HIV testing in EDs

[Rendar5]

NEW YORK (AP) -- Health officials are trying to persuade doctors to offer HIV tests to nearly every patient in a New York City community hit harder than most by AIDS.

Under a new program announced Thursday, officials have set an ambitious goal of testing a quarter million adults in the Bronx, one of five boroughs that make up New York City, within three years.

''We need every single individual to know their status,'' said Dr. Monica Sweeney, an assistant health commissioner who specializes in HIV prevention.

Like dozens of other states, New York now requires doctors to obtain a patient's written consent and provide a brief counseling session before giving them a test for the AIDS virus, a process that can take up to 20 minutes. That's enough to deter doctors and nurses from suggesting HIV tests to patients routinely, according to the city.

Now officials want health clinics to offer the tests to anyone who seeks care, even for something as simple as a broken wrist.

Federal health officials recommended routine HIV testing for all Americans ages 13 to 64 nearly two years go, but the effort has stalled. Some doctors have questioned whether so much testing is necessary, or worth the bureaucratic cost.

HIV testing in the Bronx is already fairly widespread. Nearly 7 of 10 Bronx adults have been tested at least once in their lifetime. But as many as 250,000 adults have never been tested, and statistics indicate that many are diagnosed far too late.

AIDS killed 357 residents of the borough in 2006, about a third of all AIDS deaths in the city.

City health officials have also urged changes in state law that would do away with both the consent form and the mandated counseling sessions, arguing that they have little benefit. Those changes have been opposed by some AIDS activists.

''We find that period of time extremely useful,'' said Marjorie Hill, chief executive officer of the Gay Men's Health Crisis.

She said it gives doctors a time to talk with patients about ways to avoid HIV, or deal with an HIV infection.

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[Rendar5]

Just wanted to post that AP article that I saw yesterday. I'm really excited about this renewed push in my area. I've been doing a fair bit of research on this the past year, particularly on efforts on NY and CA to increase universal screening. I was just curious about what programs and residents in areas that aren't as hard-hit think about universal testing through EM.

 

[docB]

It is inappropriate to force EDs and EPs to screen every patient that presents just because the rest of the public health system has failed. Unless the body that mandates this screening also provides funding, counselors, follow up, etc. it will cause harm to any ED's ability to meet its primary mission of providing care for emergencies. As much as society would like to dump the onus of all of the difficult areas of medicine and civilization into the cramped and struggling ERs such as HIV screening, lack of primary and prenatal care, the uninsured, the homeless, the addicted, the mentally ill and so on turning every ER into some sort of half assed health department clinic is just foolhardy.

Here's ACEP's stance on it:

HIV Testing and Screening in the Emergency Department

Approved by the ACEP Board of Directors April 2007

Early diagnosis and treatment for human immunodeficiency virus (HIV) can prolong life, reduce transmission, and has been demonstrated to be a cost-effective public health intervention.

HIV testing in the evaluation for acute care conditions in the emergency department (ED) should be available in an expeditious and efficient fashion similar to testing and results for other conditions.

HIV screening when deemed appropriate by the emergency physician must meet the following conditions:

Recommendations for HIV screening must be practical and feasible for emergency settings.
Cannot interfere with the primary acute care mission of emergency medicine.
Should be offered based on the local prevalence and medical needs of the community.
Should be integrated with the resources of the entire health care system.
Policies and procedures must adequately address patient confidentiality, informed consent (state dependent), provider training, significant need for pre and post-test counseling, and linkage to care.
All local and state requirements must be met.
Any such program must be contingent upon adequate funding to meet the added operational and personnel costs required for programs sustainability.

http://www.acep.org/practres.aspx?id=29512

 

[WilcoWorld]

What's your Pap Smear threshold?<joke font>

 

[GeneralVeers]

Nothing says "Improved Outcomes" like an unfunded mandate.

 

[Rendar5]

Well, a secondary question then to add, if you don't like the concept of ED screening, what would make it more palatable? (such as having the government absorb the $12 cost, having triage nurses offer it, dropping legal requirements of pre-test and post-test counseling, etc.). Also, there was actually a different article I meant to post which discussed specifically ED testing. I'll see if I an find it.

