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Emergency department cotesting for HIV when testing for gonorrhea and chlamydia

The U.S. Department of Health and Human Services proposed an initiative, in 2019, to reduce new HIV infections in the United States by 90 percent by 2030. The plan was to increase HIV prevention and treatment strategies in the 50 local areas or counties and seven states that represented more than half of new HIV diagnoses. One of the areas with the highest new incidences of HIV infection was Cuyahoga County, Ohio. Cuyahoga County had 190 new HIV infections in 2020, a 27 percent increase from 2019 levels. The county also had an increase in syphilis cases and the highest number of chlamydia and gonorrhea cases in the state. The Nationwide Emergency Department Sample database showed a cotesting rate of only four percent for HIV when testing for gonorrhea and chlamydia (G/C) in the emergency department (ED). Because many people use the ED as a first point of contact for health care, the United States Preventive Services Task Force recommended that HIV testing be conducted in that department. In 2020, the Cleveland Clinic implemented an HIV screening approach in all of its EDs, which extended across Cuyahoga County. A multidisciplinary team evaluated current practices for HIV testing and obstacles to such testing during an ED encounter in which G/C testing was ordered. The Cleveland Clinic studied all G/C and HIV tests ordered from the health system’s 14 EDs during a two-year period to determine if testing in the ED may be an effective approach to reaching populations at highest risk for HIV. The authors collected EHR data from ED encounters for all G/C and HIV tests ordered from Jan. 1, 2019 to Dec. 31, 2021. The patients presented to the ED for sexually transmitted infection screening, with an emphasis on G/C screening. In October 2019, the Cleveland Clinic EDs implemented HIV rapid testing and G/C screening. To support the HIV screening program, the institution implemented a standardized EHR sexually transmitted infection screening order panel, with HIV testing education at staff meetings; rapid laboratory-based blood testing for HIV, with confirmed positive results sent to infectious disease personnel for follow-up; and periodic feedback to clinicians and ED directors about ordering patterns. ED providers were encouraged to discuss HIV testing and offer an HIV test to patients screened for gonorrhea and chlamydia in the ED. The overall rate of cotesting for HIV when a G/C test was ordered at the health system during the study period of 2019 to 2021 increased to approximately 30 percent, with some EDs screening at a rate of 60 percent. The authors showed that the G/C and HIV cotesting percentage was higher in locations that were hot spots for HIV infection. Seventy-eight (1.01 percent) of the 7,654 HIV tests conducted were reactive using rapid tests. Of those 78, 67 (86 percent) were positive using standard instrument-based laboratory testing followed by confirmatory testing, which yielded an overall rate of 0.87 percent true HIV positivity. The authors concluded that the Cleveland Clinic’s approach to testing for HIV in the ED is effective. Offering HIV testing at the time of G/C screening in the ED reduces resistance to HIV testing or reluctance to test since patients are already undergoing sexually transmitted infection screening.

Phelan MP, Panikkar V, Muir M, et al. Emergency department co-testing for human immunodeficiency virus when testing for gonorrhea and chlamydia: A readily available, missed opportunity for targeted HIV testing in emergency departments. Am J Clin Pathol. 2023;159:225–227.

Correspondence: Dr. Kamran Kadkhoda at kadkhok@ccf.org