Reap the rewards of non-targeted HIV screening
Routine screening policies have many benefits
While the Centers for Disease Control and Prevention (CDC) in Atlanta has been calling on EDs to routinely test patients for HIV since 2006, the practice is hardly widespread. Even among EDs in urban areas, where the prevalence of HIV is relatively high, cost remains a significant barrier to this type of screening. Hospital administrators point to administrative hurdles and, in some cases, provider pushback as often complicating efforts to implement the kind of non-targeted, opt-out screening policies that the CDC recommends.
However, some of the EDs that have pushed through these obstacles and implemented routine HIV screening practices are beginning to see positive results from their efforts. What's more, new technologies are bringing the cost of HIV testing down, and experts suggest that once an infrastructure is in place to carry out routine HIV screening, there are opportunities to leverage these resources for additional gains.
Reduce the stigma
Even with funding assistance from the CDC, it took a year for the ED at the University of Alabama at Birmingham (UAB) to implement a non-targeted, opt-out approach to HIV testing, explains James Galbraith, MD, a physician in the UAB Department of Emergency Medicine and the testing program coordinator. "That [timeline] is pretty common anytime anyone attempts to initiate any type of high-volume testing in the ED," says Galbraith. "We ran our first test in August of 2011, and we have been testing 24/7 since then without any pauses or breaks."
The way it works is that any patient aged 19 to 64 who presents to the ED for care will be asked during triage whether he or she has ever been tested for HIV, and if so, what the result of the last test was, explains Galbraith. If the test result was negative for HIV, the nurse will inform the patient that UAB offers a free and confidential rapid HIV test for all ED patients, and that the patient should let her know if there are any questions or concerns, or if the patient wishes to decline the test.
"The nurse then allows patients to take in the information, and what we have found is that only about 13% of patients decline the test," says Galbraith. "In other models where hospitals have used pieces of paper, or registration people have gone into the triage room to ask the patients these questions, there is a much higher opt-out rate. In some cases, it is as high as 80%."
While it is important to be transparent with patients so that they know you will be testing them for HIV, you also want to make the process as routine as possible, explains Galbraith. "The less routine you make the offering, the less likely it is that patients are going to want to participate in the testing," he says. "We reduce the stigma attached to HIV testing by saying that we want to test everybody."
In one year of conducting 20,000 HIV tests, the ED has confirmed diagnoses in 72 patients; this is in an ED that sees about 63,000 patients a year, says Galbraith. He observes that the prevalence may seem quite small, but a positive diagnosis is made every three or four days at UAB, and most of these patients have not yet developed AIDS.
"It becomes cost-effective downstream for a hospital to be getting these patients linked into care, making this more of a manageable chronic disease rather than dealing with end-of-life issues, multiple ICU stays, and all of these expenses," adds Galbraith. "The mathematical models that the CDC has done suggest that if the prevalence in your community or your population of patients is greater than 0.1%, then this approach is cost-effective."
Identify patients early on
One of the reasons why expanded testing programs are important is because treatments for HIV have become so effective, explains Michael Saag, MD, director of the UAB Center for AIDS Research. "Especially when you find people early and get them into care, they will live a normal lifespan, so the trick is finding people soon after they have been infected and getting them early into care," he says. "In addition, once these patients are in care and their viral load is suppressed with treatment, they don't transmit the virus to other people, so we have both a personal health benefit and a public health benefit."
In the early stages of an HIV infection, there are usually no symptoms, so unless you are testing patients, you are not going to know they are infected, adds Saag. "Most people who are at risk for HIV don't define themselves as being at risk, so they don't even think to get tested," he says. "The ED is a great place to do testing because several studies have shown that among people who ultimately got admitted to the hospital from the ED for an AIDS-related condition, on average they had three to five ED visits in the year prior to their admission when they were never tested for HIV."
If these patients had been tested, they would have been diagnosed sooner, and that hospitalization down the road could have been averted, stresses Saag. "It is not just these patients and their families who are affected. This affects anyone who might have had contact with them down the road and picked up the infection, so the ripple effects are pretty profound."
Identify resources for follow-up care
However, Galbraith emphasizes that the benefits of expanded testing are lost if adequate resources are not in place to provide these patients with effective follow-up. "You really need to have these places identified and have a strategy in place to link these patients into care," he stresses. "The longer patients have to wait for their first appointment or the longer they have to wait for their confirmatory results, the less likely they are to follow-up."