 

[atelectasis]

I'm curious as why this needs to be done in the ED? Why not clinics or UC's? It's not like an EDP will admit someone for a new HIV diagnosis, right? Wouldn't outpatient primary care be best way to plug someone into the system? Too many people already go to the ED for primary care. And HIV's not like other STDs where the doc can simply prescribe abx for that greenish DC from their wang and send them on their way.

I think one way to increase the amount of people coming in for testing is to get rid of the 20 minute counseling that's required for a 5 minute test, or at least only do the counseling for a positive.

 

[Flopotomist]

In my previous life before medical school, I was on a team that researched one way of doing this in a busy ED. A few of the things that we did to make it a bit more palatable -

1. Elimination of pre and post test counseling.
2. Offering the test at triage, with the patient's nurse being the person actually performing the test (prevented backing up triage)
3. For newly identified positives, the HIV service assisted with disclosure during business hours freeing the physician from this task taking up more time than necessary.


It may seem like a pain, but in just one year, we identified over 100 new HIV+ patients that otherwise would likely not have been identified. Of course the ED is not the ideal place for the test, and in an ideal world all of these people would go to a more appropriate location for testing, but the fact that this type of program works so well speaks for itself.

 

[Arcan57]

The place where I trained did this with a staff of specially trained counselors funded through (I believe) grant money. You asked the patient if they wanted a free HIV test and then paged a counselor. The only downside as the doc was that the room was tied up for ~25-30 min while the pt. got counseled and was grilled in great detail about their sex life. It captured a lot of young healthy people that do not go to regular clinics and would not otherwise have been tested. Without the research dollars the PI generates, I am sure it would fold in a day.

 

[doc20]

In my previous life before medical school, I was on a team that researched one way of doing this in a busy ED. A few of the things that we did to make it a bit more palatable -

1. Elimination of pre and post test counseling.
2. Offering the test at triage, with the patient's nurse being the person actually performing the test (prevented backing up triage)
3. For newly identified positives, the HIV service assisted with disclosure during business hours freeing the physician from this task taking up more time than necessary.


It may seem like a pain, but in just one year, we identified over 100 new HIV+ patients that otherwise would likely not have been identified. Of course the ED is not the ideal place for the test, and in an ideal world all of these people would go to a more appropriate location for testing, but the fact that this type of program works so well speaks for itself.

I agree with this
There are so many tests that we run without really specifically getting a consent on from the patient, and HIV shouldnt be any different
and this becomes really important in situations like exposure to fluids, blood etc where a consent should not be required at all.

 

[DeLaughterDO]

Not our role, to say the least. Should we now also be screening EVERYONE who comes in for GC/Chlamydia/Syphilis/HSV/etc...?

This is a colossal waste of very limited ED resources, which are already stretched too thin. How is taking even more time with every patient when wait times are already several hours?

And will the patients be able to refuse?

Will there be guaranteed payment for all these tests? Including the western blot to confirm the test?

 

[docB]

Well, a secondary question then to add, if you don't like the concept of ED screening, what would make it more palatable? (such as having the government absorb the $12 cost, having triage nurses offer it, dropping legal requirements of pre-test and post-test counseling, etc.). Also, there was actually a different article I meant to post which discussed specifically ED testing. I'll see if I an find it.

It should be removed from the ED entirely. It must not intrude on ED resources, personnel time, bed space, etc. Since everyone is throwing in the towel as far as primary care and public health and fells that this just has to be tied to ED visits here is how it could be done without further destruction of the ED mandate:

After discharge the nurse asks the patient if they are interested. If they are then they go to the separate area where this gets done. Their ED chart is closed and the screening visit is a totally separate chart. Then whatever counseling, consent and so on is done there. You can save cost by alerting lab, on arrival at the screening center or whatever, that the patient may have blood already in the lab for testing. Then you guys take it from there.

