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Although an estimated 85% of people infected with HIV in the United States are aware of their diagnosis, more than 160,000 people remain unaware, leaving them without needed treatment and raising the risk of further transmissions. Experts note there are many missed opportunities to diagnose these patients and connect them to care, as patients at high risk for the virus often are not offered tests when they visit a healthcare provider. However, ED-based HIV screening programs are making progress in this area, with some using new-generation tests to identify more cases, even at the earliest acute stage.
There is no question that the country has made significant strides in identifying patients who have been infected with HIV. The CDC reports that 85% of HIV-positive people in the United States are aware of their condition. However, that still leaves more than 160,000 people who do not realize they are infected and could be transmitting the virus to others.
“Persons unaware of their HIV infections account for approximately 40% of ongoing transmissions in the United States and represent missed opportunities to improve health outcomes and prevent transmissions,” according to Brooke Hoots, PhD, MSPH, an epidemiologist in the division of HIV/AIDS prevention at the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the CDC.
Further, among patients diagnosed with HIV, Hoots notes that many have been HIV positive for many years before they become aware of their HIV status.
“Half the people diagnosed with HIV in 2015 had been infected for at least three years, and one in four had been infected for at least seven years,” Hoots notes.
Speaking at a CDC Vital Signs Town Hall about the issue in December 2017, Hoots commented that there continue to be many missed opportunities for patients at high risk for HIV to be tested. For instance, the data show that seven out of 10 people at high risk for HIV who were not tested in the previous year report that they nonetheless saw a healthcare provider during that period.
On the front lines of capturing these undiagnosed cases are EDs, some of which have implemented highly successful HIV screening programs. With different testing platforms available, hospitals have taken varied approaches toward implementing HIV screening. However, some program administrators with the longest experience in this area are beginning to see dividends in terms of regional public health improvements.
One of the earliest pioneers in ED-based HIV screening is Ben Taub Hospital in Houston, which first implemented routine, universal screening for HIV (RUSH) 10 years ago. The process still works in much the same way it did 10 years ago: Any emergency patient requiring a blood draw for any reason will be tested for HIV automatically unless the individual specifically declines or opts out of the test. However, multiple advances in testing procedures have streamlined the process and improved sensitivity.
While in the early days it could take eight hours before the results were known, risking the possibility that some patients would have been discharged from the ED before their HIV status was known, advances in testing now deliver the results within two hours, explains Nancy Miertschin, MPH, the grants program manager for Ryan White Part A-OP Medical Services in the Harris Health System.
“The order is made, the blood gets drawn, and it goes to the lab,” she explains. “The idea is that we will get the results back and inform the patient if the result is positive while he or she is still there in the ED.”
The newer, fourth-generation testing that Ben Taub uses is also much more accurate than earlier tests, capable of detecting acute HIV infections — or the initial stages of HIV that occur before antibodies begin circulating in the blood. The newer testing procedures are much more sensitive, Miertschin notes.
“We go ahead and inform patients even on what is considered preliminary results because there is such a low rate of false positives,” she says. Even with confirmatory tests, it is a very fast process, Miertschin adds.
While identifying patients with HIV is important, it doesn’t do much good unless these patients are linked to appropriate care. Consequently, a hallmark of the approach used at both Ben Taub Hospital and its sister facility, Lyndon B. Johnson Hospital, also in Houston, is the presence of trained service linkage workers who are responsible for communicating HIV test results to patients and linking them to needed treatment and services.
“The service linkage workers are the first people who receive those [HIV test] results,” Miertschin observes. “Their job is to find the patients before they leave the hospital and get them their results.”
The service linkage personnel will spend as much time as needed to answer any questions the patients may ask and to connect patients with appropriate care, Miertschin adds.
“We feel there is not much point in having a routine testing program if you are not actively linking those patients into care,” she observes. “For patients who have acute infections, we have a fast-track process so we can get them started on medication as soon as possible.”
Miertschin notes that the service linkage workers are like non-medical case managers in that they are very knowledgeable and experienced in working with patients with HIV.
“The role requires a combination of being able to understand the testing process and what the tests mean and being able to explain all of this to patients,” she says. “In fact, some of our [service linkage workers] have gotten so skilled at the task that they often wind up helping the physicians interpret the subtleties of the test results, so they are the bridge between the lab, the physicians, and the patients.”
In the early days of the RUSH program, the inclusion of service linkage personnel was critical to getting the necessary buy-in from frontline providers to initiate HIV screening in the ED.
“Anecdotally we would always hear that the physicians didn’t want to test because they didn’t want to have to give the results or be responsible for linking patients to care, so [the service linkage workers] would take this responsibility off of them,” Miertschin explains. “That was one of our real selling points in the beginning ... the physicians weren’t going to have to give the results on their own any more. Our service linkage workers would be there to do it for them or with them.”
The laws regarding consent in Texas have enabled hospitals like Ben Taub to streamline the HIV screening process so that the issue of convincing patients to agree to undergo HIV testing is not overly burdensome. “From the beginning, we wanted the flow to be as smooth and uninterrupted as possible while at the same time adhering to the law, which requires that patients be informed,” Miertschin observes. “It doesn’t require that you have a conversation with patients about [HIV testing], so there is signage posted all over the ED in English and Spanish.”
