HIV Testing at Visits to US Emergency Departments, 2018

Abstract

Background: An early HIV diagnosis improves patient outcomes, reduces the burden of undiagnosed HIV, and limits transmission. There is a need for an updated assessment of HIV testing rates in the emergency department (ED). Setting:The National Hospital Ambulatory Medical Care Survey sampling ED visits were weighted to give an estimate of ED visits across all US states in 2018. Methods:We analyzed patients aged 13-64 years without known HIV and estimated ED visits with HIV testing and then stratified by race, ethnicity, and region. Descriptive statistics and mapping were used to illustrate and compare patient, visit, and hospital characteristics for visits with HIV testing.Results: Of 83.0 million weighted visits to EDs in 2018 by patients aged 13-64 years without a known HIV infection (based on 13,237 National Hospital Ambulatory Medical Care Survey sample visits), HIV testing was performed in 1.05% of visits. HIV testing was more frequent for patients aged 13-34 years compared with that for patients aged 35-64 years (1.32% vs. 0.82%, P = 0.056), Black patients compared with that for White and other patients (1.73% vs. 0.79% and 0.41%, P = 0.002), Hispanic or Latino patients compared with that for non-Hispanic or Latino patients (2.18% vs. 0.84%, P = 0.001), and patients insured by Medicaid compared with that for patients insured by private or other insurance (1.71% vs. 0.64% and 0.96%, P = 0.003). HIV testing rates were the highest in the Northeast (1.72%), followed by the South (1.05%). Conclusions: HIV testing occurred in a minority of ED visits.There are differences in rates of HIV testing by race, ethnicity, and location. Although rates of testing have increased, rates of ED-based HIV testing remain low.

Estimates of HIV testing at visits to United States emergency departments

“…We also identified persistently low rates of HIV testing for populations prioritized in the EHE phase 1 rural jurisdictions in the South. This is consistent with previous estimates showing that both populations and regions disproportionately affected by HIV had low HIV testing rates [3]. Despite 7.7 million fewer weighted emergency department visits during the COVID-19 pandemic in 2020 than 2019, we found that testing rates were stable between 2019 and 2020.…”

“…System-level interventions, such as access to rapid testing platforms, standing orders for opt-out testing, or clinical decision support tools programmed in the electronic health record system, can increase HIV testing rates in the emergency department setting. Interventions like this have a high diagnostic yield because of the HIV rates of HIV diagnoses in communities served in the emergency department, including persons who inject drugs presenting after an overdose; those with STIs; and those who are underinsured or uninsured without alternative means of testing [3,4]. However, the lack of an increase in rates of Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.…”

“…Given the high rates of HIV diagnoses in the US South, and the EHE focus on several rural Southern jurisdictions disproportionately affected by HIV [1,2,5], we also estimated testing by facility-level characteristics including US geographic region and urban vs. rural location using nonmetropolitan statistical areas (MSAs) with lower population densities as a proxy for rural areas. We also estimated testing at emergency department visits where testing would have been indicated, such as for a visit focused on a problem associated with HIV acquisition including one for a sexually transmitted infection [3,6].…”

“…Status-neutral testing allows early diagnosis of HIV and is a critical first step to identify persons with a a negative HIV test who might benefit from HIV prevention with preexposure prophylaxis (PrEP). Emergency departments are an important setting for HIV testing; they routinely care for persons at increased risk for HIVand serve as a safety net for uninsured persons who lack financial access to healthcare and who might not otherwise have access to testing [3,4]. Despite Centers for Disease Control and Prevention (CDC) recommendations for routine opt-out and risk-based HIV testing without counseling and consent [5], rates of HIV testing in emergency departments have been historically low including during the years preceding the EHE launch in 2019 [1,3,6].…”

“…Emergency departments are an important setting for HIV testing; they routinely care for persons at increased risk for HIVand serve as a safety net for uninsured persons who lack financial access to healthcare and who might not otherwise have access to testing [3,4]. Despite Centers for Disease Control and Prevention (CDC) recommendations for routine opt-out and risk-based HIV testing without counseling and consent [5], rates of HIV testing in emergency departments have been historically low including during the years preceding the EHE launch in 2019 [1,3,6]. In early 2020, the COVID-19 pandemic decreased access to preventive care and screening, including HIV testing, especially in emergency departments with an observed large drop in emergency department visit volumes [7][8][9].…”