Counselor- Versus Provider-Based HIV Screening in the Emergency Department: Results From the Universal Screening for HIV Infection in the Emergency Room (USHER) Randomized Controlled Trial

Abstract

Objective We compare rates of rapid HIV testing, test offer, and acceptance in an urban emergency department (ED) when conducted by dedicated HIV counselors versus current members of the ED staff. Methods The Universal Screening for HIV Infection in the Emergency Room [USHER] trial is a prospective randomized controlled trial that implemented an HIV screening program in the ED of an urban tertiary medical center. ED patients were screened and consented for trial enrollment by an USHER research assistant. Eligible subjects were randomized to rapid HIV testing (oral OraQuick) offered by a dedicated counselor (counselor arm) or by an ED provider (provider arm). In the counselor arm, counselors—without other clinical responsibilities—assumed nearly all testing-related activities (consent, counseling, delivery of test results). In the provider arm, trained ED emergency service assistants (nursing assistants) consented and tested the participant in the context of other ED-related responsibilities. In this arm, ED house officers, physician assistants, or attending physicians provided HIV test results to trial participants. Outcome measures were rates of HIV testing and test offer among individuals consenting for study participation. Among individuals offered the test, test acceptance was also measured. Results From February 2007 through July 2008, 8,187 eligible patients were approached in the ED, and 4,855 (59%) consented and were randomized to trial participation. The mean age was 37 years, 65% were women, and 42% were white. The overall testing rate favored the counselor arm (57% versus 27%; P < .001); 80% (1,959/2,446) of subjects in the counselor arm were offered an HIV test compared with 36% (861/2,409) in the provider arm (P < .001). HIV test acceptance was slightly higher in the provider arm (counselor arm 71% versus provider arm 75%; P = .025). Conclusion Routine rapid HIV testing in the ED was accomplished more frequently by dedicated HIV counselors than by ED staff in the course of routine clinical work. Without dedicated staff, HIV testing in this setting may not be truly routine.

The role of nurses in HIV screening in health care facilities: A systematic review

“…Five studies were rated as low, 4 as moderate, 16 as high and 5 as very high methodological quality. Four studies (13.3%) were randomised controlled trials (RCTs) Carey et al, 2008;Munday et al, 2005;Walensky et al, 2011) in few centres (single-centre or 2-site). The RCTs were rated as moderate (n = 3) or high (n = 1) methodological quality.…”

“…Three of the 4 RCTs were specifically designed to evaluate nurse interventions Carey et al, 2008;Munday et al, 2005). In 4 other studies, nurse-driven HIV testing was associated with the participation of other staff in the HIV testing process and analysed in tandem Hack et al, 2013;Munday et al, 2005;Walensky et al, 2011). In the 13 studies comparing the results of nurse-driven HIV testing to other testing approaches, 4 did not clearly describe the testing methods.…”

“…Four of these studies examined whether nurses offered HIV testing (as charted in patient records or selfreported) more frequently than other staff Arbelaez et al, 2012;McNaghten et al, 2014;Walensky et al, 2011). Among them, 2 studies yielded a higher participation of nurses in the offering of HIV screening compared to physicians.…”

“…Among them, 10 studies (71.4%) showed that more than 60% of patients agreed to nurse-driven HIV screening, suggesting that the practice was widely accepted by patients (Table 3). In 5 studies, nurse-driven HIV screening was compared with other interventions Carey et al, 2008;Kinsler et al, 2013;Rayment et al, 2012;Walensky et al, 2011). A crosssectional study found that HIV test acceptance was higher with the physician-initiated model (permanent staff) than the nurse-driven HIV screening model (new staff members) (aOR = 2.92; 95% CI = 1.37-6.22) .…”

“…Twenty-three studies (76.7%) evaluated either test offering rates or self-reported HIV test offering, patient acceptance rates, or testing delivery rates ( 100% a 14 studies in EDs: Arbelaez et al, 2012;Casalino et al, 2012;Chen et al, 2011;d'Almeida et al, 2013;Hack et al, 2013;Haukoos et al, 2013;Hecht et al, 2011;Leblanc et al, 2012;Mumma and Suffoletto, 2011;Rayment et al, 2012;Thornton et al, 2012;Walensky et al, 2011;White et al, 2009). b 14 studies in outpatient clinics and primary care settings: Carey et al, 2008;Clerk et al, 2013;Cunningham et al, 2009;Handy et al, 2006;Herbert et al, 2012;Kinsler et al, 2013;Knapp et al, 2011;McNaghten et al, 2014;Munday et al, 2005;Rayment et al, 2012;Thornton et al, 2012) c 4 studies in antenatal and women's health care settings: Cohan et al, 2008;Kropp et al, 2006 these studies, 13 (56%) compared the results of nursedriven HIV testing to other testing approaches (Table 3).…”