Rates of HIV testing were extremely low in US emergency departments for the period between 1993 and 2005, according to a cross-sectional analysis published in the October edition of AIDS. In the course of 867 million emergency department visits during that time, an estimated 2.8 million tests were performed – a rate of only 0.32%. Testing was most frequent in African-Americans, Hispanics, and those aged 20 to 39 years.
The Centers for Disease Control and Prevention (CDC) estimate that 1 to 1.2 million Americans (0.5% of the general US population aged 18 to 49 years) are HIV-positive, and that one-quarter of these are not aware of their HIV status. Emergency departments have been recognised as a critical site for HIV testing. CDC recommendations for HIV testing in emergency have evolved through the epidemic; the most recent such recommendations (published in 2006) call for routine, opt-out HIV testing in emergency department settings.
US data on HIV testing in emergency department settings are reported in the National Hospital Ambulatory Medical Care Survey (NHAMCS) annual reports (available online here). In the study just published in AIDS, a team from Johns Hopkins University analysed NHAMCS data for the 13-year period from 1993 to 2005. The analysis included data from all patients from 13 to 64 years of age; numbers were weighted by a CDC-recommended scheme to produce estimates representative of the US population.
During the study period, NHAMCS collected data on 247,179 emergency department visits; HIV testing was performed in 1059 of these. This sample corresponds to a weighted national total of 867 million visits for patients aged 13 to 64 years old. Of the national total, an estimated 2.8 million (95% confidence interval [CI], 2.4–3.2 million) received HIV tests – an estimated rate of 0.32% (95% CI, 0.28%–0.37%).
Testing rates varied by year, showing a trend toward declining from 1993 to 2002, then tending to rise again in the period from 2003 to 2005. However, there was no significant overall trend over time.
Higher testing rates were seen in African-Americans (0.50%; 95% CI, 0.40%-0.60% versus – in white people – 0.27%; 95% CI, 0.23%-0.32%), Hispanics (0.49% [95% CI, 0.36%-0.62%] versus – in non-Hispanics – 0.31% [95% CI, 0.27%-0.36%]), people aged 20 to 39 (0.39%; 95% CI, 0.31%-0.47%), those whose payments were covered by worker's compensation (0.97%; 95% CI, 0.70%-1.24%), and patients from the geographical northeast (0.49%; 95% CI, 0.36%-0.63%). Rates were similar for men and women, despite the three- to fivefold higher HIV prevalence in men in the US. Several potential explanations, none conclusive, were proferred for the proportionately higher testing rates in women.
Perhaps unsurprisingly, the likelihood of receiving an HIV test was very much higher for patients presenting with puncture wounds or needlestick injuries, rape or sexual assault, or exposure to another person's bodily fluids, with unadjusted odds ratios in excess of 90 for each. However, testing was also done more often in those who presented with fever (adjusted odds ratio [OR] 1.88; 95% CI, 1.30-2.74) or symptoms of psychological/mental disorder (OR 1.87; 95% CI, 1.18-2.96); these symptoms may have been seen as markers of infection or risk for infection.
The investigators concluded that in this, the US' "first national-representative population-based multiyear study" of HIV testing in emergency departments, the rates of testing were extremely low, "even since 2001 when the CDC explicitly advocated including emergency department settings as a site for routine testing." Testing also "appears to be driven by the patient's clinical presentation… Given the potential role of emergency departments in the national strategy for HIV reduction, further research should be directed at discovering and alleviating the reasons for low rates of HIV testing in emergency department settings."
Reference:
Hsieh Y-H et al. National estimation of rates of HIV serology testing in US emergency departments 1993–2005: baseline prior to the 2006 Centers for Disease Control and Prevention recommendations.AIDS 22:2127–2134, 2008.