Comparison of HIV Screening Strategies in the Emergency Department: A Randomized Clinical Trial.

Importance: The National HIV Strategic Plan for the US recommends HIV screening in emergency departments (EDs). The most effective approach to ED-based HIV screening remains unknown. Objective: To compare strategies for HIV screening when integrated into usual ED practice. Design, Setting, and Participants: This randomized clinical trial included patients visiting EDs at 4 US urban hospitals between April 2014 and January 2016. Patients included were ages 16 years or older, not critically ill or mentally altered, not known to have an HIV positive status, and with an anticipated length of stay 30 minutes or longer. Data were analyzed through March 2021. Interventions: Consecutive patients underwent concealed randomization to either nontargeted screening, enhanced targeted screening using a quantitative HIV risk prediction tool, or traditional targeted screening as adapted from the Centers for Disease Control and Prevention. Screening was integrated into clinical practice using opt-out consent and fourth-generation antigen-antibody assays. Main Outcomes and Measures: New HIV diagnoses using intention-to-treat analysis, absolute differences, and risk ratios (RRs). Results: A total of 76 561 patient visits were randomized; median (interquartile range) age was 40 (28-54) years, 34 807 patients (51.2%) were women, and 26 776 (39.4%) were Black, 22 131 (32.6%) non-Hispanic White, and 14 542 (21.4%) Hispanic. A total of 25 469 were randomized to nontargeted screening; 25 453, enhanced targeted screening; and 25 639, traditional targeted screening. Of the nontargeted group, 6744 participants (26.5%) completed testing and 10 (0.15%) were newly diagnosed; of the enhanced targeted group, 13 883 participants (54.5%) met risk criteria, 4488 (32.3%) completed testing, and 7 (0.16%) were newly diagnosed; and of the traditional targeted group, 7099 participants (27.7%) met risk criteria, 3173 (44.7%) completed testing, and 7 (0.22%) were newly diagnosed. When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses (enhanced targeted and traditional targeted combined: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.7; 95% CI, 0.30 to 1.56; P = .38; and enhanced targeted only: difference, -0.01%; 95% CI, -0.04% to 0.02%; RR, 0.70; 95% CI, 0.27 to 1.84; P = .47). Conclusions and Relevance: Targeted HIV screening was not superior to nontargeted HIV screening in the ED. Nontargeted screening resulted in significantly more tests performed, although all strategies identified relatively low numbers of new HIV diagnoses. Trial Registration: ClinicalTrials.gov Identifier: NCT01781949.

Continuum of Care for Hepatitis C Virus Among Patients Diagnosed in the Emergency Department Setting.

BACKGROUND.: Urban emergency departments (EDs) seem to be able to detect new hepatitis C virus (HCV) infections at a high rate, but it is unknown the extent to which individuals screened in the ED can progress to treatment and cure. We evaluate the HCV Continuum of Care for patients identified with HCV in 2 urban EDs, and consider the results in the context of outcomes from ambulatory screening venues where 2%-10% of chronically infected patients are treated. METHODS.: This is a multicenter, retrospective cohort study of 2 ED HCV screening programs. Patients who screened HCV antibody reactive between 1 May and 31 October 2014 were followed for up to 18 months. The main outcome was the absolute number and proportion of eligible patients who completed each stage of the HCV Continuum of Care. RESULTS.: A total of 3704 ED patients were estimated to have undiagnosed HCV infection, and screening identified 532 (14.4%) HCV antibody-reactive patients. Of the 532 HCV antibody-reactive patients, 435 completed viral load testing (82%), of whom 301 (69%) were chronically infected. Of the 301 chronically infected patients, 158 had follow-up arranged (52%), of whom 97 attended their appointment (61%). Of these 97, 24 began treatment (25%), and 19 of these 24 achieved sustained virological response (79%). CONCLUSIONS.: Urban EDs serve patients with poor access to preventive care services who have a high prevalence of HCV infection. Because ED patients identified with HCV infection can progress to treatment and cure with rates comparable to ambulatory care settings, implementation of ED HCV screening should be expanded.