I realize that you are pointing out that $12 is a small cost but you have to know that we routinely have patients that come to the ED for a Tylenol prescription so they don't have to pay for it on their own and we frequently can't get things like irrigation tips because they cost 50cents.

Will all the inpatients be having this done to them while in house too? Whose doing their counseling and absorbing their costs?

 

[southerndoc]

Well, a secondary question then to add, if you don't like the concept of ED screening, what would make it more palatable? (such as having the government absorb the $12 cost, having triage nurses offer it, dropping legal requirements of pre-test and post-test counseling, etc.). Also, there was actually a different article I meant to post which discussed specifically ED testing. I'll see if I an find it.

How about continuity of care and appropriate counseling?

It is highly inappropriate for one physician to order a test and have another physician follow up on it when the result could be lethal and associated with such social stigmatism (HIV). It is difficult to counsel a patient in a busy ED, especially in ED's where patients often end up in hallways.

Twenty minutes of counseling is hardly "brief" in my opinion. It will end up being double that when the person returns for their visit.

What happens when the person doesn't return for their results, and the physician who orders it doesn't follow up on them because he/she is an ED physician without a commitment to continuity of care? If the person continues having risky behavior, is the ED physician that ordered the test now liable for infection of others if he/she did not make an attempt to contact the person?

HIV testing in the ED is a bad idea. We are skirting the main problem when we recommend ED's test for HIV. Instead of this recommendation, we should concentrate on more screening at clinics, physician offices, etc.

Having said that, I have a feeling it'll be a Joint Commission requirement within 5 years. They seem to mandate all sorts of things without proven benefit.

 

[lord_jeebus]

Having said that, I have a feeling it'll be a Joint Commission requirement within 5 years. They seem to mandate all sorts of things without proven benefit.

shhhhh don't give them ideas

 

[primadonna22274]

We're doing this in our ED. Started a few months ago. Pretty much along the same model as Flopotomist's although for positives there is a contact person we can call to counsel the patient. From what I hear there have only been 2 positives so far (50,000/yr ED, although our county is pretty hard-hit with HIV in the poor AA population), and one of them was a well-known previous positive who for some inexplicable reason 1) asked for the test and 2) the silly nurse drew it. (Wouldn't hurt to review the problem list/PMH.)

I agree with Southerndoc that failure of public health/community providers to identify patients should not mandate the ED to pick up the slack. OTOH, isn't this what the ED is for already? 🙄

Ugh.

 

[Rendar5]

How about continuity of care and appropriate counseling?

It is highly inappropriate for one physician to order a test and have another physician follow up on it when the result could be lethal and associated with such social stigmatism (HIV). It is difficult to counsel a patient in a busy ED, especially in ED's where patients often end up in hallways.

Twenty minutes of counseling is hardly "brief" in my opinion. It will end up being double that when the person returns for their visit.

What happens when the person doesn't return for their results, and the physician who orders it doesn't follow up on them because he/she is an ED physician without a commitment to continuity of care? If the person continues having risky behavior, is the ED physician that ordered the test now liable for infection of others if he/she did not make an attempt to contact the person?

HIV testing in the ED is a bad idea. We are skirting the main problem when we recommend ED's test for HIV. Instead of this recommendation, we should concentrate on more screening at clinics, physician offices, etc.

Having said that, I have a feeling it'll be a Joint Commission requirement within 5 years. They seem to mandate all sorts of things without proven benefit.

Well, it would be fairly stupid to implement a program without follow-up. And I still have my concerns about how connection to care should proceed for the positives. But I'm not too concerned about patients leaving before test results come back. Most patients are in the ED for more than the 20 minute turn-around times of the screening tests.

 

[DeLaughterDO]

I don't know where you work that has 20 minute turnaround for ANY test... much less a screening HIV, then western blot for confirmation. I can't even get a CBC in less than an hour here...

 

[southerndoc]

Well, it would be fairly stupid to implement a program without follow-up. And I still have my concerns about how connection to care should proceed for the positives. But I'm not too concerned about patients leaving before test results come back. Most patients are in the ED for more than the 20 minute turn-around times of the screening tests.