The signage states that the CDC recommends routine screening for HIV, and that a physician or nurse may order an HIV test during a patient’s emergency visit. Patients who wish to decline undergoing an HIV test are instructed to inform their caregivers of their decision before anyone draws the patients’ blood. “There is more printed material we will give patients if they have questions, but we just hardly ever have a hiccup in that process,” Miertschin notes. “What we found is that people assumed all along that they were being tested for HIV even before we started doing this.”
While Harris Health has received CDC funding to support the HIV testing program for nearly the full 10 years of the program, precisely where that funding is used has evolved.
“Initially, a big part of that money went to our lab to pay for the actual testing,” Miertschin explains. “Over time, particularly as the cost of the test has become reimbursable by Medicare and Medicaid, it meant that there was less need for us to reimburse the lab, and we hardly pay for any of that anymore because the cost of testing is now reimbursed in other ways. But the startup funding we [received] from the CDC to get this all rolling was critical before all of the third-party reimbursement became available.” With reimbursement for testing now largely settled, more funding can go toward service linkage staffing and related services. Further, with 10 years of experience and data from the RUSH program and other efforts in greater Houston, there is evidence that rigorous screening and testing is making a dent in the prevalence of undiagnosed HIV in the region.
“We have not done a rigorous study, but over the years of looking at these numbers we see that the number of new positives is declining in proportion to the numbers we have had in the past,” Miertschin observes. “That means we are clearing out some of the backlog in undiagnosed infections ... so we do think that effect is there.”
Also, Miertschin points to new research just out this year showing that the newer testing procedures, which use combination HIV antigen-antibody tests, are indeed identifying previously undiagnosed HIV cases in numbers that exceed the CDC’s recommended threshold of 0.1% for routine screening in nine EDs in six cities that offer HIV screening programs. The ED at Ben Taub was one of the EDs included in this study.1
One other effect of the long-standing, robust program at Ben Taub is that routine HIV screening in the ED is part of the culture of Harris Health, Miertschin says.
“We find that we don’t have to keep selling the program. When new residents or new staff members come in, it is just expected that we do this, and everybody does it,” she says.
While there are signs of improvement, the latest data show that HIV screening programs like RUSH continue to be warranted.
“From January through August of , we did 69,000 HIV tests. In our EDs, we did 33,000 tests, and the rest were done in ambulatory clinics,” Miertschin notes. “In that time in the ED, we had 78 new positive results and 477 previously known positives.”
The new positive results, or 0.16% of the total, are above the CDC’s recommended threshold for continuing to conduct routine HIV screening, Miertschin observes. Further, investigators found that more than 25% of the previously known HIV infections involved patients who had fallen out of care, giving the hospital an opportunity to reconnect these patients with needed care and services.
“That is another role for our service linkage workers,” she explains. “They have access not only to our hospital records, but also to the area’s HIV patient data system ... so they can quickly look to see if a patient has had a medical care visit in the last three months in Houston.”
Since Ben Taub was one of the first hospitals to initiate a large-scale HIV screening process, many other hospitals and health systems have been in touch with program administrators there for information on how to develop their own screening programs.
“We are now an AIDS Education and Training Center [AETC],” Miertschin explains. “The role of that agency, which is funded by [Health Resources and Services Administration], is to train healthcare providers in caring for HIV patients, and we view that as a platform to help other providers start up routine testing programs.”
Miertschin acknowledges that putting an ED-based HIV screening program in place is a big lift that requires commitment on many levels. “The first challenge is having the will to do it, and that depends on senior level support,” she notes.
As a large, public healthcare entity in Harris County, Ben Taub has always received considerable support for its program, which was seen as part of the hospital’s mission. However, Miertschin has observed that administrators at some hospitals face a lot of resistance to the implementation of HIV screening programs. Before formulating a screening program, Miertschin recommends that hospital administrators and clinicians thoroughly familiarize themselves with the laws regarding consent in their states and determine how they want to approach that issue.
“Always, it seems like when some place wants to start this up, the matter of consent is a big one,” she says. “Get everybody comfortable with that.”
With reimbursement for HIV testing available from both public and private payers, funding for screening is not the hurdle it used to be. In fact, hospitals with ED-based HIV screening programs have found themselves ahead of the game when it comes to carrying out recommended screenings for hepatitis C because the same infrastructure and approach can be leveraged easily.
“Two years ago, we started working with a program here at Harris Health that is testing for hepatitis,” Miertschin notes. “They were looking for the vehicle to do it, and we had the vehicle in place, so now they participate with us, and we go around and do training every year, and the tests are all done at the same time.”
In the early days of HIV testing and screening, both the stigma and the clinical consequences associated with a positive result made many people reluctant to undergo testing. Today, with vastly improved treatment regimens and outcomes, this resistance has dissipated. “Now, HIV patients can expect to live just about as long a life as anyone else if they manage their treatment,” Miertschin observes. “There is a much more hopeful message to give patients when you are telling them they have HIV now than there used to be.”
