However, in settings such as emergency departments and urgent care clinics where treatment is incident-specific and health care professionals often do not have an ongoing relationship with their patients, providing routine HIV testing can be difficult. In addition, HIV counseling and testing is time consuming and strains the already limited resources of those working in these emergent care environments.² While the CDC no longer requires prevention counseling as a part of HIV screening, the populations served by inner city emergency departments and urgent care clinics are most in need of prevention messages.³ These patients are less likely to have ongoing access to health care and would greatly benefit from exposure to HIV education. Additionally, while recommending the de-linking of counseling and testing if necessary, the CDC does acknowledge that patients might be more likely to think about HIV and consider their risks at the time of testing, creating an opportune time to provide prevention messages.¹ Consequently, it is essential to develop an effective, streamlined method of HIV counseling and testing for emergency departments and urgent care settings.

If counseling and prevention messages could be disseminated using multimedia, it would allow emergency departments to achieve an increase in testing without having to sacrifice the opportunity to provide education about HIV. Previous studies have validated the effectiveness of using video as a pretest and posttest counseling tool.⁴ In this context, HIV counseling refers to conveying the information necessary to obtain informed consent in the state of New York. This includes explaining that HIV is the virus that causes AIDS; mechanisms of HIV transmission; the only way to know one's HIV status is to be tested; that HIV testing is voluntary; anonymous and confidential HIV testing options; the process of partner notification and reporting to the Department of Health; and the meaning of positive and negative test results.⁵ The advantage of using video education is that it is available in several languages, can be repeated as often as necessary and gives patients the opportunity to learn communication and negotiation skills with little or no embarrassment by viewing interactions between actors.^6,7 Additionally, studies demonstrate that patients had better retention of information provided via video than by other methods of instruction.^8–10

Currently, counseling and testing are the primary methods of HIV prevention. Once individuals are infected the next prevention efforts, as recommended by the CDC,¹ should be to inform them of their status and immediately link them to treatment services. Immediate treatment can decrease the patient's viral load and lessen the possibility of transmission to others.¹¹ It is also beneficial because it can enhance the patients' quality of life as well as provide them with consistent risk reduction messages from medical providers.^12–15 Linkage to care for HIV-positive individuals has proven difficult^15,16 and of those patients diagnosed with HIV, 42% to 59% do not receive routine medical care.¹⁶ Both the benefits and difficulties of linking HIV-positive individuals to medical care underscore the need to develop a more streamlined system of immediately enrolling patients in treatment programs.

Of those patients who were randomized to the posttest knowledge survey, 3604 (93.5%) received a score of 60% or higher and 2770 (71.9%) received a score of 80% or higher. Of the patients who were randomized to the posttest satisfaction survey, 96.3% felt the videos answered their questions regarding HIV testing, 98.6% thought rapid HIV testing in the emergency department was helpful and 95.1% felt the PHA made the process easier for them. When asked how they would prefer HIV counseling in the future, 74.4% stated they would prefer a process that includes both the videos and the PHA. Additionally, 75.9% of patients felt they learned a moderate or large amount of new information, and 72.5% felt the videos gave them a moderate to large amount of information to change their sexual practices.

There were 57 newly diagnosed or confirmed HIV-positive patients of whom 39 (68.4%) were males, the average age was 37.7 years, and 47 were naïve to HIV treatment. There were 11 patients who knew their HIV status but requested testing in order to be linked to care or to confirm previous results; 10 of these patients (90.9%) were successfully linked to care at our clinic. Among the patients who tested positive, the most common reasons for visiting the emergency department on the date of diagnosis were HIV testing, respiratory distress, and sexually transmitted disease (STD) or genitourinary disorder. Compared to the 2.3% (n=142) of patients who tested negative, 23.3 % (n=13) of positive patients reported having sexual intercourse with an HIV-positive partner. Also, 37.5% (n=21) of positive patients reported past non-intravenous drug use, versus 26.6% (n=1635) of patients who tested negative.

Of 57 positive patients, 49 (84.2%) of them were linked to care, with linkage to care being defined as being seen by an HIV specialist provider at an outpatient clinic. Of the 49 patients linked to care, 44 were seen at ACS. Of those followed by our clinic, 34 were eligible for HAART according to the guidelines set forth by the Department of Health and Human Services¹⁷ and 27 (79.4%) were placed on HAART treatment. The mean time interval from date of diagnosis to the first medical clinic visit was 20.5 days (range, 0–696 days). The mean time interval from date of diagnosis to initiation of HAART was 31.2 days. After placement on HAART, 15 patients had a viral load less than 400 copies per milliliter, 8 of whom had a viral load less than 50 copies per milliliter (Table 2). Baseline resistance to antiretroviral treatment data was available for 20 of the newly diagnosed patients, 2 of whom were infected with strains of HIV that had genotypic resistance to HIV medications.

The videos were well received, and effective in conveying information about HIV. Nearly three quarters of those tested scored 80% or higher on the posttest knowledge measure that assessed their comprehension of the pretest and posttest counseling material presented to them. In all, 75.9% of the patients felt they learned a moderate to large amount of new information from the videos and that the information learned influenced them to change their sexual practices. The patients' receptiveness to the information presented in the videos and their preference for the use of a PHA and video when testing in the future demonstrates a high level of acceptability of the B.R.I.E.F. model to deliver HIV C&T.

