HIV screening in the emergency department

Alexander R. Ende, BA, New York County Health Services Review Organization, New York, NY and Bruce D. Agins, MD MPH, New York State Department of Health AIDS Institute, New York, NY

Editor’s Note
Below you will find an essay by Alexander R. Ende, BA and Bruce D. Agins, MD MPH. This article describes the importance of early and accessible screening of HIV. It proposes a strategy whereby such screening would be carried out in EDs. There is no doubt that such a plan will be controversial. On the surface, this seems like a radical departure from our perceived role of diagnosing and treating acute conditions. However, in a climate where a target population may be disenfranchised and have limited access to healthcare, ED screening may make sense. There is much to consider here. Who will fund this? Who will see to the acute needs of our patients while we are carrying out screening? Should this be our role? What is the best way to meet needs in the face of competing demands?

Since the beginning of the HIV epidemic, emergency departments (EDs) have played a critical role in diagnosing and treating HIV-related illness. More recently, EDs are emerging as front-line providers of key public health and prevention services, including HIV screening of high risk populations, the provision of non-occupational post-exposure prophylaxis (n-PEP) and the diagnosis of acute HIV infection (AHI).

HIV Testing
Both the Centers for Disease Control (CDC) and the New York State Department of Health (NYSDOH) recommend that HIV testing become a routine part of medical care in a variety of settings including EDs. Rapid testing in EDs has proven an effective means to increase the number of persons who are identified as HIV-positive and transitioned into appropriate care. The CDC estimates that approximately 25% of the 850,000 to 950,000 people living with HIV in the United States do not yet know they are infected. There are several benefits to early identification of HIV infection. The first is early entry into treatment and access to highly active antiretroviral treatment (HAART). In addition, knowledge of one’s infection can help prevent the spread of HIV to others.

NYSDOH is finalizing implementation plans for extending Medicaid billing for two HIV testing rates - HIV Testing and HIV Counseling (Positive) - to EDs located in hospitals enrolled in the HIV Primary Care Medicaid program. EDs may bill for the visit only when rapid tests are used and must provide HIV counseling and linkage to confirmatory testing and medical services when test results are preliminary positive. Tools and references for use in implementation may be found at http://www.health.state.ny.us/diseases/aids/regulations/ and at www.hivguidelines.org.

Acute HIV Infection
Patients with AHI frequently seek treatment in EDs. AHI is a flu-like illness which often goes undiagnosed. The AIDS Institute recommends that ED clinicians maintain a high level of suspicion for AHI in patients presenting with a compatible clinical syndrome. When AHI is suspected, a plasma HIV RNA (viral load) assay should be used in conjunction with an HIV antibody test to diagnose AHI.

HIV Prophylaxis Following Non-Occupational Exposure (n-PEP)
Persons who have been exposed to HIV through voluntary sexual activity, sexual assault, injection drug use and human bites typically present in the ED. AIDS Institute guidelines recommend post-exposure prophylaxis when the risk of HIV transmission is significant and the patient presents within 36 hours of exposure. To improve performance in providing n-PEP, the AI recommends that EDs: 1) delegate n-PEP responsibilities to staff trained in managing all types of HIV exposures and 2) develop mechanisms for tracking seroconversion and follow-up on ED recommendations.

Recently, the New York State (NYS) Department of Health AIDS Institute’s HIV Guidelines Steering Committee, comprised of the chairs of the program’s eight guidelines committees, questioned whether non-occupational postexposure prophylaxis (nPEP) guidelines are widely implemented and whether all patients are assured access to nPEP when it is indicated. The Steering Committee also noted as concerns the wide variation in prescribing practices for nPEP, lack of information about the volume of patients presenting to EDs for nPEP, the cost of providing nPEP, and the lack of an easily queried Medicaid database for ED services. To better understand these issues and to improve nPEP services in NYS, an electronic survey was developed and sent to every licensed ED in New York State. EDs were queried about protocols for both voluntary and sexual assault exposures, antiretroviral drug combination, methods for tracking seroconversion and conducting follow-up, barriers to providing nPEP, and retrospective data from 2005, including the number and type of cases seen and percentage in which PEP was initiated.

One hundred eighty-six of 207 EDs (90%) responded. One hundred seventy-seven (95%) have a protocol for sexual assault and 110 (59%) have a protocol for voluntary sexual exposure. After sexual assault, 161 EDs (87%) reported that they typically initiate nPEP in the ED; 25 (13%) either write a prescription only or refer to another facility. After voluntary sexual exposure, however, 131 (70%) typically initiate nPEP in the ED; 55 (30%) either write a prescription only or refer to another facility (p<.001). One hundred fifty-five EDs (83%) typically prescribe a highly active antiretroviral (HAART) nPEP regimen (three antiretrovirals). Only 62 EDs (33%) have a mechanism to determine whether ED-recommended follow-up occurred and only 42 (23%) review seroconversion rates after recommending nPEP. The most common barriers to providing nPEP services were lack of dedicated staff (93 facilities, or 50%), lack of information about how to treat non-occupational exposures (28 facilities or 15%), and supply of nPEP (25 facilities or 13%). Self-reported ED data indicate that 6,858 voluntary sexual exposures and 3,426 sexual assault exposures were seen in NYS EDs in 2005. The nPEP initiation rate was 65% (2,238/3,426) for sexual assault exposures versus 43% (2,931/6,858) for voluntary sexual exposures (p<.001).

The protocols and treatment rates for sexual assault and voluntary exposure suggest NYS nPEP guidelines are not widely implemented, and raise several important public health policy issues, including access to medication and follow-up care. Our results indicated resources, primarily number of dedicated staff and physician education, as two major factors contributing to this problem. Improved coordination between ED and HIV professional societies may be an essential step toward making nPEP a central part of ED services.