Universal Vs. Risk-Group Targeted HIV Screening in the ED
Universal Vs. Risk-Group Targeted HIV Screening in the ED
Objective: Universal HIV screening is recommended but challenging to implement. Selectively targeting those at risk is thought to miss cases, but previous studies are limited by narrow risk criteria, incomplete implementation, and absence of direct comparisons. We hypothesized that targeted HIV screening, when fully implemented and using maximally broad risk criteria, could detect nearly as many cases as universal screening with many fewer tests.
Methods: This single-center cluster-randomized trial compared universal and targeted patient selection for HIV screening in a lower prevalence urban emergency department. Patients were excluded for age (<18 and >64 years), known HIV infection, or previous approach for HIV testing that day. Targeted screening was offered for any risk indicator identified from charts, staff referral, or self-disclosure. Universal screening was offered regardless of risk. Baseline seroprevalence was estimated from consecutive deidentified blood samples.
Results: There were 9572 eligible visits during which the patient was approached. For universal screening, 40.8% (1915/4692) consented with 6 being newly diagnosed [0.31%, 95% confidence interval (CI): 0.13% to 0.65%]. For targeted screening, 37% (1813/4880) had no testing indication. Of the 3067 remaining, 47.4% (1454) consented with 3 being newly diagnosed (0.22%, 95% CI: 0.06% to 0.55%). Estimated seroprevalence was 0.36% (95% CI: 0.16% to 0.70%). Targeted screening had a higher proportion consenting (47.4% vs. 40.8%, P < 0.002), but a lower proportion of ED encounters with testing (29.7% vs. 40.7%, P < 0.002).
Conclusions: Targeted screening, even when fully implemented with maximally permissive selection, offered no important increase in positivity rate or decrease in tests performed. Universal screening diagnosed more cases, because more were tested, despite a modestly lower consent rate.
Early diagnosis of HIV is critical. Once diagnosed, infected individuals can engage in behavior change and treatment, which combine to decrease infectivity and reduce cost. Emergency departments (EDs) have been emphasized as a partner in HIV screening because of high patient volume, access to vulnerable populations, and utilization by a broad spectrum of society. Unfortunately, EDs are already overburdened, and separate dedicated funds to scale-up testing are not widely available. Identifying the most efficient approaches to screening will facilitate implementation.
Deciding which patients should be tested is a major challenge. Public health advocates have called for universal or nontargeted screening. This requires many tests, and concerns persist about feasibility and effectiveness, particularly when prevalence is low or presumed low. Selectively targeting increased likelihood of undiagnosed infection requires fewer tests, but failure to identify all cases is frequently cited. However, targeted screening may have failed because of incomplete implementation rather than inadequately sensitive criteria. If so, expanding targeting criteria beyond conventional risk criteria should increase sensitivity. There has been few comparative studies about the trade-offs of such an approach or which precise targeting criteria would be most advantageous.
A growing number of studies have reported yield from nontargeted screening. Direct comparisons between nontargeted and targeted approaches are scarce and confounded by many other factors such as consent method, assay type, targeting criteria and assessment method, who conducts screening, and incomplete implementation. We compared the efficacy of universal and targeted screening in the context of an opt-in ED HIV screening program, hypothesizing that given full implementation and maximally permissive selection criteria, targeted screening would detect nearly as many cases while requiring many fewer tests.
Abstract and Introduction
Abstract
Objective: Universal HIV screening is recommended but challenging to implement. Selectively targeting those at risk is thought to miss cases, but previous studies are limited by narrow risk criteria, incomplete implementation, and absence of direct comparisons. We hypothesized that targeted HIV screening, when fully implemented and using maximally broad risk criteria, could detect nearly as many cases as universal screening with many fewer tests.
Methods: This single-center cluster-randomized trial compared universal and targeted patient selection for HIV screening in a lower prevalence urban emergency department. Patients were excluded for age (<18 and >64 years), known HIV infection, or previous approach for HIV testing that day. Targeted screening was offered for any risk indicator identified from charts, staff referral, or self-disclosure. Universal screening was offered regardless of risk. Baseline seroprevalence was estimated from consecutive deidentified blood samples.
Results: There were 9572 eligible visits during which the patient was approached. For universal screening, 40.8% (1915/4692) consented with 6 being newly diagnosed [0.31%, 95% confidence interval (CI): 0.13% to 0.65%]. For targeted screening, 37% (1813/4880) had no testing indication. Of the 3067 remaining, 47.4% (1454) consented with 3 being newly diagnosed (0.22%, 95% CI: 0.06% to 0.55%). Estimated seroprevalence was 0.36% (95% CI: 0.16% to 0.70%). Targeted screening had a higher proportion consenting (47.4% vs. 40.8%, P < 0.002), but a lower proportion of ED encounters with testing (29.7% vs. 40.7%, P < 0.002).
Conclusions: Targeted screening, even when fully implemented with maximally permissive selection, offered no important increase in positivity rate or decrease in tests performed. Universal screening diagnosed more cases, because more were tested, despite a modestly lower consent rate.
Introduction
Early diagnosis of HIV is critical. Once diagnosed, infected individuals can engage in behavior change and treatment, which combine to decrease infectivity and reduce cost. Emergency departments (EDs) have been emphasized as a partner in HIV screening because of high patient volume, access to vulnerable populations, and utilization by a broad spectrum of society. Unfortunately, EDs are already overburdened, and separate dedicated funds to scale-up testing are not widely available. Identifying the most efficient approaches to screening will facilitate implementation.
Deciding which patients should be tested is a major challenge. Public health advocates have called for universal or nontargeted screening. This requires many tests, and concerns persist about feasibility and effectiveness, particularly when prevalence is low or presumed low. Selectively targeting increased likelihood of undiagnosed infection requires fewer tests, but failure to identify all cases is frequently cited. However, targeted screening may have failed because of incomplete implementation rather than inadequately sensitive criteria. If so, expanding targeting criteria beyond conventional risk criteria should increase sensitivity. There has been few comparative studies about the trade-offs of such an approach or which precise targeting criteria would be most advantageous.
A growing number of studies have reported yield from nontargeted screening. Direct comparisons between nontargeted and targeted approaches are scarce and confounded by many other factors such as consent method, assay type, targeting criteria and assessment method, who conducts screening, and incomplete implementation. We compared the efficacy of universal and targeted screening in the context of an opt-in ED HIV screening program, hypothesizing that given full implementation and maximally permissive selection criteria, targeted screening would detect nearly as many cases while requiring many fewer tests.
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