Scaling up HIV Testing in an Academic Emergency Department: An Integrated Testing Model with Rapid Fourth-Generation and Point-of-Care Testing

Abstract

Objective. We evaluated two approaches for implementing routine HIV screening in an inner-city, academic emergency department (ED). These approaches differed by staffing model and type of HIV testing technology used. The programmatic outcomes assessed included the total number of tests performed, proportion of newly identified HIV-positive patients, and proportion of newly diagnosed individuals who were linked to care. Methods. This study examined specific outcomes for two distinct, successive approaches to implementing HIV screening in an inner-city, academic ED, from July 2012 through June 2013 (Program One), and from August 2013 through July 2014 (Program Two). Program One used a supplementary staff-only HIV testing model with point-of-care (POC) oral testing. Program Two used a triage-integrated, nurse-driven HIV testing model with fourth-generation blood and POC testing, and an expedited linkage-to-care process. Results. During Program One, 6,832 eligible patients were tested for HIV with a rapid POC oral HIV test. Sixteen patients (0.2%) were newly diagnosed with HIV, of whom 13 were successfully linked to care. During Program Two, 8,233 eligible patients were tested for HIV, of whom 3,124 (38.0%) received a blood test and 5,109 (62.0%) received a rapid POC test. Of all patients tested in Program Two, 29 (0.4%) were newly diagnosed with HIV, four of whom had acute infections and 27 of whom were successfully linked to care. We found a statistically significant difference in the proportion of the eligible population tested—8,233 of 49,697 (16.6%) in Program Two and 6,832 of 46,818 (14.6%) in Program One. These differences from Program One to Program Two corresponded to increases in testing volume ( n = 1,401 tests), number of patients newly diagnosed with HIV ( n=13), and proportion of patients successfully linked to care (from 81.0% to 93.0%). Conclusion. Integrating HIV screening into the standard triage workflow resulted in a higher proportion of ED patients being tested for HIV as compared with the supplementary staff-only HIV testing model. New rapid fourth-generation testing technology allowed the identification of acute HIV infection and same-visit confirmation of a positive diagnosis.