How to Manage Preliminary HIV Positive Results in the ED

Segment Description: Investigators with The University of Texas Health Science Center embarked on a study to determine whether HIV disclosure at the emergency department should be based on preliminary results. Their poster was presented at IDWeek 2019 by Elizabeth A. Aguilera, MD, clinical research coordinator, The University of Texas Health Science Center; Gloria Heresi, MD, professor of pediatrics, McGovern Medical School, The University of Texas Health Sciences Center; and Samuel Prater, MD, executive vice-chair of clinical affairs at McGovern Medical School.

Interview transcript: (modified slightly for readability)

Dr. Prater: Just talking about background for why we started doing routine screening at the Department of Emergency Medicine at McGovern Medical School in Houston, we've definitely moved beyond the idea that emergency medicine's only role is just to save patients' lives. We definitely recognize that there's a critical component in patients' access into the health care system and our role in public health and population health. This started with Dr. Jamie McCarthy several years ago, but we recognize the value that there is a portion of the population that is really living on the fringes of health care and don't have everyday access to a health care provider. And so we need to move beyond just taking care of their immediate emergencies and looking at their overall health and how that plays into the health care system. But also, it's very important to insurance carriers and hospitals, as well, that we sort of control how they access the health care system. And so, diagnosing some of these diseases like HIV and hepatitis C very early is way more important to not only just the patient and their overall wellbeing, but also to the health care system as a whole in terms of the financial wellbeing, in terms of identifying these patients early, rather than very late with an AIDS-defining illness. That's where the impetus of this program started many years ago. We're a very important access point for a very vulnerable portion of our population and identifying them early, whether that's HIV or hepatitis C.

Dr. Heresi: Many people are walking around without knowing they have HIV and they are transmitting...What Sam is saying [about] treatment for the patient and the comorbidities increase, it is also to stop transmission to other people because if you don't know, sometimes people don't protect themselves.

Dr. Aguilera: An emergency department visit is a great opportunity to test. So from 2017, we implemented a routine screening program. Every patient from 18 to 65 years old with [a Glasgow Score > 9] are eligible for a screening test. We follow the CDC recommendations so, for the screening test, we use the 4 generation antibody/antigen combo and for the confirmatory the Gennius^TM HIV1/HIV2 antibody.

Dr. Prater: It's really been automated. When it first started, it was just constantly, for lack of a better word, but nagging the nurse like, "Please remember to send this tube of blood with the rest of the blood that you're sending for their CBC and chemistry and panel, just remember to send this." [It] was just constant nagging. But now it's sort of automated to [where] it's a mandatory part of the nursing assessment. So they have all these questions that they're supposed to ask, including "have you ever traveled outside the country?" And under that is "have you ever been tested for HIV or not?" That is a mandatory question now, so when the nurses complete that, then that automatically generates a screening test for HIV.

Dr. Heresi: What is recommended by the CDC is to do an opt-out screening. So what is opt-out? It is that you tell the person, "Listen, we're going to test you today for HIV." And unless the person says "no," you do it. So it's simpler. Now, as Sam said, initially it wasn't easy with the nurses because people feel that they are getting in the private lives and the sex lives of people. But we try to take this thing out, and [say] no, it's more important that we diagnose them. Sex is a part of life. Why should it be difficult to ask the question?

Dr. Aguilera: In our program, we tested 12,040 patients and 232 were positive (like 1.9%) and 22 were false positives, with screening positive and the confirmatory was negative. So just 63% of these patients we follow with a viral load undetectable, and 1 patient we repeated testing, but 36 of the patients we lost to follow-up because we could not locate them after the discharge from the emergency department.

Dr. Heresi: Many people in the past suggest that, in the ED when you have that rapid test, you should disclose immediately and contact that patient for care in the HIV facilities. However, when you see that 10% [of positive screening tests] could be false, that is probably not the best idea. We had a discussion between us—[Dr. Aguilera and I] are ID and Sam is ED—so we discussed together, and we decided that we should [disclose] when we have the confirmatory results.

Dr. Prater: It's very easy for someone with their background and their expertise to sit down and spend half an hour with a patient talking about their status for HIV, what that means for them, and what treatment options for them are, how long they need to be engaged in this process, versus the ED physician who works an 8-hour shift and he's got to see between anywhere from 24 to 35 patients...many of these patients have chest pain, weakness, shortness of breath, they're septic [or] they're trauma patients. We have a very limited amount of time that we get to spend with these patients. And so the success of our program is really all the layers that we've built behind the doc, so somebody who reliably follows up the result, somebody [who] tracks these patients down, somebody [who] then brings the patient in to do a face-to-face disclosure with the patient, and then help link that patient to care. That's the success of our program. If it relied on the everyday doc who's working in the emergency department and seeing 30 to 40 patients in a shift, the program would fall apart. It would just be completely unsustainable and unreliable. That's the success of our program is all the layered individuals in the background doing all the really hard work to track these patients down, disclose the result, and link them to care. That's the success of our program. What we found also with the false positive rate is if we did do something like that in the emergency department, how disruptive that is to the patient [because] for the next 3 to 5 days...their world is sort of turned upside down and all the implications.

Dr. Aguilera: The confirmatory tests are available [in] 24 hours or more than 24 hours. So, meanwhile...[until we have] the confirmatory test, [we are] generating social and personal disruption in the patients' lives.

Dr. Heresi: What we do is we have a visitor linkage person who, when we know the test result is positive, calls the patient [and asks them to come in]. We sit and explain and talk. HIV is still very stigmatized, and we all try to fight it but it's a stigma even in the health care providers, everybody. Things have improved since the '80s, but it's still terrible for people to learn they have HIV, their families, etc. [So the disclosure] is in person and the linkage to care [is right there]. We have different options in Houston. We're doing a lot with Legacy because they can see a patient very fast and they can start a patient on treatment within a week.

Dr. Aguilera: For the future, we're going to expand. Currently our program is in Texas Medical Center, so we are going to expand in other Memorial Hermann hospital centers.

Dr. Heresi: There [will be] influence in all the EDs in all the Memorial system, and Memorial system is huge.

Dr. Aguilera: We have 14 hospitals.

Dr. Heresi: We are moving to extend, with the experience we have now, to the other EDs in the Hermann hospital complex.

Dr. Prater: Memorial Hermann has the largest percentage of the health care market in the Houston area. And so we're trying to have multiple different hospitals throughout the area and multiple different suburbs...[In] our previous experience with Dr. McCarthy's work, we've identified some zip code hotspots, obviously the Texas Medical Center is one of them, but there's 2 other hospitals in the region where the zip codes have higher than usual rates and so we're going to be expanding into those 2 areas as well.

Dr. Heresi: In the next few months, we're expanding to 2 hotspots, as Sam said.

The poster, "Should HIV Disclosure at ED Based on Preliminary Results?", was presented on Friday, October 4, 2019, at IDWeek 2019 in Washington, DC.