Three HIV screening strategies identified comparable numbers of new HIV diagnoses, a new study found.
Targeted HIV screening strategies in emergency departments were no better than universal screening for identifying infections, according to a recent prospective clinical trial that compared HIV screening strategies in 4 urban hospitals.
The study, published in JAMA Network Open , included 76,561 patient visits at 4 hospitals from April 2014 to January 2016. Participants were in 3 groups: non-targeted HIV screening, enhanced HIV screening, and traditional targeted screening, to compare strategies for HIV screening in the Emergency Department.
“No single screening approach, targeted (risk-based) or non-targeted (non-risk-based), proved superior at identifying HIV patients in the ED,” Jason S. Haukoos, MD, MSc, professor of emergency medicine and director of emergency medicine research at Denver Health Medical Center, told Contagion . “All three approaches we studied identified comparable numbers of newly diagnosed patients with non-targeted screening, which resulted in the majority of tests being performed.”
Of the 25,469 participants randomly assigned to the non-targeted group, 6,744 (26.5%) completed the test and 10 (0.15%) were newly diagnosed. Of the 25,453 in the enhanced target group, 4,488 (32.3%) completed the test and 7 (0.16%) were newly diagnosed. Of the 25,639 in the traditional target group, 3,173 (44.7%) completed the test and 7 (0.22%) were newly diagnosed.
Haukoos said he was surprised by "the relatively small number of new HIV diagnoses and that neither arm of the study was identified as superior to the other."
"We anticipated finding a much larger number of HIV patients, but we did not, which may be related to intensive public health/prevention efforts at the national level before and during the trial," he said.
The study was conducted in high-volume emergency departments in Baltimore, Maryland; Cincinnati, Ohio; Denver, Colorado; and Oakland, California. The median age of the participants was 40 years, with 51.2% being female, 39.4% Black, 32.6% non-Hispanic White, and 21.4% Hispanic.
In the non-targeted HIV screening arm, all patients were notified that they would be tested for HIV unless they declined. The enhanced targeted HIV screening arm used the Denver HIV Risk Score, a quantitative risk prediction tool, to automatically calculate a score, which triggered a message notifying patients with high scores that they would be tested for HIV. Patients in the traditional targeted HIV screening arm answered conventional risk questions, and a behavioral risk assessment tool determined their risk and need for screening.
“Non-targeted HIV screening, also known as 'universal' or 'non-risk-based' screening, results in a greater number of patients being tested for HIV and helps identify ED patients living with HIV,” said Haukoos. “This approach is also likely the easiest to implement in routine ED care, as no questions about risk are required. Although not specifically studied in this trial, ongoing efforts to expand HIV screening in EDs remain a critical public health need.”
Targeted strategies required significantly fewer tests to produce a similar number of new HIV diagnoses to non-targeted screening, but all 3 screening strategies exceeded the CDC's suggested 0.1% testing prevalence threshold for routine screening.
Further research is needed to examine the effects on operational efficiency, cost-effectiveness, acceptance by patients and staff, and to determine the best approach for HIV screening.
“There are approximately 140 million emergency department visits each year in the U.S., most of which occur in community (i.e., non-academic) emergency departments where HIV screening is still not very common,” Haukoos said. “Beyond expanding HIV screening efforts, identifying high-risk but HIV-negative patients and referring them to PrEP services, and initiating PrEP for those at highest risk, will likely be the next important step in HIV prevention in emergency departments. It is very common for patients at highest risk of HIV to only connect with healthcare through emergency departments, making emergency departments a clinical sentinel area for impacting the HIV epidemic.”
HIV testing declined by 17.5% during the COVID-19 pandemic from March to October 2020, according to a recent study . Another recent study showed that incorporating universal HIV screening into COVID-19 testing at the University of Chicago Medicine's Emergency Department maintained HIV testing volumes throughout the pandemic.