Nontargeted HIV Testing in EDs Has Modest Impact

Eileen Koutnik-Fotopoulos

The benefit of nontargeted HIV rapid test (RT) screening was only modest among emergency department (ED) patients in Paris. The testing resulted in identifying only a few new HIV diagnoses, often at late stages and predominantly among patients who belonged to a high-risk group and had been tested previously, according to study results reported in the Archives of Internal Medicine [2012;172(1):12-20].

National health agencies in the United States, the United Kingdom, and France have promoted nontargeted HIV RT screening in healthcare settings to reduce the number of undiagnosed infections and to improve early detection. The study aimed to assess the public health impact of nontargeted HIV RT screening among ED patients in the metropolitan area of Paris (11.7 million inhabitants), where half of France’s new HIV cases are diagnosed annually. The researchers noted that EDs appear to be an ideal setting to assess nontargeted HIV RT screening of the general population because an estimated 25% of inhabitants (14 million) visit an ED annually in France.

Researchers from the Emergency Department HIV-Screening Group in France conducted an interventional study in 29 EDs from May 2009 through September 2010. The intervention lasted for 6 consecutive weeks, randomly allocated. During that time at participating EDs, patients who were 18 to 64 years of age who were able to provide consent for HIV testing were offered a finger-stick whole-blood HIV RT. Exclusion criteria included self-reported HIV infection; inability to provide consent because of neuropsychiatric disorders; unstable medical illness; and being seen at the ED for prophylaxis after exposure to HIV.

The primary end points were the number of patients tested for HIV and their characteristics versus those of the general metropolitan Paris population. Also, the proportion of newly diagnosed HIV-positive patients among those tested and their characteristics compared with those from the national HIV case surveillance.

Of the 138,691 patients who were seen at EDs during the study period, 78,411 (56.5%) were eligible, 20,962 (26.7%) of whom were offered HIV RT and 13,229 (63.1%) accepted. The ED patients’ characteristics reflected the general population distribution (age, sex, country of birth, sexual behavior, and HIV testing history).

The HIV RT screening identified 18 patients with new HIV diagnoses (0.14%; 95% confidence interval [CI], 0.08%-0.22%). The mean age of the newly diagnosed patients was 32.9 years. Of these patients, 12 (66.7%) reported previous HIV testing (median time since the last HIV test, 1 year), 7 (39%) were men who reported having sex with men, and 10 (55%) were heterosexuals from sub-Saharan Africa. Of the newly diagnosed patients, 6 (33.3%) did not return for their first follow-up visit, 4 (22.2%) were hospitalized for HIV infection–related signs and symptoms, and 8 (44.4%) attended their first follow-up visit. Similar to the national HIV case surveillance patients (n=3008), the newly diagnosed patients belonged to a high-risk group (n=17), were previously tested (n=12), and were either symptomatic or had a CD4 lymphocyte count <350/µL, suggesting late-stage infections (n=8); 12 patients were linked to care.

The findings also showed that the proportions of newly identified HIV infections in EDs were highest in men having sex with men (2.61%; 95% CI, 1.06%-5.31%) and African-born heterosexuals, particularly women (1.57%; 95% CI, 0.63%-3.20%).

A study limitation noted by the investigators was that the patients who refused the HIV RT might be at higher risk of HIV infection than those patients who agreed to the test. Based on the results, the researchers said their findings “do not support the implementation of nontargeted HIV screening of the general population in EDs,” despite the fact HIV RT screening is feasible and can reach a large segment of ED patients.