20 minutes for an HIV test? What world do you live in? There is a rapid HIV test available, but it's only for screening purposes of healthcare personnel who have had an exposure. It must be followed up with testing that takes slightly longer than 20 minutes.

 

[atelectasis]

I used to volunteer here:
http://www.noaidstaskforce.org/article.php?story=testing

They use Oraquick, which takes 20 minutes for results. Negative = Negative. Positive = Need for confirmation with western blot. The whole process takes 1 hour, however, because of the need for counseling.

 

[SoCuteMD]

20 minutes for an HIV test? What world do you live in? There is a rapid HIV test available, but it's only for screening purposes of healthcare personnel who have had an exposure. It must be followed up with testing that takes slightly longer than 20 minutes.

Rapid testing is available for more than just healthcare professionals. It's used for women in active labor, in outpatient clinics to give same day results, and in emergency departments for the kind of testing the OP is discussing. However, you are correct in saying that 20 minutes is unreasonable - because patients still get pre- and post-test counseling which takes significant time.

 

[BADMD]

Every patient that is seen in our ED is offered the Oraquick. I'm not sure what I think about it. There are a group of people who are dedicated to doing this and they are essentially 24/7. I am less than impressed with the level of counseling they give. Usually it is basically a pamphlet. I haven't had to deal with any positives (or that were revealed to me as positive, since they don't tell me the result since I didn't order the test). I can only imagine coming to the ED for something minor and then being told

"Oh, BTW, you might have HIV and are likely going to die from it. See your doctor for a confirmation test, 'cause this one might not be right. KTHANXBYE"

 

[southerndoc]

Rapid testing is available for more than just healthcare professionals. It's used for women in active labor, in outpatient clinics to give same day results, and in emergency departments for the kind of testing the OP is discussing. However, you are correct in saying that 20 minutes is unreasonable - because patients still get pre- and post-test counseling which takes significant time.

I was under the impression that any positive test had to be confirmed.

 

[SoCuteMD]

I was under the impression that any positive test had to be confirmed.

It does. The patient gets the result of his/her rapid test at that time and blood is drawn at that time and sent for western blot (I think it's Western...but don't quote me on that). They are scheduled for follow-up in a few days with the HIV clinic unless they need admission for an opportunistic infection and unrelated illness.

 

[Apollyon]

(I think it's Western...but don't quote me on that)

Ironically, as I quote you...

The Southern blot came first (named after someone - Edwin Southern) - that is DNA. The Northern blot was next, which is RNA. The capitalization was kept for convention. Likewise, the Western blot (again keeping the convention, and west vs. east because it was a guy in California) detects proteins.

 

[RxnMan]

Ironically, as I quote you...

The Southern blot came first (named after someone - Edwin Southern) - that is DNA. The Northern blot was next, which is RNA. The capitalization was kept for convention. Likewise, the Western blot (again keeping the convention, and west vs. east because it was a guy in California) detects proteins.

And the test that looks for DNA-binding proteins is called...a Southwestern blot.

 

[Rendar5]

And the test that looks for DNA-binding proteins is called...a Southwestern blot.

omg, this is why I hated biochem and basic science 😕

 

[matt_mt19]

At my locale --
National top 10 adult academic tertiary referral center. (approx 1200 beds)

1. All patients presenting to OB triage are subject to "opt-out" HIV testing (rapid test returns a result in less than 30 minutes). Meaning there are no longer consents, all patients are subject to the test unless they specifically sign to not get it, which when I asked how common that was -- I was told "basically no one." Whatever number that correlates to...

2. ALL ED patients presenting to triage are subject to "opt-out" HIV testing. (We're starting next month, so I'll let ya know). (90,000+ census)

National top 10 pediatric academic tertiary referral center (approx 500 beds)

1. All children presenting to triage are subject to "opt-out" HIV testing, with focus on the teenage population. I'll find out some numbers on that...(60,000+ census)

-- At current the above standards seem to be catching an oddly high number of positives. We expected similar numbers to the above stated, however the oB triage numbers seem to be quite a bit higher than that (don't have them in front of me right now).