To make these connections quickly at UAB, Galbraith hired a linkage care coordinator whose primary responsibility is to call all patients who have tested HIV positive on the next business day after they have received counseling in the ED. "The patients are also given the linkage care coordinator's phone number so they can call in," says Galbraith. "An encouraging sign for us is when the patient leaves the ED and calls the linkage care coordinator right away."
A disproportionate percentage of patients with HIV are "extremely under-served," adds Galbraith. "They don't have health insurance, they don't have care, and they may not have a phone," he says. "Their mind is set every day on food, shelter, and water; HIV is very low on the priority list, so the easier you can make [accessing care] for them, the better the chance you have of getting the benefit of screening."
Before the HIV testing program began at UAB, Galbraith communicated with all of the HIV care resources within the community to discuss how they would care for an influx of newly diagnosed patients in terms of logistics and funding. "In the first year, we have had 72 new cases, and we were able to handle it just fine," he says.
While the patients identified as having HIV will definitely benefit from being connected to care at an early stage, any cost savings from the screening program will take time to realize. "We won't potentially see the effects of expanded testing for 3, 4, or 5 years, when these patients would otherwise develop AIDS," notes Galbraith. In addition, he suggests there is a preventive effect from screening because if people know they have HIV, they can take steps to insure that they do not pass the disease on to others. Public health experts estimate that roughly 20% of persons who have HIV are not aware that they have the disease.
"The CDC's argument is if you wait until the epidemic gets much worse before you start a screening strategy, it is going to get much more out of control. This is a means of prevention by getting these patients identified," explains Galbraith.
Provide training to clinicians, staff
There is no question that implementing a non-targeted screening program of this size and scope requires additional personnel. In addition to the linkage care coordinator, Galbraith has brought on a project coordinator to handle the financial end of the program and three dedicated lab personnel to carry out the roughly 20,000 HIV tests per year required.
Galbraith acknowledges that getting the ED physicians on board with the program was challenging because many were concerned about the time it would take to counsel patients with a positive diagnosis, and many were also uncomfortable taking on that role. "I did sessions on how to counsel, and I had counselors from our HIV clinic come over and train everybody about the initiative," he says. "We also trained the nurses about the initiative and the rationale behind it. All these things took several months before we implemented the screening."
While some EDs have attempted to put the responsibility for HIV testing on a single person, there is no way to operate such a program on a 24/7 basis, observes Galbraith. "We use what is called a hybrid model, which means that the burden of this testing program on our department is shared throughout," he says. "The physicians are responsible for providing the results of the tests, the nurses are responsible for collecting the samples as well as the triage questions, and the lab staff process all the samples. It is a team effort in the ED."
Galbraith adds that new, fourth-generation HIV tests can detect HIV at an earlier stage than previous tests, they can deliver results within 30 minutes, and they have reduced the per-test cost by more than half.
Initially, UAB's testing program was funded just through 2013, but because of the success the program has achieved in identifying patients with HIV and linking them into care, the CDC has now extended its funding through 2016. Galbraith explains that the contract UAB has with the CDC is basically reviewed every three years, and he is hopeful that the funds will continue even after 2016. "If the funding went away, we would struggle to offer this type of screening, and would probably have to resort to more of a targeted approach or go back to a diagnostic strategy," says Galbraith.
Consider future benefits
Once the infrastructure and processes are in place to support HIV screening in the ED, the approach can easily be applied to other diseases as well, says Saag. In fact, the ED at UAB has already begun to apply the same testing approach to identifying patients who have hepatitis C and then linking them into care. "Rather than starting from scratch, once you have an HIV screening procedure in place, it is relatively straightforward to add this in, and a positive result can be managed in exactly the same way."
The potential health benefits and cost savings are significant, Saag says. "There is a revolution going on right now in hepatitis C therapeutics. Within the next five years, I think we will be curing hepatitis C in up to 90% of the people who have the infection," he says. "This has already started to happen, so [these improvements] will significantly trim health care expenditures and prevent long-term complications like cirrhosis of the liver and liver cancer."
- John Galbraith, MD, FACEP, Physician and Testing Program Coordinator, Department of Emergency Medicine, University of Alabama, Birmingham, AL. E-mail: firstname.lastname@example.org.
- Michael Saag, MD, Director, Center for AIDS Research, University of Alabama, Birmingham, AL. Phone: 205-934-5191.