In the United States, the Centers for Disease Control and Prevention (CDC) estimates that 1.1 million people aged 13 and older are currently living with a human immunodeficiency virus (HIV) infection. Approximately 15 percent of these individuals were unaware of their HIV infection (2016 estimate). In the US, it is estimated that 40 percent of HIV transmission is from individuals unaware of their positive-HIV status.
In 2019, the U.S. Department of Health and Human Services (HHS) launched an initiative to end the US HIV epidemic by 2030. HIV testing is a critical component of the initiative to prevent new transmissions and treat those currently infected. Currently, the CDC and U.S. Preventative Services Task Force guidelines recommend screening for HIV in adolescents and adults aged 15–65 and especially screening high risk patients.
The need for rapid HIV testing in the emergency department
There continues to be a disproportionate impact of HIV on underserved communities. The emergency department (ED) is a frequent health care access point for at-risk populations at high risk for HIV infection. Because these populations and others use ED services for evaluation of sexually transmitted infections (STI), expanded testing programs, including those provided in the ED, may lead to earlier detection and further reduction in the transmission of HIV.
In a policy statement by the American College of Emergency Physicians (ACEP), several factors were bulleted where ED-based screening programs would have the greatest impact to public health. One such statement from the college was that HIV testing in the ED should be available in a timely and efficient fashion similar to testing and results for other conditions.
At our health system, the majority of hospitals are located in Northeast Ohio circa Cuyahoga County, which is designated a “high burden county” by the HHS. Several areas within the county have more than a 10-fold incidence of HIV compared to the US as a whole. In January 2020, rapid HIV testing was made available to the EDs. To support this mission, a multidisciplinary team including laboratory medicine, emergency medicine, infectious disease, pharmacy, and information technology was assembled.
Selecting a testing option
Several options were considered for this initiative including testing location (ED versus laboratory) and testing type (instrument versus rapid). Point-of-care testing can provide quicker turnaround times but considerations such as non-laboratory personnel performing the test and following appropriate testing algorithms need to be considered.
Fast turnaround time is of particular consequence to ensure results are available while patients are in the ED. This allows for on-site guidance on HIV transmission prevention and appropriate care coordination with the Department of Infectious Disease for treatment.
Rapid tests do not require additional instrumentation thus alleviating some of the burdens of a standardized, multisite initiative. The decision was made to deploy a rapid test performed in the laboratory. An algorithm that follows CDC guidelines was built into our laboratory information software. Succinctly, specimens with positive results from the rapid test had further testing reflexively ordered.
This initiative was able to provide rapid HIV testing to EDs in Northeast Ohio. Detection of HIV can reduce transmission through reduction of at-risk behavior and treatment. Across the 12 EDs where rapid HIV testing was made available, we routinely see 400 orders a month. Overall, the positivity rate reflects the area’s high HIV burden. This successful initiative would not be possible without the support and efforts of the multidisciplinary team assembled.