By the results of this study, we estimate that approximately 39% of English-speaking 18- to 55-year-old ED patients with a subcritical illness or injury would agree to be tested in an opt-in, universal, rapid HIV screening program (subject to the exclusion criteria employed in this study) conducted by nonclinical ED staff. It is difficult to directly compare the proportion accepting testing in this study with previous HIV testing studies, as none of these studies randomly selected patients for inclusion in the study, and details of the testing program methods are incomplete.
Nevertheless, in comparing this study with those shown in our summary of published reports of U.S. ED HIV screening programs, 1993–2007 (available from: URL: http://www.brown.edu/Departments/BRUNAP/US_ED_HIV_screening_programs.pdf
), higher acceptance of HIV testing occurred in studies that employed targeted screening, permitted provider referrals for testing, included patients who requested testing, and offered some type of incentive. The estimate from this study can serve as the basis of comparison for future programs that attempt to improve uptake of HIV screening by offering incentives, conducting risk-based targeted screening, using an opt-out approach, or employing other methods. The estimate can also assist ED-based screening programs that use an opt-in approach to anticipate demand for testing and accompanying resources needed. The focus of future research can be to develop methods of increasing uptake of HIV screening in the ED.
The study findings indicate that even when an opt-in screening program is conducted in a universal instead of a targeted fashion, ED patients will not be universally screened. This is an unfortunate observation because one of the hopes for ED-based HIV screening is that it would serve as a means of screening large populations of previously untested people, regardless of their HIV risk. As demonstrated in this study, certain demographic groups will remain less likely to be tested for HIV when an opt-in universal HIV screening program is employed. Even more concerning, some patients who have not previously been tested for HIV will remain untested in an opt-in universal screening program—namely patients who are 45 years and older, white, married, and have private health insurance. These patients form a group for whom other approaches to facilitate screening appear to be necessary.
It is noteworthy that patients who are less likely to ever have been tested for HIV and less likely to accept HIV screening in the ED are part of demographic groups that traditionally have better access to medical care. This finding suggests that access to care does not necessarily confer better access to HIV screening, as it typically does for other types of screening. Universal screening in all health-care settings may help improve HIV screening uptake among these demographic groups. It is encouraging to observe that males who have not been tested elsewhere are at least willing to be screened in the ED. Because males are, in general, less frequent users of routine medical care than females, ED-based HIV screening might be a good testing venue for them. It also is encouraging to note that a third of patients not previously tested for HIV did agree to undergo screening in the ED. Developing ways to increase the percentage of first-time HIV test recipients is an important future goal if the ED is meant to serve as a place to capture those who have not been tested previously.
Because opt-in HIV screening involves an active choice for screening, patient-reported reasons for accepting or declining screening can be helpful in designing future methods to increase the percentage of patients who will be screened in an ED-based program. Wanting to know one's HIV status and having a possible exposure to HIV were associated with a greater acceptance of screening, while declining screening was related to having previously been required to be tested and perceiving oneself to not be at risk for HIV infection. Reasons for acceptance or decline of screening varied by participant demography. In particular, those who were married or not partnered declined HIV screening out of a belief of not being at risk for HIV infection. These findings again suggest that even when screening is universally conducted, uptake will not be universal.
Patients self-select or target themselves for screening based upon their perception of risk and the need for testing. It is likely that years of targeted screening for HIV, based upon risk and demographic characteristics, have helped build a perception that HIV screening is only necessary for those in certain demographic groups and among those at traditional risk for an infection. These findings suggest that a major public health challenge to increasing uptake of HIV screening is to reverse a public perception that HIV testing should be based upon perceived risk. It is not yet known if universal, routine HIV screening, particularly opt-out screening, can help eliminate this perception.
Acceptance of HIV screening also varied according to which RA performed the study. This variation occurred despite patients being randomly selected for the study; the use of a standardized script for how patients were to be asked about HIV screening; extensive training of RAs on the study protocol; and regular, periodic, direct observation and critiques of the RAs. It could be that nonverbal or verbal cues, in the form of subtle encouragement, or unobserved deviations from the protocol could account for this variation. This finding also suggests that interpersonal factors influence testing decisions. Identifying these factors or skills and then teaching or reinforcing them to RAs or staff may facilitate acceptance of screening across populations that remain resistant to screening.
This study had a number of limitations that affected the interpretation of the study results. First, the study was from a single, urban, academic hospital ED in the U.S. HIV testing histories and demographic characteristics are likely to vary widely across the nation's EDs. As such, the patient population included in this study might not be comparable to those in other EDs. However, given the random sampling, ED patient volume-weighted sampling, year-long sampling, and the diverse groups of patients included in the sample, the participants represented a reasonable cross-section of patients at this ED. Given the methods employed in the three-stage sampling scheme, we believe that the 14.3% of ED patients randomly selected for possible inclusion in the study well represent the greater population of English-speaking patients with a subcritical illness or injury who presented for medical care during the study period.
Second, the exclusion criteria and nature of the study limit how the study findings can be generalized. It is not clear if acceptance of ED-based HIV screening using an opt-in approach would be the same for patients who were excluded in this study. However, an opt-in approach to screening might not be appropriate for patients who are not able to provide consent to testing because of their medical illness or injury.
Third, this study did not include an HIV risk-assessment profile, which limited, for example, our ability to determine whether a patient's decision to decline screening was reasonable, given that patient's self-reported risk for HIV. We are currently conducting a study to assess ED patient risk factors for an HIV infection and to determine if patient awareness of their risk for HIV motivates them to be tested in the ED.
Fourth, because this study rested on self-reported data, there might be inaccuracies in objective data points, particularly in the items from the HIV testing history. Social desirability factors might have influenced some patients in their responses to reasons for accepting or declining screening or for having been previously tested or not tested for HIV. Although we cannot objectively assess the extent of the impact of self-reported data upon our analyses, we believe this influence would not have had a significant impact on our findings, given the large sample involved in this study.