Pilot study: An ED-based HIV screening program can be more productivewhen combined with a peer referral program
Dedicated clinicians, streamlined process are key to successful implementation
While health policy experts at the Centers for Disease Control (CDC) in Atlanta have long recommended that EDs routinely screen patients for HIV, the concept remains controversial. Some argue that EDs should not be involved with screening activities, and that emergency providers are already overburdened as patient volumes continue to increase. However, there are also efforts underway to leverage the unique setting of the ED to go beyond just screening in order to reach more people with undiagnosed HIV.
"People who are thinking about preventive health care and population health would suggest that the time when the ED can just sit back from the population and solely respond reactively to acute care needs is starting to go away," explains Michael Lyons, MD, an assistant professor of emergency medicine and director of the Early Intervention HIV Program at the University of Cincinnati (UC) in Cincinnati, OH. "It is clearly true that if you move away from fee-for-service, then the issue becomes maintaining the health of the population, and the hospital is clearly invested in that whether you are talking about value-based purchasing, 30-day readmits, or even just the simple idea that the hospital could pay for an awful lot of HIV tests rather than admit one person to the ICU who is diagnosed late."
In fact, Lyons and colleagues at UC Academic Health Center are pushing some of those boundaries. In a new study, they have found that combining an ED-based HIV testing program with a peer-referral program can, indeed, bring more people into the ED for testing and uncover more cases of HIV. Between May and September of 2011, the researchers report that they tested 466 patients, with four of these individuals testing positive for HIV. Among participants in the testing/peer-referral program, 34% had no prior visit to the ED, and 69% had never been tested by the ED-based HIV testing program.1
Leverage social networks
Lyons explains that peer referral programs are typically used by health departments to identify people with undiagnosed HIV. These programs are highly effective, he says, because they enable health care workers to seek out the friends and colleagues of people who are either HIV positive or at high risk for HIV. Alternatively, ED-based HIV screening programs typically tend to stop with the screening of the initial individual.
"We wondered how these two ways to intervene might relate to each other, and whether implementation problems in one setting or the other might be solved or mitigated somewhat," says Lyons. "We tried to do it in a very streamlined, very general way, and also in a very large-volume way."
The ED used for the study already offers HIV testing, and has dedicated testers to handle this work. For the study, researchers targeted patients from this screening program to receive coupons that they could pass along to their friends or partners to come in for free HIV testing. "The initial case would come from the screening program," explains Lyons. "But if we found people who were high risk or HIV positive, instead of just stopping or referring the new HIV-positive patients to the health department for case finding, we would try to do more with these people. We would try to do more to make use of their social relationships."
While the coupon aspect of the program has attracted a lot of attention, Lyons notes that a more compelling aspect of the program was that the testers tried to also target companions who were there in the ED with the people being tested. "In this day and age if you test in an ED and you test positive, and your partner is there with you, that person is probably not tested," says Lyons. "They might be referred. They might choose to go register as a patient, but that whole interaction is not worked out."
For instance, Lyons explains that in many ED settings that offer HIV screening, a young man might test positive while his girlfriend who is sitting in an adjacent room does not receive any care because she is not an ED patient, explains Lyons. "What we did was not only solve that problem, but try to target the problem," he says, explaining that program staff would ask whether there were any family, friends, or partners there in the ED with the person being tested who might also benefit from testing. "We had the partner testing, the coupon program, and the social network component."
Streamline the process
One issue that was key in making the program work was the fact that UC already had a policy in place that enables people to receive HIV testing in the ED without having to register as ED patients. "The reason we attacked this problem was because we were obligated by our health department funding to offer HIV testing to walk-in patients, but on the one hand we didn’t want to be offering HIV testing to people in the ED and then have no record that they were there; however, at the same time having them register as an ED patient seemed incorrect," notes Lyons. "What we did was develop a process where we register these patients as outpatients, so there is a record of them being there, but they are not charged as an ED patient."
The process enables patients to bypass any need for a medical screening exam or any of the charges that go along with a typical ED admission. "We actually have the patients who come in for HIV testing sign a paper that says that they waive their right to be evaluated in the ED," says Lyons. "That way they don’t have to see a physician, they don’t have to be triaged; they don’t need to do any of that."
Lyons acknowledges that figuring out how to implement the process was difficult, but once all the administrative hurdles were worked out, it became a simple operation for the ED to manage. "We developed this in conjunction with the hospital, and I don’t think it is widely done, but it has a lot of interesting ramifications," he says.
For example, Lyons notes that the process could potentially be used for research patients, patients requiring forensic exams, or potentially other preventive health care services. "This is an expanded and controversial view of what an ED can do, but it does point out the unusual fact that there are millions of people who are in EDs who are not ED patients, and occasionally those people are of interest in the ED," he observes.
Consider increased patient volume
Even with dedicated testers, program staff did have some difficulties dealing with the volume of patients that came in for HIV testing. "If you start bringing in five people an hour, and you try to find a corner to do something with them, that can be a problem," notes Lyons. "We ran into those problems and had to scale back the volume of what we were doing."
Further, Lyons points out that the ED could not have offered the coupon component of the program without the outside funding that was paying for coupons and personnel. However, the HIV screening program, which is funded through the health department, remains. "We still have our dedicated testing program, so we still refer HIV-positive patients to the health department much like other places do," he says. "We probably do that with a little more emphasis and monitoring than some places do, and we still have the companion testing component."
In fact, the dedicated testers recently identified someone who was HIV positive who just happened to be in the ED with someone else who was also HIV positive. "We have an example, a proof-of-concept case of finding someone with undiagnosed HIV through the companion testing program," notes Lyons. "Even if we didn’t have dedicated testers, I would still want that mechanism to be available to the physician if he or she chose to use it."
More study needed
However, now that the pilot has been completed and the funding for that project has ended, the coupons for free HIV testing and the social networking aspects have also concluded, at least for the time being. And Lyons suggests there are still more questions to be answered about the approach before it should be implemented on a broad scale in the ED setting.
For instance, he would like to learn more about how to best capitalize on the yield of screening programs to feed forward into social network programs, and he would like to get better estimates about what the potential benefits of social networking programs are when done in conjunction with screening programs. "In the cost-effectiveness models of health care screening, they don’t include a component where, when you identify a person who is HIV positive, that leads to another person and another person and another person being identified as positive because the assumption that they make is that everyone in the entire population will receive the test in the health care setting," explains Lyons. "So our question is, if you don’t manage to test everyone in the health care setting, what is the extra benefit in terms of combining with these social network programs?"
In the pilot study, researchers found evidence that screening programs and social networking programs are complementary and not entirely redundant, but Lyons acknowledges that there is more work to do in terms of testing the approach with different types of programs and collaborations. "A lot of the implications of this are either controversial or they are just now developing," he says. "We anticipate that this is going to be of great interest, but we have to get farther in terms of packaging our findings for the practice and research communities. We also have to see how things develop in terms of health care before we will know the real impact."
1. Paulsen R, Ruffner A, Lindsell C, Hart K, et al. Can a social network HIV testing program expand HIV testing beyond the usual emergency department population? Acad Emerg Med. 2013;20:S223-S224.
• Michael Lyons, MD, Assistant Professor, Emergency Medicine, and Director, Early Intervention HIV Program, University of Cincinnati, Cincinnati, OH. E-mail: firstname.lastname@example.org.