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by PAIGE HEWITT

Special Contributor toAnnals News & Perspective

When the CDC in 2006 recom-mended that emer-gency departments

EDs) across America routinelyest for HIV, EDs—on boardn spirit—responded with arm pause. Emergency medi-ine of course supported thedeal of diagnosing HIV pa-ients and linking them toare and counseling as early asossible. After all, as the HIVpidemic marches, the ED—een by some advocates as aerfect touch point for earlyetection— has a front-roweat in caring for many of the na-ion’s 1 million HIV patients, anstimated 250,000 of whom don’tnow they’re infected and thus aret greater risk to themselves andthers.

“The initial reaction was rela-ively positive. Provider groupsere supportive of the proposal

nd intent. But there were con-erns about some logistics,” saidernard Branson, MD, associateirector for laboratory diagnos-ics for the CDC’s Division ofIV/AIDS Prevention.The American College of

mergency Physicians’ boardf directors in April 2007 en-orsed ED-based screening, asong as it’s practical andoesn’t interfere with the pri-ary acute care mission of the ED.“Early diagnosis and treatment for

HIV] can prolong life, reduce transmis- g

16A Annals of Emergency Medicine

ion, and has been demonstrated to be aost-effective public health intervention,”he board said.

However, EDs across the nation—over-urdened, underfunded—flatly ignored theuidelines initially, arguing on legitimate

rounds and noting the CDC’s recommen-ation was not accompanied with a how-to

uide to address critical issues. What kind u

f testing should be done? Which patientshould be tested? How do you address con-dentiality, ethics? Who has the time ortaff to conduct all those tests? Should HIVcreening get financial priority over otherypes of screening? And, of course, whoould pay?

The barriers turned up in a national surveyf preventive services in US EDs, published innnals of Emergency Medicine in February 2011.

t found that only 19% of ED directors re-orted that their institution offered HIVcreening (it didn’t establish how widespreadhe screening was, or to whom the test wasffered). Only 2% wanted to implement HIVcreening, meaning they were far less enthu-iastic about ED-based HIV testing than the0 other public health interventions in theurvey.

“Proponents of ED HIV screenings,such as the CDC, will needto demonstrate that HIVscreening is not just a wor-thy priority among thecompeting priorities foracute care but also a prior-ity among the other pre-ventive services that ED di-rectors appear to prefer,”the authors wrote.

Although the CDC’srecommendation is stillmet with reluctance—anda slew of logistics and sus-tainability concerns stilllinger—many EDs none-theless are stepping uptheir HIV testing, and afew have adopted substan-tive components of theguidelines during the lastyear or two, emerging asmodels for an increasingnumber of providers ex-ploring how it might bedone, said Michael S. Ly-ons, MD, Department ofEmergency Medicine, Uni-versity of Cincinnati Col-lege of Medicine. (See re-lated story on HIV testingexperience in Washington,DC.)

Advocates for routine HIVtesting in the ED, who say

esting is prevention, point to such indicatorss a suggestion that a shift of sorts may be

nder way.

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Dr. Lyons said CDC’s 2006 guidelines—which recommended broader HIV testing,including at such nontraditional sites atEDs—have provoked more dialogue, moredollars, and more study on testing for HIV inthe ED.

Dr. Branson, with CDC, observed thesame. “I think we will see continuation of alot of programs, and potentially expansion.People have gained more experience in doingthis kind of screening, and their approacheshave evolved into being potentially more fea-sible and cost effective,” he said.

FINDING FUNDINGDC launched the HIVinitiative—recommendingthat EDs administer such

screening unless undiagnosed in-fection fell below 0.1%—with$35 million in supplemental fund-ing, distributing the money thr-ough health departments to 25 ju-risdictions with large numbers ofAIDS cases among blacks, dispro-portionately affected by the epi-demic, Dr. Branson said.

“That fostered implementa-tion and relieved concerns,” Dr.Branson said. “It made it af-fordable. The CDC funding ismade available to the health de-partments, which sort of decideand negotiate who gets it, ex-actly how they will do testing,and which people get tested.”

