Do emergency departments represent a window of opportunity to identify otherwise undiadnosed HIV infections?

Issue: Baltimore has historically experienced high HIV rates. Innovative, evidence-based testing strategies have increased the number of persons aware of their HIV status and improved referrals to treatment services. Urban populations often use emergency departments (ED) for primary care, thus presenting a window of opportunity to test those missed through other testing efforts. Routine testing in an ED setting may be ideal for identifying those who may not be perceived as high-risk and are unaware of their status. Description: In 2008, the Health Department implemented routine HIV testing programs in seven EDs. Outreach, partner services, linkage-to-care, re-linkage, and referral to prevention and support services are part of the comprehensive services provided. Data collected from these testing sites (2008-2011) were analyzed to determine outcomes. Lessons Learned: 56,600 tests have been conducted since 2008 with 334 (0.59%) confirmed positives. Of these, 261 (0.46%) were newly diagnosed and 171 (66%) were linked to care. The majority of those tested, self-reported not being previously tested or diagnosed with HIV. Positivity rates have declined from 1.11% in 2008 to 0.41% in 2011 despite high testing volumes. Further evaluation is needed to identify the potential reasons for the decreasing positivity rates. Recommendations: ED routine testing reaches population often missed by other testing services, promoting HIV status awareness, early diagnosis and treatment, which can result in lower transmission and mortality rates, increased years of productivity, and cost savings. This unique program has policy implications for expanding opt-out routine HIV testing in healthcare settings and pertinent third-party reimbursement.