Evidence is mounting for expanded use of HIV rapid testing programs
ERs, jails, community health are ideal settings
HIV/AIDS researchers continue to find strong evidence that using rapid HIV testing in settings likely to capture high-risk populations is wise public health policy.
Yet programs that combine rapid testing with care linkage and prevention education are underutilized, research shows.1
Experts cite implementation complications, state HIV counseling laws, and financial barriers as the main reasons why rapid testing hasn't saturated sites serving high-risk populations.
A recent study found that a surprisingly low number of community-based organizations (CBOs), and hospitals are using rapid testing, says lead author Laura M. Bogart, PhD, senior behavioral scientist for the Rand Corp. of Santa Monica, CA.
"Only 22% of clinics, 10% of CBOs surveyed, and 52% of hospitals were using the test," Bogart says.
"The discouraging thing about hospitals is that about half were using it, but they were using it for occupational health and not for routine care or trying to get HIV testing to the general public," Bogart says. "About 29% of hospitals were using the test in the labor and delivery area, and only 13% were using it in the ER, although it's in the ER where research has found a much higher prevalence of HIV infection than in other kinds of health care general settings."
ERs: Greatest need, greatest difficulty
For instance, a new study looked at offering a rapid HIV test to high-risk patients in a large urban hospital emergency room (ER). The study identified new infections at a rate of one in 50 people screened.2
"We have found that the ER is very receptive to rapid testing, but the big question is whether the ER is equipped to do it," says Indira Brar, MD, program director, infectious diseases fellowship at Henry Ford Hospital in Detroit, MI.
Henry Ford Hospital has used a model, funded by the city and state, which has worked very well: a registered nurse or trained HIV counselor/tester meets with ER patients identified as being at high risk and offers them a rapid HIV test during their wait for other lab results, Brar explains.
"I think the ER is a very important place for a lot of people in marginalized society who do not really use other forms of health care," Brar says. "We really need to work with this group to bring them into care and to provide them with the same good care that can be provided for anyone else."
Emergency departments (EDs) are the most difficult place to integrate rapid testing protocols, Bogart notes.
"But they're probably the area of the greatest need right now," she says.
"It seems that because EDs can be very chaotic and have high patient volume, it's hard for ED providers to take time for rapid testing," Bogart explains. "But the model that seems to work, and we're still waiting for more data, is if somebody from outside the ED comes in and does the testing while people are waiting in the emergency department."
A hospital in Los Angeles had a room off the ED where the HIV tester could take patients for testing, counseling, and waiting for results, Bogart says.
Testing behind, beyond bars
HIV public health experts note that besides the emergency department, an optimal place for using the rapid HIV test is in correctional facilities, including local jails and detention centers.
"One quarter of the people with HIV in this country cycle through the correctional system," says Frederick L. Altice, MD, professor of medicine and director of clinical and community research, section of infectious diseases, AIDS program, at the Yale University School of Medicine in New Haven, CT.3
"With all of these people with HIV coming in and out of the criminal justice system, it's a wonderful opportunity to identify people, stabilize them, and have them return to the community in better care and less infectious to others," Altice says.
While HIV testing has become more routine in prisons, it's less available in jails because of the transient nature of the population and because of funding obstacles, Altice says.
"It's complicated issue, and cost is an issue," Altice says.
"There should be a rapid test in jail because people come in and get out an incredibly high rate," he adds. "But the rapid test is more expensive, and there are impediments that happen at the state level."
Many states require pre-test and post-test counseling and licensed HIV testers, Altice says.
In places where there are fewer barriers to HIV screening in jails, such programs will work well.
For instance, investigators researching the use of routine HIV rapid testing in Rhode Island jails have demonstrated feasibility and acceptance.4,5
A new pilot study enrolled 264 men in Rhode Island jails to test a combination of a rapid HIV test with prevention activities, says Curt G. Beckwith, MD, assistant professor of medicine at the Alpert Medical School of Brown University in Providence, RI.
The men receiving the HIV test were followed back to their communities as part of the study's look at their risk behaviors.
The point was to show that it would be feasible to provide routine HIV rapid tests in the jail and combine these with brief prevention education.
ER model can work if funded
Routine HIV rapid tests in ERs might be easier logistically than HIV testing in jails, but there are some financial and staffing requirements to manage.
For the Henry Ford project, which receives state and city funding, a nurse and HIV clinic counselor/tester provide all of the rapid HIV tests and prevention counseling.
Between the two, the ER is covered most days and evenings.
"We studied this between 2004 and 2008, but it's ongoing," Brar says. "We offer the rapid HIV test to everyone who comes into the ER for treatment of a sexually-transmitted disease (STD), as well as any one else who is identified as high risk."
People who come to the ER for treatment of what appears to be Pneumocystis pneumonia (PCP), people who are drug users, and those who are identified through medical histories as having multiple sex partners are all offered the rapid HIV serum test, Brar says.
Of 2,575 people offered the HIV test, only 42 declined, she notes.
"No matter how many STD programs you have out there, some groups of people will use the ER as their point of entry or for getting tested for STDs," Brar notes. "As long as we can work with the ER staff, this is a very feasible program."
During the 20 minutes that patients are waiting for the HIV test results, the nurse or counselor will tell them about what being HIV positive means and discuss prevention.
"If the test comes out positive, we help them get into care immediately," Brar says. "Our goal is to get the patient seen at our HIV clinic the next day or within 48 hours since the clinic is closed on the weekend."
All HIV positive tests on the rapid test are confirmed with the confirmatory Western blot HIV test. So far, there have been no false positives, Brar says.
Part of the post-positive test counseling includes educating patients about decreasing HIV transmission and safe behavior and encouraging them to talk about their diagnosis with partners and bring those partners in for testing, Brar adds.
"My nurse has informed me that we've had people bring in other partners to be tested," she says.
The counselor/tester helps the patient make an appointment at the clinic and encourages them to follow-up on their care. As a result, the study shows that all follow-up visits were scheduled within one week of the positive result, and only three patients out of 56 people newly-diagnosed with HIV infection did not show up for their follow-up appointment, Brar says.
References
- Bogart LM, Howerton D, Lange J, et al. Scope of rapid HIV testing in private nonprofit urban community health settings in the United States. Am J Pub Health. 2008;98(4):736-742.
- Brar I, Baxa D, Mumby K, et al. Rapid HIV testing in the emergency room: effective or not. Abstract presented at 48th Annual ICAAC/IDSA 46th Annual Meeting in Washington, DC:Oct. 25-28, 2008. Abstract: H-466.
- Basu S, Smith-Rohrberg D, Hanck S, et al. HIV testing in correctional institutions: evaluating existing strategies, setting new standards. AIDS & Pub Pol J. 2005;20:1-22.
- Beckwith CG, Atunah-Jay S, Cohen J, et al. Feasibility and acceptability of rapid HIV testing in jail. AIDS Pat Care & STDs. 2007;21:41-47.
- Kavasery R, Altice FL. Letter to the Editor: Observations on implementing routine HIV testing in jails. AIDS Pat Care & STDs. 2007;21(10):715-716.
- Beckwith C, Liu T, Bazerman L, et al. HIV Risk behavior pre- and post-HIV testing and counseling in jail. Abstract presented at 48th Annual ICAAC/IDSA 46th Annual Meeting in Washington, DC:Oct. 25-28, 2008. Abstract: H-449.
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