While many hospitals have duplicated aspects of the ED-based HIV screening and testing approach used at Ben Taub, other approaches have proven successful, too. For instance, after earlier trials that used blood draws to conduct HIV screening, Desert Regional Medical Center in Palm Springs, CA, now uses an opt-in approach whereby any patient who presents to the ED is offered an HIV test toward the end of their encounter (rapid finger-stick testing, in this instance).
“We chose to use finger-stick testing because it was the fastest test and [best suited] to what we wanted to do for our future state,” explains Arthur Dominguez, Jr., DNP, MSN, RN, CEN, CPEN, TCRN, CCRN, CENP, who led the effort to implement the ED-based HIV screening effort when he served as assistant chief nursing officer at Desert Regional. Today, Dominguez is the chief nursing officer at Sierra Vista Regional Medical Center in San Luis Obispo, CA, which also is a Tenet Health facility.
“We knew that eventually we wanted to screen everybody, or at least offer HIV testing to [everybody who presents to the ED], without it severely impacting capacity or discharge length of stay, and we wanted a test that worked into the process flow for the clinicians,” Dominguez notes. “It takes 60 seconds for the results to come up.” Identifying patients with HIV is an issue of particular importance to California’s Coachella Valley, where Desert Regional Medical Center is based, because health data show that HIV prevalence is close to three times the national average in the region. Consequently, beginning in 2014, Tenet became one of the lead sponsors of a $1.5 million initiative to increase HIV awareness, point-of-care testing, and linkage to care.
In phase one of the implementation of the HIV screening test at Desert Regional, only patients who were admitted to the hospital from the ED were offered the finger-stick test. During this period, the process was streamlined and fine-tuned. Then, the ED began offering the test to any patient who presented to the ED.
“It increased our ability to let patients know in real time if they screened positive,” Dominguez says regarding the rapid finger-stick test. “If they screened positive, we were then able to link them to care through the Desert AIDS Project [DAP], a community-based, not-for-profit organization that originally began as an AIDS service organization, but is now a Federally Qualified Health Center.”
For patients who screen positive on the rapid finger-stick tests, blood is drawn and sent to the lab for validation, although Dominguez notes that the finger-stick tests are highly accurate. “The reason we chose to use the finger-stick test is because it gave us the opportunity to have that conversation ... if patients screen positive,” he explains. “It allowed us to use the physician in the ED to let patients know what the screening meant.”
In addition, for patients who screen positive, a social worker arrives to make sure that any additional psychological or navigational needs of the patients are met in terms of transitioning them to an appropriate care and treatment path. When determining where in the ED workflow process to offer the finger-stick test to patients, the main concern of physicians was that the screening test should not hinder or delay care for the issue that brought the patient to the ED.
“They wanted to make sure that we weren’t ignoring or putting [a patient’s] chief complaint second,” Dominguez notes. “They wanted to treat the acute reason why the patients were there and make [HIV screening] a secondary addition.”
Consequently, a standardized procedure was developed to carry out the HIV screenings at the end of patient encounters in the ED, just prior to discharge. Dominguez notes that most of the work actually falls on the nursing staff members who had to go through competency training for both performing and talking to patients about the test.
“They aren’t having to interrupt the physician that many times,” he says. “They just let [the physician] know if a patient screened non-reactive or reactive.”
For patients who screen reactive (positive) for HIV, the physician talks with those patients just like they would with any abnormal lab result, Dominguez explains. The physician details what care and treatment is required, whether it is on the inpatient side or if patients are being discharged, and he or she will make sure patients are linked to care either through the DAP or their primary care physician. In fact, during business hours, the DAP will send a representative to the ED to speak with the patient before he or she is discharged. The arrangement is convenient because the DAP facility is less than one mile from the hospital, Dominguez adds.
Between April 2014 and May 2017, Desert Regional performed 461 HIV finger-stick tests, of which 13 were reactive. In addition, the hospital performed 2,572 blood-drawn HIV tests, of which 65 tested reactive (one tested indeterminate).
For other hospitals considering the implementation of ED-based HIV screening, Dominguez advises that it is crucial to get administrative support for the effort from all levels of the hospital, including risk management, quality, the clinical staff, and social services. Also key is a thorough understanding of community needs as well as organizations that can help fulfill the mission of connecting patients to care. Putting a process together that works well for everyone involved may take some time, Dominguez acknowledges.
“We went through various, multiple committees to make sure we didn’t lose the linkage to care for patients who screen positive because we know how important it is for them to get care and treatment,” he explains. “I’ve literally got this huge, two-page value-stream mapping process that the facility specifically follows.”
In Desert Regional’s process, patients must opt-in for the HIV screening, but Dominguez notes that patients have been very open to the test.
“Actually, one of the first patients was a heterosexual female in her 90s. She had never been tested before. She came back positive and had no idea,” he says. “That painted a picture that it is not just the LGBTQ population that is at risk or HIV positive. It is the heterosexual population as well.”
Financial Disclosure: Physician Editor Robert Bitterman, Author Dorothy Brooks, Editor Jonathan Springston, Executive Editor Shelly Morrow Mark, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.