ED Co-testing for HIV When Testing for Gonorrhea and Chlamydia

Abstract and Introduction

Abstract

Objectives: Conducting human immunodeficiency virus (HIV) testing in emergency departments (EDs) can be an effective approach to testing and reaching populations at highest risk of contracting HIV.

Methods: All gonorrhea and chlamydia (G/C) and HIV tests ordered in the Cleveland Clinic Health System's 14 EDs were included in the analysis. Data were collected from electronic health records. Descriptive statistics, with medians and means, were computed.

Results: From January 1, 2019, to December 31, 2021, we reviewed ED visits for the purpose of sexually transmitted infection (STI) screening, with an emphasis on G/C screening. In October 2019, both HIV rapid testing and G/C testing began across all 14 Cleveland Clinic EDs. The overall rate of co-testing for HIV when obtaining a G/C test for STI evaluation increased overall to around 30% for our health system EDs, with some individual EDs approaching 60%.

Conclusions: The approach the Cleveland Clinic implemented is an effective way to test for HIV in the ED. Local health departments and stakeholders in HIV communities should support and collaborate with EDs in their jurisdictions to accelerate HIV testing initiatives by using an HIV plus G/C co-testing metric.

Introduction

In 2019, the US Department of Health and Human Services proposed the Ending the HIV Epidemic Initiative. The goal of this initiative was to reduce new human immunodeficiency virus (HIV) infections in the United States by 90% by 2030 by increasing HIV prevention and treatment strategies in the 50 local areas/counties and 7 states that accounted for more than half of new HIV diagnoses. Cuyahoga County, Ohio, was identified as one of the counties contributing to the high burden of HIV incidence in the United States. In 2020, Cuyahoga County had 190 new HIV infections, which was second highest in the state,^[1] a 19% increase from 2019. Since 2017, the number of new infections has increased by 27%. The populations most affected by HIV incidence in Cuyahoga County are Blacks, adults under 30 years of age, and men who have sex with men (MSM). In 2020, Blacks made up 71% of new cases, with almost 50% of new cases occurring in patients younger than 30 years of age at the time of diagnosis. Additionally, 48% of new cases were in men identified as having MSM sexual contact.^[1] In addition to high HIV incidence, Cuyahoga County has faced a high incidence of sexually transmitted infection (STI). In 2020, the county had 515 total syphilis cases, the second-highest rate in Ohio,^[2] and the highest number of chlamydia and gonorrhea cases in the state at 10,941 and 6,960, respectively.^[3,4]

An evaluation of the Nationwide Emergency Department Sample database showed a co-testing rate of only 4% for HIV when gonorrhea and chlamydia (G/C) are tested in the emergency department (ED), suggesting a missed opportunity for HIV testing in a high-risk group of emergency patients.^[5] According to the US Centers for Disease Control and Prevention (CDC), nearly 1 in 5 people does not know that they are infected with HIV.^[6] People knowing their HIV status is an important first step in addressing the HIV epidemic. Recently, emphasis has been on normalizing HIV testing and increasing testing in nontraditional settings among high-risk populations. As more people use the ED as their first point of contact with health care, the CDC and United States Preventive Services Task Force (USPSTF) have recommended HIV testing in the ED. In addition, the National HIV Strategic Plan for the US recommends HIV screening in the ED.^[7]

Approaches to implementing ED-based HIV screening have varied, however, ranging from universal to targeted screening. Universal screening uses the approach of testing all patients who enter the ED without any assessment or prescreening. A targeted screening approach typically uses a risk assessment or prescreening to determine who should be offered an HIV test. With HIV and other STIs having similar risk factors and priority populations, presentation for STI testing is frequently involved in the assessment.

In 2020, the Cleveland Clinic implemented an HIV screening approach in its EDs systemwide across Cuyahoga County. A multidisciplinary team of emergency medicine, infectious disease (ID), laboratory medicine, and pharmacy personnel identified and evaluated current practices for and obstacles to HIV testing during ED encounters in which G/C testing was ordered. In addition, the team built a follow-up structure for positive HIV results so that all patients would be followed by the ID HIV team. The following interventions were implemented: a standardized electronic health record (EHR) STI screening order panel, with HIV testing education at staff meetings; introduction of rapid laboratory-based blood HIV testing, with confirmed positive results sent to ID for follow-up; and periodic feedback to clinicians and ED directors regarding department-level ordering patterns after implementation. The ED providers were encouraged to discuss and offer an HIV test to any patient who was being screened for G/C infection in the ED.