Need for Consensus Definitions
The importance of human immunodeficiency virus (HIV) testing in the emergency department (ED) has long been recognized,1
and the Centers for Disease Control and Prevention (CDC) recently charged emergency providers with making HIV testing a “routine” part of clinical emergency medical care.2
Although still in its infancy, ED-based HIV testing has grown beyond the few initial pioneering centers.3–12
Ongoing clinical programs, research studies, and demonstration projects are under way in many EDs, often with funding from a variety of organizations, including health departments, the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), the CDC, and various private foundations. The programmatic details of ED HIV testing are complex and are highly dependent on individual settings. As a result, variations in methods for ED HIV testing are becoming increasingly apparent.7,11,13–24
As ED HIV testing evolves beyond feasibility studies to larger-scale implementation, objective data that allow comparison of research and program experiences are needed. Productive debate and translation of knowledge is enhanced by transparent and consistent use of common terminology that decreases the likelihood of misinterpretation or ambiguity. The existence of terminology ambiguity in relation to ED-based HIV testing is already apparent in the literature,14,17,25
and thus it is timely to develop consensus nomenclature and definitions. In November 2007, an open-invitation panel of experts was convened in part for that purpose.
Consensus Development and Process
An organizing committee of emergency researchers with experience in ED-based HIV testing planned a national meeting to systematically discuss key issues related to ED-based HIV testing, including terminology and definitions, guidelines for reporting practices and research findings, ethical and regulatory issues, operational variables, and screening impact. The inaugural conference of the National Emergency Department HIV Testing Consortium convened in Baltimore, Maryland, on November 12, 2007. Invitations to attend the conference were extended to those known by the conference organizers to be involved in existing or planned ED-based HIV testing at academic and community institutions. Attendees were encouraged to further distribute invitations to other potential participants from other institutions. Selected leadership organizations were also asked to send representatives. In total, there were 98 attendees at the conference, and 42 healthcare institutions from around the country were represented. Organizational representatives included those from the Society for Academic Emergency Medicine (SAEM), the American College of Emergency Physicians (ACEP), the HIV Medicine Association (HIVMA), and the CDC, as well as state health departments, advocacy organizations, and foundations.
A primary goal of the conference was to develop consensus definitions that would provide a common lexicon for the reporting of results from ED-based HIV testing research and clinical programs. A related goal was to develop a reporting guideline using these consensus definitions that would further characterize optimal presentation and content when preparing submissions relevant to ED-based HIV testing. Prior to the meeting, the primary authors of this article prepared a set of terms and definitions with an associated draft reporting guideline for ED-based HIV testing efforts, derived from their combined experiences and knowledge of the field. All conference attendees were encouraged to review a discussion guide, the draft definitions, the reporting guideline, and several pertinent manuscripts,2,14,17
which were all distributed 1 month prior to the conference. The discussion guide listed questions that would be posed during the conference and specifically highlighted key areas of likely controversy, where there was known ambiguity and new approaches were being proposed.
Conference attendees were divided into four groups of 20–25 persons. Each group attended a 70-minute discussion session focused on development of consensus definitions and reporting guidelines. Conference organizers formed the groups in advance of the meeting and attempted to diversify the group composition to provide a mixture of persons from different academic, clinical, and institutional backgrounds. Each group session was led by a trained focus-group facilitator, and the session proceedings were recorded by video tape, audio tape, and a scribe. One of four moderators (MSL, CJL, JSH, RER; the primary authors) was present at each of the sessions to answer questions and provide any needed clarification about the definitions, the intent of the project, and the scope of the discussion sessions.
The focus group facilitator used a structured guide to direct discussion. Participants were first asked to initiate the discussion with any points they wanted to raise about content, scope, or consensus process. Following these discussions, the facilitators posed predetermined questions that the moderators believed might be the most controversial or contain areas of ambiguity.
After the consensus conference, the primary authors reviewed all comments recorded by the scribe and facilitator. In addition, the lead author reviewed the session recordings to ensure that the scribe and facilitator records accurately and completely reflected the discussion content. The primary authors then revised the definitions according to input from conference participants. Conference participants were sent electronic copies of the revised definitions for further review using an electronic listserv, in the attempt to not only promote critique, but further public discussion.
After reviewing further critiques and then finalizing the consensus definitions, the first draft of this article was developed by the primary authors and distributed to the larger group of core authors for further revision. Finally, the draft was distributed to all conference participants, including organizational representatives, for final comment to ensure that it ultimately reflected consensus. This article contains the final version of the terms and definitions developed via the consensus process described. A follow-up article utilizing these definitions will serve to provide the detailed consensus guideline for reporting on ED HIV testing.