Funding was not strictly ear-marked for EDs, but most of itwent to EDs in the first 3 years,Dr. Branson said. “Given the sub-stantial benefits of treatment andvery likely high benefit for preven-tion . . . the goal was to ensure thatpeople who were HIV infected didnot go through the health care sys-tem without finding out,” he said.“HIV is treatable, like any otherchronic condition, like diabetes. If they arediagnosed early and treated, they can achievenormal life expectancy. The earlier you findsomeone, the more effective you can be inpreserving their immune system.”

Secondary goals included makingHIV testing more feasible and less stig-matizing, he said.

The CDC renewed that 3-year fund-

ing for 2010, increasing it to $47 mil- a

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lion. The number of jurisdictions alsowas increased, to 35, Dr. Branson said.

Dr. Lyons said EDs around the nation areimplementing various components of CDC’sguidelines, and in different ways. He empha-sized that each ED is unique and has its ownneeds and priorities, which may not necessar-ily include routine HIV testing or screening.

Some sites test routinely; others don’t.Some EDs use opt-in testing, in whichtesting is conducted only when a patientrequests it. Some sites administer opt-outtesting—passing the burden to patients tosay no—to all patients or only to high-risk

patients. EDs in Houston, Dallas, San Fran-cisco, Washington, DC, and Denver, forinstance, have opt-out HIV testing.

OPT OUTDs have various approaches in place,but all of course are subject to stateconsent laws, which vary widely

cross the country, Dr. Lyons said. But w

or sites that meet the CDC’s bench-ark—in which undiagnosed infection

as not dropped below 0.1%—a key el-ment in opt-out testing is commitment,r. Lyons said. In other words, if there iswill to make it work, it just might.He said there is indeed such will at Ben

aub General Hospital in Houston, whereIV long has been at a crisis point. Benaub’s new HIV cases represent a 0.65 posi-

ive rate, more than 6 times higher than theDC’s standard. Among the CDC’s original5 sites in the initiative, Ben Taub is part ofhe Harris County Hospital District and a

Level I trauma center whose EDtreats about 300 patients per day.

Ben Taub, implementingopt-out HIV testing, “hascome the closest” to adoptingthe substance of what theCDC recommended 4 yearsago, Dr. Lyons said. Its EDlinks with the hospital dis-trict’s freestanding HIV/AIDStreatment operation, ThomasStreet Health Center, with afocus on early detection.

“It’s terribly exciting,what’s been going on in Hous-ton,” Dr. Lyons said. “There’sa lot to learn from them.”

Ben Taub, which receives 2or 3 visits/inquiries monthlyabout its opt-out testing fromother EDs around the nation,started its Universal Screeningfor HIV program in August2008, operating on about $1.2million since its inception, thehospital said. All patients aged18 to 64 years and requiringblood tests during their visitto Ben Taub’s ED, as well asthe other county hospital,LBJ, are routinely tested alsofor HIV unless they opt out ofthe testing. Blood is processedin fewer than 2 hours; coun-

elors meet with patients who receiveositive test results.

Patients are alerted about the op-outesting by signs posted about the ED;taff inform them verbally and privatelyuring admission. Such opt-out test-ng—avoiding singling out patients—urther helps to “de-stigmatize the topicf HIV, which even in the health care

orld is unfortunately often treated as

Annals of Emergency Medicine 17A

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taboo,” said Shkelzen Hoxhaj, MD, MPH,MBA, Emergency Services, Ben TaubGeneral Hospital, and Emergency Medi-cine, Baylor College of Medicine. “For usit’s no different than testing for diabetes,”said Dr. Hoxhaj, who has been creditedby others for being a key driver behindBen Taub’s mission to diagnose, espe-cially patients unaware they are infected.

Ben Taub tests with rapid blooddraws, costing $4 each, compared withoral swab tests, which are more time con-suming and cost the ED $10. Testingthere is paid for with federal monies andlocal funds. Medicare and Medicaid donot cover routine testing, and it’s toosoon to know if and how the nation’s newhealth care measure will affect routineHIV screening, Dr. Hoxhaj said.

