Are EDs Useful Venues for Identifying Undiagnosed HIV Infections?

Background: HIV remains a major public health problem that disproportionately affects the urban poor who often utilize emergency departments (ED) for primary care.  Baltimore City’s HIV incidence rate remains high, (81.4/100,000) warranting the need to continue scaling up various testing efforts to find undiagnosed infections.  BCHD initiated routine HIV testing in EDs in 2008 and have identified over 400 positives within the first five years. This study estimates how many HIV positive cases tested in the EDs were not previously screened elsewhere.

Methods: Records of HIV positive cases identified through the ED program from July 2012 to June 2013 were retrospectively searched on BCHD electronic databases to check if the patient was ever tested by any of the public-funded programs that report HIV testing activities to BCHD. Proportions of new and previous HIV cases that had previous tests reported to BCHD versus those lacking evidence of previous reporting were compared.

Results: The EDs conducted 19,625 tests and 87 positives were identified.  48/87 were new, 32/87 were previously diagnosed, and 7/87 were discordant tests. 34/87 (39%) of all positives and 30/48 (63%) of all new positives had no previous testing history. 

Conclusions: 63% of all new HIV positive cases identified by the EDs in this period had probably not been previously tested. Despite the declining new positivity rates, (1.05% in 2008; 0.5% in 2009; 0.5% in 2010; 0.3% in 2011; 0.25% in 2012), Baltimore EDs still surpass the cost-effectiveness threshold of 0.1% for undiagnosed rate that warrants routine testing. Limitations of this study include small sample size and incomplete reporting of negatives. Nonetheless, this finding gives merit to the utility of ED testing programs in identifying acute HIV positive cases, those utilizing the EDs for primary care, and those not perceiving themselves to be at risk that might not be tested elsewhere.