Emergency Provider Attitudes and Barriers to Universal HIV Testing in the Emergency Department

doi:10.1016/j.jemermed.2009.07.038

The Journal of Emergency Medicine

Volume 42, Issue 1, January 2012, Pages 7-14

https://doi.org/10.1016/j.jemermed.2009.07.038 Get rights and content

Abstract

Background: The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED). Study Objective: The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines. Methods: Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions. Results: There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]). Conclusions: After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.

Introduction

In 2006, the Centers for Disease Control and Prevention (CDC) published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of persons 13–64 years of age in all health care settings, including the emergency department (ED) (1). In settings like the ED, the rapid pace of patient flow, coupled with substantial disease severity, may lead providers to focus preferentially on acute patient care over HIV screening. The successful implementation of any HIV testing program in the ED setting depends upon the willingness and commitment of ED providers to adopt such a program.

In April 2007, the American College of Emergency Physicians responded to the new CDC guidelines with a policy statement suggesting criteria under which EDs would embrace HIV testing. The criteria include requirements that ED-based HIV testing be feasible, practical, and based on local needs. The requirements also require that testing have adequate funding and not interfere with the acute care mission of Emergency Medicine (2). The implementation of an HIV testing program requires the provision of ED resources in addition to those required to meet the acute care mission. A more detailed understanding of emergency provider knowledge, attitudes, perceptions, and barriers toward HIV testing is needed for successful implementation of such a program.

The Universal Screening for HIV-infection in the Emergency Room (USHER) Trial is a National Institutes of Health-funded study examining alternative strategies for implementing routine HIV testing in the ED at the Brigham and Women's Hospital, Boston, Massachusetts. Before and after trial initiation, ED providers were surveyed to examine their attitudes and perceived barriers to HIV testing. The objective was to identify these barriers and then to see if they changed over time. The data collected may help inform further HIV testing programs so that these barriers can be addressed early and long term, thereby facilitating program success.

Section snippets

Study Design

The USHER Trial is a randomized, prospective clinical trial designed to evaluate alternative approaches to routine HIV testing in the ED. For this study, a survey was distributed to ED health care providers before (T0, December 2006) and 6 months after (T1, July 2007) clinical trial initiation. To be eligible for survey inclusion in this analysis, providers had to be full-time ED staff at both time points.

The analysis was focused on ED providers' knowledge and attitudes toward routine HIV

Characteristics of Study Subjects

At T0 (baseline), 357 emergency providers were employed in the Brigham and Women's Hospital ED, and 161 were excluded based on their part-time or per-diem status. Among the 196 eligible full-time ED providers, 159 (81%) completed the survey before USHER Trial initiation (Figure 1). At T1 (6 months), 358 emergency providers were employed and 151 were excluded for the same reasons. Among the 207 eligible providers, 141 (68%) completed the survey 6 months after program initiation. The intersection

Discussion

This study reports results from a survey of providers in an urban ED before and after the implementation of an HIV testing program. The results suggest that emergency providers generally favor the implementation of a large-scale HIV testing program in accordance with the CDC recommendations, but due to several major barriers, they are still generally unwilling to offer the test (1). Whereas some of the perceived barriers to testing were improved over time, other barriers were reported at an

Conclusion

ED health care providers are generally supportive of the recent CDC guidelines recommending routine HIV testing in the ED setting (1). Results of this study emphasize the importance of understanding provider barriers to HIV testing, as these perceived barriers highly correlate with providers' support of testing programs. These results have significant implications for EDs trying to implement routine testing efforts, and suggest the need to collect data specific to individual institutions,