AND (just my .02) --> to those of you who don't believe its useful/should be done in the ED, can you tell me a positive result wouldn't change your management of this patient who presents with a myriad of possible chief complaints? I can tell you that when I see HIV listed under PMHx then my differential becomes more broad...

 

[docB]

AND (just my .02) --> to those of you who don't believe its useful/should be done in the ED, can you tell me a positive result wouldn't change your management of this patient who presents with a myriad of possible chief complaints? I can tell you that when I see HIV listed under PMHx then my differential becomes more broad...

Sure it'd be nice to know. But there are a lot of burdens surrounding it that should not be placed on the ED. How is it paid for? Who has to go do the counseling or if there's no counseling who has to inform the patient? Who is liable for false postives (mental anguish) and false negatives (others who got infected by a patient your center told was negative)? How do you handle the additional reporting load? And so on...

If you read the ACEP position they note that the EP should be able to order it when it's clinically relevent. That's because some places won't allow it to be done in the ED specifically to avoid the above mentioned issues. ACEP supports my ability to order the test if I need it because I suspect HIV. But getting it on everyone as a screen for community health purposes just does not belong in the ED. You could just as well argue that we should be doing prostate exams and breast exams on everyone whose age puts them at risk. Getting an HIV test on everyone who comes in with a sprained ankle is just a poor use/abuse of the ED.

Would knowing HIV status help when working up the patient with a lot of vague complaints? Maybe. I'd really also need to know their CD4 count and their viral load which I can't get back for at least 24 hours. I have a feeling that the HIV+ will translate into a lot of admissions for the rest of the HIV workup, all of which should be done out patient via an appropriate clinic.

I think that the main fallacy behind these programs is the belief that if we screen enough people and tell them they're HIV+ they'll go out and quit having unprotected sex and sharing needles. I think that is unlikely.

 

[Rendar5]

I think that the main fallacy behind these programs is the belief that if we screen enough people and tell them they're HIV+ they'll go out and quit having unprotected sex and sharing needles. I think that is unlikely.

Actually, based on some papers I've seen, knowledge of HIV status is correlated with lower levels of risky behavior. Don't have the reference on hand at the moment, but can find it tomorrow if you were interested at all.

 

[docB]

Actually, based on some papers I've seen, knowledge of HIV status is correlated with lower levels of risky behavior. Don't have the reference on hand at the moment, but can find it tomorrow if you were interested at all.

Sure. I'm curious if they used a lot of self reporting to get their data. However, if doing tons of screening works then great. Just move it out of the ED and into a more appropriate arena.

 

[Rendar5]

Sure. I'm curious if they used a lot of self reporting to get their data. However, if doing tons of screening works then great. Just move it out of the ED and into a more appropriate arena.

Yeah, I need to read the paper again. That would seriously degrade the quality of the study. I'll be able to get ahold of it tomorrow.

 

[southerndoc]

Actually, based on some papers I've seen, knowledge of HIV status is correlated with lower levels of risky behavior. Don't have the reference on hand at the moment, but can find it tomorrow if you were interested at all.

I honestly think counseling someone on alcohol abuse, tobacco abuse, or drug abuse (why didn't I just write substance abuse?) would be more time efficient and have more impact since it affects more of the population.

 

[kalico]

I rotated through a community ED that had counselors based in the ED who did pre- and post-counseling and provided resources (as well as made appointments for follow up for patients).

Each patient who either asked for an HIV test, or who was recommended for one based on any clinical presentation (IVDU, other STD's, young people with odd, frequent infections) got an Oraquick. They received a significant amount of pre- and post-counseling including verbal and written information. It seemed to be an adequate program. It was taken out of the hands of the ED physicians, and the patient had nurses/social workers that they could spend as much time as they needed to.

It's one thing to make it mandatory (which may be overwhelming for us), it's another to at least have a program in place that makes it available for patients who are high risk. I hate that I can't offer some patients an HIV test in certain clinical situations, AT ALL without sending them somewhere else.

