Revising Expectations from Rapid HIV Tests in the Emergency Department

Abstract

Background Expanded HIV screening efforts in the United States have increased the use of rapid HIV tests in emergency departments. The reported sensitivity and specificity of rapid HIV tests exceed 99%. Objective To assess whether a reactive rapid oral HIV test result correctly identifies adults with HIV infection in the emergency department. Design Diagnostic test performance assessment within the framework of a randomized, clinical trial. Setting Brigham and Women's Hospital emergency department (Boston, Massachusetts) from 7 February to 1 October 2007. Patients 849 adults with valid rapid oral HIV test results. Intervention Rapid HIV testing with the OraQuick ADVANCE Rapid HIV-1/2 Antibody Test (OraSure Technologies, Bethlehem, Pennsylvania). Patients with reactive rapid test results were offered enzyme-linked immunoassay, Western blot, and plasma HIV-1 RNA testing for confirmation. Measurements Specificity and positive likelihood ratio. Results 39 patients had reactive results (4.6% [95% CI, 3.2% to 6.0%]). On confirmation, 5 patients were HIV-infected (prevalence, 0.6% [CI, 0.1% to 1.1%]) and 26 were non–HIV-infected (8 patients declined confirmation). The estimated rapid test specificity was 96.9% (CI, 95.7% to 98.1%). Sensitivity analyses of the true HIV status of unconfirmed cases and test sensitivity resulted in a positive likelihood ratio of 8 to 32. Western blot alone as a confirmation test provided conclusive HIV status in only 50.0% (CI, 30.8% to 69.2%) of patients at first follow-up. The addition of HIV-1 RNA testing to the confirmation protocol improved this rate to 96.2% (CI, 88.8% to 100.0%). Limitation Test sensitivity cannot be assessed because nonreactive OraQuick test results were not confirmed. Conclusion Although patients with a reactive oral OraQuick HIV screening test in the emergency department had an 8- to 32-fold increased odds of HIV infection compared with the pretest odds, the specificity of the test was lower than anticipated.

Acceptance of Rapid HIV Screening in a Southeastern Emergency Department

“…41,42 These recent reports have caused widespread concern with the performance of the OraQuick test. Our program had a low falsepositive rate (0.06%), which is consistent with the manufacturer's reported specificity.…”

Provider and Practice Characteristics Associated with Use of Rapid HIV Testing by General Internists

“…Sensitivity and specificity of commercially available rapid tests are over 99%, 7 although specificity may be lower in actual practice. [8][9][10][11][12][13] Research has focused on use of rapid testing in episodic care settings such as emergency rooms, [11][12][13][14][15] hospitals, 16 STD clinics, 17 and jails and prisons. 9,18 In these settings, rapid testing is acceptable and associated with a reduction of loss to follow-up after a positive HIV test.…”

Rapid Human Immunodeficiency Virus Screening in an Emergency Department in a Region with Low HIV Seroprevalence

“…The positive HIV test rate in urban EDs is higher than the local seroprevalence, which implies the cost effectiveness of screening in EDs (Table 3) (9,11,12,16,19,25,26,28,(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41). Therefore, the US CDC recommends ED HIV screening and suggests that this strategy is particularly effective in health care facilities with HIV prevalence rates above 0.1z.…”