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While the effectiveness of emergency departments (ED) in screening for HIV and syphilis is understood, less is known about dual screening programs. We aim to evaluate the impact of an opt-out provider-initiated HIV and syphilis program on screening, diagnosis, and linkage to care outcomes.
We performed a retrospective review of patients screened pre (2014–2017) and post (2017–2021) program implementation. Primary outcomes include HIV and syphilis screening, incidence of positive tests, and proportion of patients linked to care. Secondary outcomes included pre-exposure prophylaxis (PrEP) referral and successful linkage rates for HIV-negative syphilis-positive patients.
Pre-implementation, 882 HIV tests were performed, of which 22 (2.49%) were new cases and 18 (81.82%) were linked to care; 754 syphilis tests were performed, of which 33 (4.38%) were active infections and 30 (90.91%) were treated. No eligible patients received PrEP referral. Post-implementation, 12,999 HIV tests were performed, of which 73 (0.56%) were new cases and 55 (75.34%) were linked to care; 10,885 syphilis tests were performed, of which 216 (1.98%) were active infections and 188 (87.04%) were treated. 25 (9.09%) eligible patients were referred for PrEP, and four (16.0%) attended their appointment.
Post-implementation, there was a 1373.81% and 1343.63% increase in screening, and a 231.82% and 554.55% increase in positive cases of HIV and syphilis, respectively. Dual screening programs can be successfully implemented within the existing ED framework to increase screening and early detection for HIV and syphilis.
Communicable Disease Screening and Human Immunodeficiency Virus Prevention in the Emergency Department
2024, Emergency Medicine Clinics of North America
Principles of Screening for Disease and Health Risk Factors in the Emergency Department
2023, Annals of Emergency Medicine
Citation Excerpt :
The American College of Emergency Physicians (ACEP) supports the CDC screening guidelines, additionally noting the importance of confidentiality, informed consent, linkage to care, and adequate funding for program sustainability.27 ED HIV screening has been shown to be highly acceptable to both patients and ED staff.28,29 Nearly all states have now embraced HIV screening using an opt-out model with no requirement for separate consent or pretest counseling.30
The emergency department serves as a critical access point to the health system for many patients, especially those with limited resources. Screening for disease or risk factors for poor health outcomes can potentially improve both individual and population health. Screening initiatives should focus on evidence-based strategies and take local epidemiology and ED capacity into consideration. Initiatives should strive for community support and transparency with patients. They should also be financially sustainable for those involved. Screening can identify patients who can then be counseled, provided with prophylaxis or treatment, or referred to external resources. Through screening and intervention, the ED can serve as a vital contributor to individual and population health.
Factors associated with HIV testing among patients seeking emergent injury care in Kigali, Rwanda
2022, African Journal of Emergency Medicine
Emergency centres (ECs) can be important access points for HIV testing. In Rwanda, one in eight people with HIV are unaware of their infection status, which impedes epidemic control. This could be addressed via increased testing. This cross-sectional study evaluated factors associated with EC-based HIV testing among injured patients at the Centre Hospitalier Universitaire de Kigali (CHUK), in Kigali, Rwanda.
Adult injury patients were prospectively enrolled between January-June 2020. Trained study personnel collected data on demographics, injury aspects, treatments, HIV testing, and disposition. The primary outcome was the completion of EC-based HIV testing. Differences between those receiving and those not receiving testing were assessed. Regression models yielding adjusted odds ratios with associated 95% confidence intervals (CI) were calculated to quantify magnitudes of effect.
Among 579 patients, the majority were under 45 years of age (78.1%) and male (74.4%). The most common mechanism of injury was road traffic accidents (50.3%). EC discharge occurred in 54.4% of cases. HIV testing was performed in 221 (38.2%) cases, of which 5.9% had a positive result. HIV testing was more likely among males (aOR=1.69, 95% CI: 1.02–2.78; p=0.04), cases transported by prehospital services (aOR=2.07, 95% CI: 1.28-3.35; p=0.003) and those receiving surgical consultation (aOR=3.13, 95% CI: 1.99-4.94; p<0.001). Cases with lower acuity were less likely to be tested (OR=0.70, 95% CI: 0.55-0.90; p=0.004), as were those discharged (OR=0.28, 95% CI: 0.18-0.43; p<0.001).
In the population studied, most patients did not undergo HIV testing. EC-based physician directed testing was more likely among male patients and patients with greater care needs. These results may inform approaches to increase EC-based testing services in Rwanda and other similar settings with high HIV burdens.
An Assessment of Emergency Nurses’ Perspectives on Nurse-Driven Human Immunodeficiency Virus Testing in the Emergency Department
2020, Journal of Emergency Nursing
Citation Excerpt :
Although 87.0% of the nurses in a previous study did not feel the screening slowed down the ED workflow, a few of them (13.0%) reported the program as “disruptive.”10 In addition, providers sometimes exhibited testing resistance because of their own perceived barriers to a testing program.30,35,36 Plausible and effective solutions to the reported barriers, particularly the time constraints, have been reported.
