Project B.R.I.E.F. consists of integrated HIV C&T in the emergency department/UCA during standard and off-hour shifts with immediate linkage to clinical care. The program has redesigned the traditional model of HIV C&T specifically to address the vulnerable, at-risk population that utilizes the emergency department for their urgent health care needs. It allows for an increase in the number of people tested without sacrificing the opportunity to provide education and prevention messages. The results of this study indicate that as a model for rapid HIV testing in the emergency department, the Project B.R.I.E.F program is both feasible and acceptable to the patient population. This suggests that the emergency department is a valid site for HIV C&T. Nearly all the patients tested felt that rapid HIV testing in the emergency department was helpful and that the PHA made the process easier for them. The majority of those tested preferred the B.R.I.E.F. model to any other model of HIV C&T.
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 238
(). 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.
The success of Project B.R.I.E.F. demonstrates that it is not necessary to delink counseling and testing in order to achieve an increase in the number of people aware of their serostatus. Furthermore, the B.R.I.E.F. program illustrates that maintaining the education and counseling component of testing is feasible in emergency departments. This is of utmost importance because testing in emergency departments is a vital component of the fight against HIV/AIDS. Testing in hospitals, emergency departments, outpatient, and community clinics account for greater proportions of positive test results compared to private physicians and HMOs.31
According to the 2000–2003 Supplement to the HIV/AIDS Surveillance Report, hospitals, emergency departments, outpatient, and community clinics accounted for 31% of HIV tests but 48% of positive results.31
For several reasons, urban emergency departments are ideal sites for reaching populations most vulnerable to contracting HIV. First, emergency departments have access to at-risk populations. Small studies looking at the prevalence of HIV-1 infected adult patients presenting to inner-city emergency departments, using anonymous testing, have demonstrated that 3%–17% of patients are unaware they are HIV positive.32–35
Second, emergency departments provide disease prevention information and do so effectively.36,37
Third, emergency departments located in urban areas have a unique trusting relationship with their communities, as they often provide routine primary health care for many inner-city patients. With the use of a small, dedicated PHA staff and a multimedia rapid HIV testing model, emergency departments can increase serostatus awareness in these populations, while continuing to provide them with education and prevention messages.