The success of any ED-based HIV testing program relies heavily on the investment of a designated “champion(s)” who will lead the efforts within the ED community and hospital. As efforts often mirror compensation, this leadership role might ideally be a funded effort as a fraction of a full-time employee (FTE). The program’s success will very much rely on the passion that this person conveys toward the HIV testing mission. His/her capacity for leadership, action, and consensus within all aspects of the ED staff will likely portend the program’s success.
A needs assessment within the community and the patient population is also a helpful early step. What is the HIV prevalence within the hospital catchment area? At that prevalence, is there an unmet need for HIV testing services? It is also helpful to understand the referral base for patients who might be identified within the ED testing program. For the newly identified HIV-infected patients, what is the wait time for a new patient appointment? Is there clinical HIV outpatient capacity to longitudinally care for them? Finally, the implementation of such a program is largely facilitated by dedicated funding support prior to its implementation. During the needs assessment and analysis of current services, the possible funding mechanisms for the project may become evident. Can this information be shared with hospital administrators to indicate a need for dedicated resources toward the program? Draft budget proposals should consider necessary resources for personnel (e.g., counselors, social workers), HIV test kits, training sessions (often run by consultants), and confirmatory laboratory expenses (if not covered under clinical care). The short- and long-term sustainability of the HIV testing program often relies on a dedicated funding source.
Early in the program development, it is helpful to engage a comprehensive team required to ensure the necessary support for success. The hospital administration leadership, representatives from public affairs, and legal counsel may facilitate funding, issues that might draw lay press attention, and consent processes. Legal counsel may offer further invaluable assistance to ensure compliance with state and hospital regulations on patient confidentiality, name-based reporting to the state, medical liability, patient record documentation, and contractual issues.
Emergency department providers
The implementation of HIV testing within the ED impacts all ED staff including departmental leadership, faculty, residents, nurses, staff, social workers, and interpreters. As such, each provider’s engagement, training, and understanding of their motivation is crucial to embark on such an effort. When applicable, it might be helpful to approach the leaders of each staff group individually (e.g., chair, clinical director, residency director, nurse manager, and assistant nurse manager) because of the differing impact the program may have on their respective employees. In order to remain focused on the primary ED mission, HIV screening efforts should be integrated with careful priority to patient care and flow. The goal is therefore to assimilate the program within (rather than layered on top of) the current standard ED processes. If directly involved in the testing program, each employee will want to know his/her expected role and its effect on his/her current patient care responsibilities. Consider requesting feedback from staff to modify the testing protocol appropriately.
Infectious disease providers
Critical to the mission of an HIV testing program is the capacity to link newly identified patients to care. As such, the HIV testing program should be handled in close collaboration with the infectious disease (ID) division that will often provide the patient’s first follow-up visit. Early discussions with ID collaborators often include issues related to capacity (are there enough providers to serve newly identified patients?) and linkage to care (how soon can a patient identified in the program get a “new patient” appointment?). The ID division often has helpful resources that might be useful in the development of such protocols, creating synergy within the collaboration.
Laboratory services personnel
The involvement of the clinical laboratory can help facilitate compliance with HIV testing regulations. Engaging laboratory services early will assist with decisions regarding choice of tests (attributes and drawbacks of each). It may be valuable to seek their expertise on important items such as point of care testing, quality control measures, and HIV confirmatory procedures. A rapid, reliable, and laboratory compliant test should be the goal.
Patient satisfaction and flow in the ED often rely on turn-around times for test results (both initial and confirmatory); this may also be an important component of the discussion with laboratory services.