HIV screening in emergency departments/process/model
Will Patients “Opt In” to Perform Their Own Rapid HIV Test in the Emergency Department?

https://doi.org/10.1016/j.annemergmed.2011.03.029Get rights and content

Objective

We evaluate the feasibility and accuracy of existing point-of-care HIV tests performed by an untrained patient compared with the routinely used HIV point-of-care test offered to patients in 2 urban emergency departments (EDs).

Methods

From April 2008 through December 2009, patients who had completed a standard HIV oral fluid test performed by a trained health care professional and who were unaware of their results were recruited to perform a rapid point-of-care HIV test. Patients were given a choice of the oral fluid or the fingerstick blood point-of-care test. Evaluation of acceptability to perform the mechanics of the test was accessed by questionnaire. For the “self-test,” the participant obtained his or her own sample and performed the test. The patient's results were compared with standard oral fluid results obtained by the health care professional.

Results

Overall, 478 of 564 (85%) patients receiving a standard oral fluid HIV test volunteered, with a mean age of 38 to 39 years. Ninety-one percent of participants chose oral fluid and 9% chose blood (P<.05). Self-test results were 99.6% concordant with health care professionals' test results. For the self-testers, 94% of oral fluid testers and 84.4% of blood testers reported trusting the self-administered test result “very much.” Furthermore, 95.6% of the oral fluid group and 93.3% of the blood group would “probably” or “definitely” perform a test at home, if available.

Conclusion

This study demonstrated that a significant proportion of patients offered a self-HIV point-of-care test volunteered and preferred using oral fluid. Patients' results agreed with standard HIV point-of-care results. The majority of participants trusted their results and would perform a point-of-care HIV test at home, given the opportunity.

Introduction

Implementation of the Centers for Disease Control and Prevention guidelines for an “opt-out” policy under which HIV testing is normalized and offered routinely for patients aged 13 to 64 years and who are in contact with primary care has not been well implemented.1, 2, 3, 4, 5, 6

Our hypothesis was that if patients could be encouraged to perform their own HIV rapid test during the lengthy waiting periods after triage procedures in the emergency departments (EDs), significant staff time and money might be saved, but only if feasibility and accuracy could be demonstrated.

Our objective was to evaluate the feasibility and accuracy of existing point-of-care HIV tests performed by untrained patients compared with results of oral fluid point-of-care HIV tests performed by health care professionals in urban EDs.

Section snippets

Setting

The study was conducted in 2 urban EDs in Baltimore, MD. ED 1 is an inner-city ED with 60,000 visits/year, whose population is socioeconomically disadvantaged, composed of greater than 75% blacks and 15% injection drug users, and has an 11% to 12% HIV prevalence and a 2% to 3% newly recognized HIV infection rate. ED 2 serves an ethnically and socioeconomically diverse urban population, with 50,000 visits per year and 30% to 35% blacks. It has a high sexually transmitted disease prevalence, with

Characteristics

Overall, 478 of 565 (85%) patients who volunteered had just received the standard oral fluid HIV test. Ninety-one percent of participants chose the oral fluid test and 9% chose the blood test (P<.05). The demographics of the groups are presented in Table 1.

Primary Outcome of Collection and Performance

Ninety-seven percent of participants in the oral test group reported oral fluid “not at all hard to collect,” whereas 84% stated blood was “not at all hard to collect” from the fingerstick (Table 2). Similarly, 98.8% of the oral group and

Limitations

There are several limitations to this study. Because these were primarily urban hospital EDs, the results may not be generalizable to a population with different demographics. The design of the study, which required the patient to have just received an HIV point-of-care test and collected the oral fluid for the standard test, probably biased the validity of the participants who chose the oral fluid test. Because very few patients had a positive test result, those who interpreted their test

Discussion

This pilot study demonstrated that a significant number of patients offered a point-of-care HIV self-test in the ED would volunteer to perform their own HIV test. The 85% volunteer rate needs replication, especially because the participants already received an HIV test. Because ED clinicians are often time constrained and frequently have barriers and inadequate staff support to assist with offering routine HIV screening to patients,5, 7, 8, 9, 10, 11, 12 our team sought to study the

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Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Funded by grants NIBIB, NIH U-54EB007958, and U01 AI068613. Dr. Rothman and the HIV testing program were funded in part by a grant from Maryland Department of Health and Mental Hygiene and from Gilead Sciences, Inc.

Publication of this article was supported by Centers for Disease Control and Prevention, Atlanta, GA.

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Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.