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Emergency departments (EDs) are increasingly recognized as important sites for HIV testing because of the relatively high prevalence of HIV infection among patients who receive care there. To evaluate rapid HIV testing in this setting, investigators studied a busy ED in Chicago, where undiagnosed infections were identified through a two-pronged approach: (1) Testing staff offered HIV screening to as many eligible patients as possible, and (2) ED clinicians referred specific patients with suspected HIV infection to the testing staff.
From January 2003 through April 2004, 2824 of 4849 patients (58%) who were approached for HIV screening agreed to be tested. Thirty-five of these screened patients (1.2%) were found to be HIV-infected. Among patients referred to the testing team by ED providers, 414 of 436 (95%) agreed to be tested, and 48 (11.6%) were found to be HIV-infected. About half of the infected patients in each group denied having any identifiable risk factors for HIV infection. The proportion of infected patients with CD4 counts <200 cells/mm3 at testing was significantly smaller in the screened group than in the referral group (45% vs. 82%). The screened group also had a smaller proportion of infected patients with opportunistic infections (6% vs. 21%). Most patients found to be HIV-infected entered HIV specialty care.
Lyss SB et al. Detecting unsuspected HIV infection with a rapid whole-blood HIV test in an urban emergency department. J Acquir Immune Defic Syndr 2007 Apr 1; 44:435-42.
Comment
In this busy urban ED, having both a screening program and a referral program for HIV testing proved to be very effective in diagnosing new HIV infections. Acceptance was high among all patients offered testing, whether through provider referral or the general screening program. Although the screening program had a lower diagnostic yield per test than did the referral program, patients identified through screening were diagnosed earlier (as indicated by higher CD4-cell counts and fewer opportunistic infections) than were those identified through referrals. The testing program was linked to HIV specialty care, but no mechanism was in place for rapid entry into such care. Consequently, more than 20% of those referred for care did not attend the HIV clinic within 4 months of diagnosis. Compared with HIV testing done at other sites in Chicago, screening ED patients was a relatively high-yield approach. The strategy of focusing HIV testing programs in acute-care settings, particularly EDs, seems quite sound and should be practiced more widely.