sattin RW, Miller KM, Dias JK, Wilde JA. Acceptance of rapid HIV screening in a southeastern emergency department. Acad Emerg Med 2009; 16: 1156–1164.
37. Brown J, Kuo I, Bellows J, et al. Patient perceptions and acceptance of routine emergency department HIV testing. Public Health Rep 2008; 123 (suppl 3): 21–26.
38. Haukoos JS, Hopkins E, Conroy AA, et al. Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients. JAMA 2010; 304: 284–292.
39. White DA, Scribner AN, Vahidnia F, et al. HIV screening in an urban emergency department: Comparison of screening using an opt-in versus an opt-out approach. Ann Emerg Med 2011; 58 (suppl 1): S89–S95.
40. Haukoos JS, Hopkins E, Bender B, et al. Comparison of enhanced targeted rapid HIV screening using the Denver HIV risk score to nontargeted rapid HIV screening in the emergency department. Ann Emerg Med 2013; 61: 353–361.
41. Lyons MS, Lindsell CJ, Ruffner AH, et al. Randomized comparison of universal and targeted hiv screening in the emergency department. J Acquir Immune Defic Syndr 2013; 64: 315–323.
42. Haukoos JS, Lyons MS, Lindsell CJ, et al. Derivation and validation of the Denver Human Immunodeficiency Virus (HIV) risk score for targeted HIV screening. Am J Epidemiol 2012; 175: 838–846.
43. Haukoos J, Lyons M, Rothman R, et al. Validation of the refined Denver HIV Risk Score using a national HIV testing cohort. Conference on Retroviruses and Opportunistic Infections, 2014; Boston, MA; March 2014.
44. The HIV TESTED Trial Investigators. The HIV Testing using Enhanced Screening Techniques in Emergency Departments (TESTED) Trial, 2014. Available at www.DenverEDHIV.org
. Accessed April 7, 2014. ClinicalTrials.gov Identifier: NCT01781949.