Hepatitis C Virus Screening and Emergency Department Length of Stay.

BACKGROUND: Recent studies demonstrate high rates of previously undiagnosed hepatitis C virus (HCV) infection among patients screened in urban emergency departments (ED). Experts caution, however, that public health interventions, such as screening for infectious diseases, must not interfere with the primary mission of EDs to provide timely acute care. Increases in ED length of stay (LOS) have been associated with decreased quality of ED care. OBJECTIVE: In this study, we assess the influence of an integrated HCV screening protocol on ED LOS. METHODS: This was a retrospective cohort study analyzing timestamp data for all discharged patients over a 1-year period. The primary outcome compared the median LOS in minutes between patients who completed HCV screening and those who did not. Further analysis compared LOS for HCV screening by whether or not complete blood count (CBC) testing was conducted. RESULTS: Of 69,639 visits, 2,864 (4%) had HCV screening tests completed and 272 (9.5%) were antibody positive. The median LOS for visits that included HCV screening was greater than visits that did not include screening (151 versus 119 minutes, P < 0.001). Among the subset of visits in which CBC testing was conducted, there was no significant difference in median LOS between visits that also included HCV screening and those that did not (240 versus 242 minutes, P = 0.68). CONCLUSION: Integrated HCV screening modestly prolongs ED LOS. However, among patients undergoing other blood tests, screening had no effect on LOS. Programs may consider routinely offering HCV screening to patients who are undergoing laboratory testing.

High-impact hepatitis C virus testing for injection drug users in an urban ED.

OBJECTIVES: We implemented the "High-Impact Testing for Injection Drug Users", or the "HIT IDU" initiative, an emergency physician (EP)-based hepatitis C virus (HCV) testing program. The objective of this study was to evaluate the outcomes of this clinical protocol. METHODS: This was a prospective observational pilot study. The HIT IDU initiative encouraged EPs to integrate targeted HCV testing into care, with an emphasis on screening all people who inject drugs (PWID). Physicians selected the primary indication for HCV testing from a drop-down menu integrated into the electronic ordering process. The primary outcome was the absolute number and overall proportion of EP-based HCV antibody positive tests, further stratified by the indication for testing. RESULTS: Over the 3-month study period, 14,253 unique patients were evaluated, and EPs tested 155 patients for HCV (1.1%; 95% confidence interval [CI], 0.9%-1.2%), of which 40 (26%, 95% CI, 19%-33%) were HCV antibody positive. The proportion of HCV antibody positivity by testing indication was as follows: PWID 47% (34/73; 95% CI, 35%-59%), patient requested test 10% (4/40; 95% CI, 3%-24%), confirm patient report 67% (2/3; 95% CI, 9%-99%), liver disease of uncertain etiology 0% (0/3; 95% CI, 0%-71%), and other 0% (0/36; 95% CI, 0%-10%). There were 22 patients chronically infected, 19 had a follow-up appointment arranged, 3 attended their follow-up appointment, and 1 patient was treated at 1 year of follow-up. CONCLUSIONS: Although the overall number of EP-based HCV tests performed was low, high rates of infection were identified, particularly among PWID. There were significant challenges with linkage to care.

Patient Understanding of HIV and Hepatitis C Testing in an Emergency Department with an Integrated Program.

INTRODUCTION: We implemented triage nurse rapid HIV and hepatitis C virus (HCV) screening, in parallel with physician diagnostic testing, in our urban emergency department (ED). METHODS: A 2-month cross-sectional survey was performed to determine the proportion of patients who correctly reported being tested for HIV and HCV. RESULTS: A total of 492 patients were surveyed. Fifty-one (70%) of the 73 patients who reported being HIV tested and 372 (89%) of the 419 patients who reported not being HIV tested were correct. Thirty (60%) of the 50 patients who reported being HCV tested and 416 (94%) of the 442 patients who reported not being HCV tested were correct. CONCLUSION: Although most ED patients correctly reported whether testing was performed, there were many who did not. Although ED screening programs for HIV and HCV serve as an important venue for screening, strategies to improve communication require attention.