 

[Rendar5]

Southern, I agree that counseling is going to be more effective in those cases than in HIV. I'm actually not even a fan of pre-test counseling. I don't really think HIV counseling by EM doctors is appropriate under most circumstances.

DocB: The article I remember was as follows. I haven't seen it in awhile, and won't have a chance to look through it til later this week. But if you're interested: Marks G, Crepaz N, Senterfitt JW, Janssen RS. 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: 446-53.

Not in reply to anyone particular:
The main reason I like the concept of HIV screening is that it can delay time to AIDS. Half of newly dx'd HIV patients progress to AIDS within a year, which has a pretty big impact where I am. I like HIV screening programs operating out of the ED because way too many of my patients don't have any primary care. I think a well-designed program can accomplish that while adding a minimal amount to physician workload (minimal meaning 0-30 seconds per patient). But it would need support and law changes in a lot of places. I've seen a couple programs that are able to accomplish this, and some that try and fail.

 

[southerndoc]

I think a well-designed program can accomplish that while adding a minimal amount to physician workload (minimal meaning 0-30 seconds per patient). But it would need support and law changes in a lot of places. I've seen a couple programs that are able to accomplish this, and some that try and fail.

Earth to Rendar, time to face reality!

30 seconds?!? Thanks, I needed that great laugh!

 

[Rendar5]

Earth to Rendar, time to face reality!

30 seconds?!? Thanks, I needed that great laugh!

If you don't agree with HIV screening, I'm not going to actively try to convince you otherwise. But I'm not as unrealistic as you might think about time constraints.

Essentials of current CDC screening guidelines:
"We do rapid HIV screening tests on all patients we take blood samples from [at no additional cost to you] as part of our healthcare policy. If you don't want this, let us know."

<15 seconds. Not realistic or legal in some locations, but realistic and legal in others. In an effective program, someone else usually does post-test counseling and connection to follow-up care. Pretty much the same thing as is done in obstetrics.

 

[southerndoc]

<15 seconds. Not realistic or legal in some locations, but realistic and legal in others. In an effective program, someone else usually does post-test counseling and connection to follow-up care. Pretty much the same thing as is done in obstetrics.

Great, so let's add another person to the ED payroll. I think I would rather add another nurse that can give medicines to patients -- the 30 patients I see everyday for every 1 HIV patient that needs testing in the ED.

 

[jbar]

It depends on the hospital set up. If you already have an HIV clinic or a person to do HIV counseling you don't have to hire anyone. If anything man power needs should be less since the new rules do away with pre testing counseling. While I understand the people who argue that the ED isn't the best place for this testing, I'd counter that the ED sees a lot of people who are high risk, and many of those people don't go to clinics or have PMDs. So the ED is a good place to do testing, considering the large numbers of patients who are getting blood drawn anyway.

The details of who pays for the testing, the counseling etc are tricky but should be solvable. You aren't going to be able to stop the HIV epidemic until you treat those infected, and you can't do that until you figure out who they are. True you may not be able to effect behavior change (safe sex) but putting those people on anti virals will slow the transmission cycle.

 

[southerndoc]

It depends on the hospital set up. If you already have an HIV clinic or a person to do HIV counseling you don't have to hire anyone. If anything man power needs should be less since the new rules do away with pre testing counseling. While I understand the people who argue that the ED isn't the best place for this testing, I'd counter that the ED sees a lot of people who are high risk, and many of those people don't go to clinics or have PMDs. So the ED is a good place to do testing, considering the large numbers of patients who are getting blood drawn anyway.

The details of who pays for the testing, the counseling etc are tricky but should be solvable. You aren't going to be able to stop the HIV epidemic until you treat those infected, and you can't do that until you figure out who they are. True you may not be able to effect behavior change (safe sex) but putting those people on anti virals will slow the transmission cycle.

