Although the CDC recommendations on offering HIV testing to all ED patients aged 13 to 64 years are relatively new, they have proven to be controversial. Advocates have viewed them as a major step in the fight against HIV in the U.S., and have recommended ED HIV screening as a significant public health opportunity.
Several years before the CDC recommendations, the Society of Academic Emergency Medicine had recommended HIV screening in certain settings as “recommended for direct application in the ED setting.”5
Rothman echoed this in an important systematic review of ED HIV screening published in 2004. He noted that “[s]ince EDs provide health care to many underserved and socially marginalized sections of the community, who otherwise have limited or no access to routine preventive health services, development of ED-based HIV screening programs has particular social importance.”6
Others have been critical of the recommendations in general, and of ED HIV screening in particular. Melanie Sovine, executive director of the AIDS Survival Project in Atlanta, opined that “[a]ny policy that suggests you are just testing someone and just giving them a piece of information without support is not going to be well-received by this community.”2
However, our research suggests that in point of fact, the community of those being tested is overwhelmingly supportive of ED HIV testing.
To our knowledge, this is the first large survey of patient perceptions toward ED HIV testing. Hutchinson reported the results of six focus groups at urgent care centers that explored patient perspectives of both rapid and routine HIV testing in an urgent care center at an urban public hospital. Among these groups, the most common reasons for refusing an HIV test (and for not returning for the results) were fear and stigma. In Hutchinson's focus groups, 60% of the participants were uninsured and 89% of the participants were African American.7
In contrast to Hutchinson, our study found that fear and stigma were very rarely given as the reasons for refusing a test. Offering a survey to all patients in the ED is more likely to result in a representative sample of their beliefs, and we believe that the concerns raised by the participants in Hutchinson's study cannot be generalized to the ED population.
In our study, the two most common reasons for declining an HIV test were “not at risk” and “already tested.” These are identical to the two most common reasons for declining an HIV test at urgent care centers reported from Massachusetts,8
although the 67% refusal rate at those centers was considerably higher than the refusal rate at our site. These findings emphasize that perception of risk is the main reason that patients decline an HIV test. Several prior studies have demonstrated that a substantial number of people with HIV infection do not perceive themselves to be at risk for HIV or do not disclose their risks.9–11
This information, together with the findings of both our survey and the one performed in Massachusetts, strongly suggest that patients need to be educated about perception of risk and the realities of HIV infection. For example, EDs that offer HIV testing should provide educational materials about HIV risk factors. This information may help patients better understand their personal risks and may decrease the numbers of patients who decline testing based on perceived risk factors.
Overall, there is a high rate of acceptability of routine ED HIV screening. More importantly, among African Americans—the racial/ethnic group with the greatest burden of HIV disease in the U.S.—the acceptance rate of ED HIV testing is higher than for any other racial/ethnic group. In addition, African Americans were less likely to decline a test because they did not feel at risk, suggesting they may have a higher self-awareness of their HIV risk than other racial/ethnic groups, which is likely to be a factor in their higher acceptance rates.
This study had several limitations. First, the study was limited to one urban academic institution in a city that has an ongoing HIV screening campaign. These results will, therefore, need to be validated in other settings. Secondly, this survey represented a convenience sample of the approximately 40,000 patients seen in the ED during the study period. Although a large number of patients were surveyed, we did not collect data on the patients who declined to answer the survey. Individuals who refused to participate in the survey may have different perceptions of ED HIV testing compared with individuals who were willing to answer the survey. Moreover, socially desirable answers may have biased the responses, as ED patients were being surveyed about their perceptions of care in the ED while they were waiting for care. However, the survey was completely anonymous, and participants were informed that their responses would not affect their care in the ED. Third, we did not study all the variables that might affect satisfaction rates, such as knowledge about HIV infection, interaction with the staff offering the test, and concerns about confidentiality. However, this study provided insight on patient perceptions about the acceptability of conducting HIV screening in the ED.