Missed Opportunities for STD and HIV Testing in a North Carolina Emergency Department

Background: In 2008, a North Carolina Emergency Department (ED) implemented a targeted HIV testing program. Due to the importance of HIV/STD co-infections and the high STD prevalence in North Carolina, physicians were instructed to recommend HIV testing for all patients with an STD test order, among other targeted indications.

Objectives: To assess the agreement between syphilis and HIV test orders and evaluate the ED HIV testing program.

Methods: Analysis included patients visiting the ED from January 1, 2008 through March 31, 2009; individual ED visits were used as the unit of analysis. Kappa statistics evaluated agreement between syphilis test (RPR) and HIV test orders.

Results: Of the 142,470 visits to the ED during the study period, 420 (0.3%) patients had an HIV test performed and 554 (0.4%) patients had an RPR test performed.  Agreement between RPR and HIV test orders was low (kappa = 0.35, 95% CI: 0.30, 0.40). The positivity rates for the HIV and syphilis tests were 6.0% (25/420) and 5.8% (32/554), respectively. Only 31% (173/554) of patients receiving an RPR test also had an HIV test performed. Of these, 8 (4.6%) tested positive for HIV and 15 (8.7%) tested positive for syphilis; 4 (2.3%) were co-infected with both HIV and syphilis.

Conclusions: All patients receiving an STD test in clinical settings should also be tested for HIV.  However, almost 60% of patients receiving a syphilis test in the ED did not concurrently receive an HIV test, indicating missed opportunities to provide both HIV and STD testing in a high-prevalence community.

Implications for Programs, Policy, and/or Research: Efforts should be made to increase adherence to national and facility-level HIV/STD testing guidelines and promote the integration of HIV/STD screening programs in clinical settings.