“The greatest success is identifying pa-tients who would have never been testedand catching them early in the disease pro-cess when they are healthier and have betteroutcomes,” Dr. Hoxhaj said. “Additional-ly—those who knew they had tested HIVpositive in the past but never sought caredue to any number of reasons, includingdenial—this gives us an opportunity to in-tervene and link these patients into appro-priate HIV care.”

PROMISING RESULTSesults: Ben Taub and LBJ havescreened about 80,000 patients

since starting the program in Au-

ith HIV/AIDS. That’s triple the overall

UAg(sctTr

18A Annals of Emergency Medicine

gust 2008. Among those cases, 459 peo-ple who did not know they were infectedlearned they had HIV. There were an-other 950 reconfirmed cases in which pa-tients had not sought medical care.

Ben Taub is pleased with their results,but there have been obstacles along theway, and challenges remain, Dr. Hoxhajsaid. Early on, some staff were reluctant.“The biggest challenge was getting nurs-ing and physician buy-in that this was animportant issue in the emergency centerand getting everyone on board with atrue opt-out HIV testing,” he said. “Weovercame this by sharing the staggeringprevalence in our community and thebenefits of early detection and treatmentto the patient and slowing the spread ofthe disease in the community.”

Another problem has been trainingbecause Ben Taub is a teaching hospital.“The turnover is great, and residents gothrough the areas regularly,” said KenMalone, HIV testing project coordinatorfor the county’s HIV/AIDS clinic. “It is achallenge to monitor the results and fine-tune problem areas, but overall, it hasworked well.”

Another relatively smaller challenge wasthe availability of counselors on weekendsand nights, so physicians and nurses wereeducated on that issue, and the ED devel-oped education and follow-up materials forpatients, Dr. Hoxhaj said.

Linkage—ensuring patients return to

clinics for definitive HIV care—is still

outine—and as free of stigma—as other

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the system’s greatest challenge. “Often-times our patients do not give us accuratecontact information, or it changes fre-quently,” Dr. Hoxhaj said. “This has be-come better as our staff has been trainedin behavior-based interviewing and inter-vention.”

Those approaches have shown somepromise. Ben Taub’s linkage-to-care ratehas increased to 80% in recent monthscompared with less than 40% when itsopt-out testing was started, Dr. Hoxhajsaid.

Dr. Lyons said that although testing isprevention, he acknowledged the nationcannot test its way out of an epidemic,marked and holding steady with 56,000new cases annually. “But I think we’vereached a tipping point. It’s not going togo away,” he said.

Section editor: Truman J. Milling, Jr, MDFunding and support: By Annals policy,all authors are required to disclose anyand all commercial, financial, and otherrelationships in any way related to thesubject of this article that might createany potential conflict of interest. Theauthor has stated that no such relation-ships exist. See the Manuscript Submis-sion Agreement in this issue for exam-ples of specific conflicts covered by thisstatement.

doi:10.1016/j.annemergmed.2011.02.007

ommon tests and screenings and in therocess challenge common misconcep-ions about how HIV testing will in-rease crowding, add to length of stay,nd burden an already burdened staff.

Not every hospital in DC has yet goneull speed ahead on testing, despite thencouragement of the city’s Department

Routine HIV Testing inthe EDThe Experience in the Nation’s Capital

f Health, which has observed progress in

by JOANNE KENEN

Special Contributor to

Annals News & Perspective

An estimated 3.2% of Washington,DC’s, population—and more than7% of its black men—are infected

S rate and as severe as in some parts offrica. Those rates constitute an emer-ency, and local emergency departmentsEDs) have responded with initiatives tocreen patients and direct those who re-eive positive test results to clinics wherehey can receive life-prolonging care.hey are trying to make HIV testing as

xpanding free testing and getting peoplento care before the disease progresses.ut those EDs that have embarked onD-based testing, largely using free testits supplied by the city, have found thatt’s workable and worthwhile.

“The argument is made that the ED isot a public health intervention kind oflace,” said Jeremy Brown, MD, researchirector and director of ED HIV screen-

ng, Department of Emergency Medicine

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