My point is this:

We seem to concentrate more on psychologically more important diseases than the most common diseases. We spend billions of dollars on HIV treatment programs in Africa because it gets the most psychological impact. However, more lives would be saved if we spent more money on mosquito nets to decrease the incidence of fatal malaria.

Likewise, we can spend money on HIV testing in the ED and target a relatively small number of patients, or we can concentrate on screening patients for HTN, diabetes, smoking, etc. that would collectively target a significantly more number of patients at risk for cardiovascular diseases.

The top 10 causes of death in this country:

Heart disease: 652,091
Cancer: 559,312
Stroke (cerebrovascular diseases): 143,579
Chronic lower respiratory diseases: 130,933
Accidents (unintentional injuries): 117,809
Diabetes: 75,119
Alzheimer's disease: 71,599
Influenza/Pneumonia: 63,001
Nephritis, nephrotic syndrome, and nephrosis: 43,901
Septicemia: 34,136

Let's concentrate on preventing these rather than concentrating on preventing a disease that will have relatively few bang for the buck (no pun intended). We may need to test 50-75 people before we get a positive. At $10 per test, that's over $500 before a first positive. A fingerstick glucose is only 50c, a blood pressure costs only labor (but is included in a routine exam anyhow), etc.

I would rather counsel someone on smoking cessation, HTN, diabetes, or injury prevention than offer both pre- and post-test counseling for HIV, which takes considerably more time than just "you're HIV test is positive, you need to stop having risky sex and sharing needles."

If there is extra personnel in the ED to do this, then I say put them to work trying to prevent the top 10 causes of death rather than HIV.

Again, as I mentioned before, everyone centers on HIV testing because of its psychological impact, not its actual statistical or societal impact.

 

[docB]

I'm bumping this thread because of the recent Annals Supplement devoted entirely to HIV screening in the ED.

So with several years of hearing about this idea on the back burner what does everyone think? Is it coming, is it inevitable? Is the Annals issue a herald of the future or more ivory tower pipe dreams?

Of note the supplement has 9 articles. The last one "Less Encouraging Lessons From the Front Lines: Barriers to Implementation..." addresses a lot of the issues we talked about here in '08.

 

[Rendar5]

I'm bumping this thread because of the recent Annals Supplement devoted entirely to HIV screening in the ED.

So with several years of hearing about this idea on the back burner what does everyone think? Is it coming, is it inevitable? Is the Annals issue a herald of the future or more ivory tower pipe dreams?

Of note the supplement has 9 articles. The last one "Less Encouraging Lessons From the Front Lines: Barriers to Implementation..." addresses a lot of the issues we talked about here in '08.

I'm less gung-ho about it as a resident now than i was as a med student researcher =p. I've got more than enough stuff to do with their chief complaint that this isn't something I routinely ask.

We recently implemented it at my current ED. patients are offered the test at triage. If they want it, they sign the piece of paper they're given which amounts to pre-test counseling in NY. The only thing we have to do is have the nurse notice it, ask us to order it, then make sure the patient stays around 30 minutes to an hour to inform them of their results. only place it is an issue is fast track when the patient is ready to go, but needs to wait for their test results. If the test is positive, they get an outpatient referral to infectious disease.

The only other thing I'd add is that I no longer live/work in an epicenter of HIV. When I was in the Bronx, 5-10% of my hospitalized patients had HIV, and at least 2% of the ED population would screen positive for it. Screening there would pick up a person every 2-3 shifts. I'd see an HIV-related illness at least once a week. Early treatment would save a ton of money and greatly reduce hospital costs for those patients.

Now I live an hour away and the percentage is under 1%; we just don't have the huge healthcare cost of HIV that we did where I used to work. All my HIV patients are receiving great care, and it's very rare that I hit upon a severe HIV-related illness, let alone a patient with a CD4 count under 250 (maybe once a year). I've seen 2 HIV malignancies in 3 years, and not a single HIV encephalopath, nephropath, or vasculopath, etc. NYC, Atlanta, San Fran, no question is it a great idea. Everywhere else? I'm not so sure. I don't see the healthcare costs out in the suburbs or other cities.