The use of multimedia also ensures that education and prevention messages are accessible to a large population of patients with varying literacy levels. According to the 2003 National Assessment of Adult Literacy, 30 million adults with “below basic prose literacy” are unable to do much more than sign a consent form or search a document to determine what they can or cannot consume before undergoing a medical test.¹⁸ In the Bronx, 46% of the population is functionally illiterate and 33% are marginally literate.¹⁹ In such a setting it is beneficial to use multimedia to disseminate information. Videos are an effective method of making health education available to patients regardless of their level of literacy.

It is interesting to note the wide difference between the number of patients who stated they were previously tested (71.0%) and those who reported receiving prior HIV counseling (42.6%). There are several reasons that could account for this discrepancy, the most likely of which is that the percentage of patients who said they had previously tested, was falsely elevated. According to a recent survey, 23% of Americans believe that they are tested for HIV during routine check-ups or each time their blood is drawn.²⁰ None of the 80 patients were found to have documentation of previous HIV testing in our hospital network. However, the discrepancy between those patients who state prior testing and prior counseling could also be attributed to the way in which patients view new streamlined methods of HIV counseling. Some institutions may only provide written counseling materials or quickly run through a script or list of facts, as a method of conveying HIV education. Many patients may not register or perceive these types of information delivery as actual pretest counseling. By providing the essential elements pre-test counseling as defined by New York State law, via video before the PHA obtains informed consent, the B.R.I.E.F. model ensures that patients fully understand the testing process and are aware of the care and services they are about to receive.⁴

The feasibility of the B.R.I.E.F. program is demonstrated by the high percentage of both patients who accepted testing and patients who were identified as positive and subsequently linked to care. Of the 7109 eligible patients approached, 87.41% accepted testing and 57 patients tested positive. Identifying positive patients is imperative to combating the HIV epidemic because knowledge of one's positive serostatus often leads to a reduction in risky behavior. Studies have shown that persons aware of their HIV positive status are 68% less likely to engage in unprotected intercourse with uninfected partners.²¹ Additionally, the transmission rate is 3.5 times higher for individuals unaware of their serostatus as compared to individuals who know they are positive.²² This difference in transmission rates is not only attributed to a change in behavior but also the benefits of positive patients being placed in medical care. Early detection and immediate linkage to clinical care can significantly improve the patient's quality of life. The success of antitretroviral therapy allows patients to live longer, healthier lives if the therapy is started before advanced immune dysfunction occurs.^23,24 Of the 57 positive patients identified, 49 were linked to care, 5 of whom were seen at outside clinics. Out of the 44 patients seen at ACS, 34 met the criteria for HAART treatment and 25 were placed on HAART. At their most recent follow-up examinations the clinic found that 15 of those patients had a viral load less than 400 copies per milliliter. Of those 15 patients, eight had an undetectable viral load (<50 HIV-1 RNA copies per milliliter). The average of 20.54 days to be linked to medical care and 32.73 days to initiate HAART (if eligible), as well as the excellent response of many patients to their treatment, are indicative of the efficacy with which the B.R.I.E.F. program links patients to care. Immediate linkage to care has become an increasingly crucial component of HIV prevention and patient care over the past 10 years due to advances in research that have made HAART more effective.

While these findings demonstrate the benefits of linking patients to care, the remainder of the data on the HIV positive patients illustrates the continued need for an increase in testing. On average, the patients who tested positive had made 8.9 visits to the North Bronx Healthcare Network (NBHN) before being diagnosed with HIV and had an initial CD4 count of 238cells/mm³ (Table 3). Of those patients, 27 developed AIDS less than 1 year after diagnosis. These numbers indicate that patients are being diagnosed late in the course of their disease.

However, the success of Project B.R.I.E.F. is encouraging. Compared to other testing sites,^25–27 it seems to be one of the more effective programs at providing rapid HIV testing in urban emergency departments and addressing the needs of that particular patient population. Recent studies have had varying degrees of success recruiting patients into emergency department HIV testing programs with 40%–60% of patients accepting testing.^25–29 However, Haukoos et al.³⁰ found that 93% of patients would have accepted an offer of HIV testing from a physician in the emergency department; this suggests that patient acceptance can be drastically increased depending on the context in which the test is offered. It is possible that the high rate of acceptance among patients tested through the B.R.I.E.F. program is due to the fact that the test is offered after patients watch an informational video. While using an opt-in approach and obtaining written informed consent as mandated by New York State law the PHAs were still able to offer testing to a substantial number of patients (8257). This is partly due to the use of video counseling, which allows the PHAs to perform parallel testing, enabling them to recruit a greater number of patients and focus their efforts on counseling high-risk negatives and ensuring that positive patients are linked to care. Also, compared to other EDs offering rapid HIV testing using an opt-out approach or streamlined C&T, testing through the B.R.I.E.F. program achieves high acceptance rates, testing for 100% of patients who are offered the opportunity, identifies a substantial amount of positive patients and links them to care, all while continuing to provide the health education most needed by this vulnerable patient population. Although patients are more likely to be receptive to prevention messages at the time of testing, most other programs do not provide standard posttest counseling to patients who test negative.¹ Althrough Program B.R.I.E.F. all patients were provided with risk reduction counseling and HIV education in addition to the pretest information required by New York State law. In addition, most programs only collect risk factors for patients who test positive. The multimedia component of Program B.R.I.E.F. eases the acquisition of all patient data, and risk factor information is available for all those who test.