Non-targeted HIV testing in emergency departments identifies only a few new cases, French study finds

"During the last 15 years, human immunodeficiency virus (HIV) screening combined with early treatment has effectively reduced HIV-related mortality, and some authors have postulated that this strategy plays a key role in controlling the epidemic," the authors write as background information in the article. Late diagnoses remains common even though there is free HIV testing in France. "To lower the number of undiagnosed infections and to improve early detection, nontargeted HIV rapid test (RT) screening in health care settings has been promoted by national health agencies in the United States, the United Kingdom, and, more recently, France." They add, "In France, because an estimated 25 percent of inhabitants (14 million) visit an ED [emergency department] annually, EDs appear to be an ideal setting to assess nontargeted HIV-RT screening of the general population.

Kayigan Wilson d'Almeida, M.D., and colleagues from the Emergency Department HIV-Screening Group in France, conducted an interventional study in 29 emergency departments from May 2009 through September 2010 that lasted for six consecutive weeks, which were randomly assigned. During that time at the participating emergency departments, 18- to 64-year-old patients who were able to provide consent for HIV testing were offered a fingerstick whole-blood HIV RT. "Main outcome measures were the number of patients tested for HIV and their characteristics vs those of the general metropolitan Paris population and the proportion of newly diagnosed HIV-positive patients among those tested and their characteristics vs those from the national HIV case surveillance."

"Among 138,691 visits, there were 78,411 eligible patients, 20,962 of whom (27 percent) were offered HIV RT; 13,229 (63.1 percent) accepted testing and 12,754 (16.3 percent) were tested," the authors report. "The ED patients' characteristics reflected the general population distribution. Eighteen patients received new HIV diagnoses (0.14 percent)." The authors note that the average age of the patients with the newly diagnosed infection was 32.9 years. Of these patients, "12 (66.7 percent) reported previous HIV testing (median [midpoint] time since the last HIV test, one year), seven (39 percent) were men who reported having sex with men, and 10 (55 percent) were heterosexuals from sub-Saharan Africa."

"In conclusion, ED-based HIV RT screening is feasible and can reach large numbers of patients. However, unexpectedly, nontargeted screening identified only a few new diagnoses, often already at late stages, and most newly diagnosed patients belonged to a high-risk group and had been tested previously. Therefore, our observations do not support the implementation of nontargeted HIV screening of the general population in Eds."

Commentary: The Ongoing Need for Targeted Strategies

In an invited commentary accompanying the article, Jason S. Haukoos, M.D., M.Sc., from Denver Health Medical Center, Denver, Colo., writes: "Early identification of human immunodeficiency (HIV) infection remains a critical public health priority. In the United States, approximately 240,000 individuals remain undiagnosed and 56,000 new infections occur annually."

Dr. Haukoos notes that the "Centers for Disease Control and Prevention (CDC) has recommended 'routine' (nontargeted) opt-out HIV screening in healthcare settings, including emergency departments (EDs) because EDs are considered the most common site of missed opportunities for diagnosing HIV infection."

"Rigorous, large-scale, comparative effectiveness research is needed to understand how best to identify patients with undiagnosed HIV infection. In the end, the use of targeted HIV screening strategies may still help prioritize HIV testing and prevention resources where the epidemic is concentrated."