Engaging emergency clinicians in universal human immunodeficiency virus screening is paramount to achieving goals of reengaging human immunodeficiency virus–positive persons into care, identifying new human immunodeficiency virus cases, and linking them to care. The study aim was to identify beliefs and barriers towards opt-out human immunodeficiency virus testing among emergency nurses.
A cross-sectional study used Qualtrics software to deliver a survey on a tablet device to emergency nurses in a private Level 1 trauma hospital in Houston, Texas during downtimes of their clinical shifts. The survey evaluated perspectives on human immunodeficiency virus screening and knowledge relative to rapid screening and human immunodeficiency virus prevalence rates locally and nationally.
Fifty emergency nurses were enrolled. Few nurses accurately identified human immunodeficiency virus prevalence rates at the local hospital and city level (10% and 42%, respectively). Most (54%) of nurses correctly estimated human immunodeficiency virus prevalence rates nationally. Nearly half of the nurses (42.0%) correctly predicted the cost of a rapid human immunodeficiency virus test with accuracy and most were willing to offer rapid human immunodeficiency virus testing all the time (60.0%). Eighty-eight percent of nurses were supportive of facilitating universal human immunodeficiency virus screening. However, 92.0% strongly supported human immunodeficiency virus testing for high risk patients only when compared to 80.0% support of testing for all eligible patients. Qualitative data revealed time constraints and follow-up concerns as barriers.
Emergency nurses reported barriers that sometimes prevented application of Centers for Disease Control and Prevention recommendations to human immunodeficiency virus screening. Strategies to overcome these barriers are instrumental to programmatic success. Solutions can corroborate the importance of emergency nurses to the nation’s Ending the HIV Epidemic plan.
How well are U.S. primary care providers assessing whether their male patients have male sex partners?
2018, Preventive Medicine
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In our study, PCP gender, practices (i.e., routine screening for HIV, affiliations with teaching hospitals), and perceptions (i.e., beliefs about most effective HIV prevention approach or perceived proportion of MSM patients) were independently associated with using a systematic method, which highlights how societal and cultural norms might hinder or facilitate the assessment of MSM status. Our findings complement previous studies that suggest female providers are more aware of the sexual orientation of their MSM patients (Petroll and Mosack, 2011) and are more likely to favor routine HIV testing (Arbelaez et al., 2012). Providers have also stated that PCP knowledge about the rationale for routine HIV testing could facilitate testing (White et al., 2015).
Identifying patients at-risk for HIV infection, such as men who have sex with men (MSM), is an important step in providing HIV testing and prevention interventions. It is unknown how primary care providers (PCPs) assess MSM status and related HIV-risk factors. We analyzed data from a panel-derived web-based survey for healthcare providers conducted in 2014 to describe how PCPs in the U.S. determined their patients' MSM status. We calculated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to describe PCP characteristics associated with systematically determining MSM status (i.e., PCP used “a patient-completed questionnaire” or “routine verbal review of sex history”). Among the 1008 PCPs, 56% determined MSM status by routine verbal review of sexual history; 41% by patient disclosure; 39% by questions driven by symptoms/history; 23% by using a patient-completed questionnaire, and 9% didn't determine MSM status. PCPs who systematically determined MSM status (n = 665; 66%) were more likely to be female (aPR = 1.16, CI = 1.06–1.26), to be affiliated with a teaching hospital (aPR = 1.15, CI = 1.06–1.25), to routinely screen all patients aged 13–64 for HIV (aPR = 1.29, CI = 1.18–1.41), and to estimate that 6% or more of their male patients are MSM (aPR = 1.14, CI = 1.01–1.30). The majority of PCPs assessed MSM status and HIV risk factors through routine verbal reviews of sexual history. Implementing a systematic approach to identify MSM status and assess risk may allow PCPs to identify more patients needing frequent HIV testing and other preventive services, while mitigating socio-cultural barriers to obtaining such information.

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: This research was funded by the National Institute of Mental Health (R01 MH0735445, R01 MH65869) and the Doris Duke Charitable Foundation (Clinical Scientist Development Award to Rochelle P. Walensky, md, mph), ClinicalTrials.Gov: #NCT00502944.

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Original contributionEmergency Provider Attitudes and Barriers to Universal HIV Testing in the Emergency Department

Abstract

Introduction

Section snippets

Study Design

Characteristics of Study Subjects

Discussion

Conclusion

Am J Emerg Med

J Prof Nurs

Am J Emerg Med

Addict Behav

Ann Emerg Med

Ann Emerg Med

Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings

MMWR Recomm Rep

HIV testing and screening in the emergency department

Ann Emerg Med

Emergency departments: an important component of public health

J Natl Med Assoc

Routine screening for intimate partner violence in the emergency department: Importance of patient and provider factors

Ann Emerg Med

Barriers to effective screening for domestic violence by registered nurses in the emergency department

Crit Care Nurs Q

Original contribution
Emergency Provider Attitudes and Barriers to Universal HIV Testing in the Emergency Department