Differences Between Emergency Nurse Perception and Patient Reported Experience With an ED HIV and Hepatitis C Virus Screening Program.

INTRODUCTION: Nontargeted human immunodeficiency virus (HIV) screening and targeted hepatitis C virus (HCV) screening for selected high-risk patients (those born between 1945 and 1965 and those who report injection drug use) was integrated into our ED triage process and carried out by nurses. Determining whether emergency nurses accurately perceive what patients experience is important to know because staff misperceptions may pose a barrier to program adherence and sustainability. METHODS: We performed a cross-sectional survey study of emergency nurses and patients to assess the accuracy of emergency nurses' perception of patient experience with the HIV/HCV screening program. Respondents evaluated their level of agreement using a 5-item Likert scale for 9 statements across 4 domains related to the patient experience with the screening process (satisfaction, sense of autonomy, sense of privacy, and comfort level). RESULTS: Surveys were completed by 65 of the 153 eligible emergency nurses (42%). Of the 1040 patients approached, 610 (59%) were eligible, and 491 of the 610 eligible patients (80%) completed surveys. Across all domains, statistically significant differences were found between emergency nurse perception and patient report, P < .001. Emergency nurses perceived patients to be less satisfied with the screening program, more uncomfortable with being asked screening questions, more concerned about privacy issues, and less likely to feel that the decision to decline screening was autonomous than were patients. DISCUSSION: Emergency nurses not only frequently misperceive how patients experience ED-based HIV/HCV screening, but these misperceptions are skewed toward the negative, representing a type of staff bias. Further research is recommended to determine if such misperceptions adversely affect implementation of screening.

Results of a Rapid Hepatitis C Virus Screening and Diagnostic Testing Program in an Urban Emergency Department.

STUDY OBJECTIVE: We describe the results of an emergency department (ED) hepatitis C virus testing program that integrated birth cohort screening and screening of patients with a history of injection drug use, as well as physician diagnostic testing, according to national guidelines. METHODS: We conducted a retrospective cohort study using data collected as part of clinical care. The primary outcome was the hepatitis C virus prevalence among tested patients. We evaluated factors associated with testing positive with logistic regression. RESULTS: Of the 26,639 unique adults aged 18 years or older and presenting to the ED during the 6-month study, 2,581 (9.7%) completed hepatitis C virus screening (2,028) or diagnostic testing (553), of whom 267 were antibody positive (10.3% prevalence). Factors associated with testing positive for hepatitis C virus included injection drug use (38.4% prevalence; odds ratio [OR] 10.8; 95% confidence interval [CI] 7.5 to 15.5), homeless (25.5% prevalence; OR 3.1; 95% CI 1.5 to 6.8), diagnostic testing (14.8% prevalence; OR 2.6; 95% CI 1.7 to 3.9), birth cohort (13.7% prevalence; OR 3.6; 95% CI 2.4 to 5.3), and male sex (12.4% prevalence; OR 1.4; 95% CI 1.0 to 2.0). Of the 267 patients testing positive for hepatitis C virus antibody, 137 (51%) had documentation of result disclosure and 180 (67%) had confirmatory ribonucleic acid testing performed, of whom 126 (70%) had a positive result. Follow-up appointments at the hepatitis C virus clinic were arranged for 57 of the 126 (45%) patients with confirmed positive results, of which 30 attended. CONCLUSION: This ED screening and diagnostic testing program found a high prevalence of hepatitis C virus antibody positivity across all groups. Challenges encountered with hepatitis C virus screening included result disclosure, confirmatory testing, and linkage to care. Our results warrant continued efforts to develop and evaluate policies for ED-based hepatitis C virus screening.