September 18, 2016
Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.
In the late 1990s, a patient was admitted to our hospital with HIV-associated PCP. He had advanced AIDS, a CD4 cell count < 100, and was sick enough to require a temporary stay in our ICU.
Those clinical details aren't so remarkable -- "late" diagnoses of HIV still happen, and happened even more back then. What's remarkable is what happened to him before he got admitted.
As an (early) freelance web designer, he had no medical insurance, and received his infrequent care through an emergency department at a hospital near his apartment. He had gone there around a month before we admitted him with cough and weight loss; no pneumonia was seen on his CXR at that point. He told the doctor who saw him that he was worried he had AIDS since he was a gay man and hadn't been tested in many years.
According to the patient, the doctor there told him that he was right to be concerned, but that the policy of the ED was that they could not do HIV tests. He urged him to see a primary care doctor soon after discharge from the ED to get this checked.
Never happened -- he didn't have a primary care provider. His illness smouldered along for a while, until it became severe enough that he was admitted here with pneumonia. He said repeatedly that if he knew he was HIV positive, then he would have sought care much earlier.
When I told this story to someone from our ED way back then, they said the same thing -- that it was a "policy" (unwritten but widely agreed upon) that they should not send HIV tests, even if they clinically suspected a patient had AIDS.
One of our current Emergency Medicine doctors, Kelli O'Laughlin, explains:
Historically there is a sentiment in emergency medicine that energy and resources in the emergency department should be reserved for dealing with urgent medical conditions rather than on diagnosis of chronic medical issues. Additionally, emergency medicine clinicians have avoided testing patients in the ED for HIV because of the concern results will return when the patient is no longer in the ED. This can make it challenging to share results with the patient, which can expose physicians to legal risks. Other barriers to HIV testing in the ED include lack of provider knowledge and comfort with pre-test counseling and post-test counseling.
Well a lot has changed with HIV testing since the late 1990s, most notably the landmark CDC HIV testing guidelines, issued almost exactly 10 years ago today. (Happy 10th Birthday!) Those guidelines have been critical in reducing the proportion of people in the USA with HIV who are unaware of their status (now around 10-15%), allowing those with HIV to get life-saving treatment before getting AIDS-related complications, and preventing further HIV transmissions.
While the guidelines are often cited for recommending an HIV test for most US adults and removing the requirement for written informed consent, just as important was that they specified where HIV testing should take place -- namely "all health-care settings." If that's not clear enough, this is:
The recommendations are intended for providers in all health-care settings, including hospital EDs [emphasis mine], urgent-care clinics, inpatient services, STD clinics or other venues offering clinical STD services, tuberculosis (TB) clinics, substance abuse treatment clinics, other public health clinics, community clinics, correctional health-care facilities, and primary care settings.
I don't think it's an accident that hospital EDs are listed first among health-care settings in the CDC testing guidelines. As noted here:
HIV disproportionately affects populations that are likely to be without a regular source of care or have a history of barriers to care, which may contribute to delayed diagnosis and further transmission of HIV. Many are dependent on the public sector for the financing and delivery of their care. ... Consequently, EDs -- whose patients include large numbers of underinsured and uninsured -- are likely the only source of health care for many people with HIV or at risk for HIV.
And what about guidelines about HIV testing specifically from the American College of Emergency Physicians? They're in agreement, and have been since 2007.
This post is undoubtedly "preaching to the choir" -- who reads an ID/HIV blog, after all? -- but the main reason I'm writing it is not just because of the impending 10 year anniversary of the CDC guidelines, but to underscore just how difficult the culture shift has been in certain EDs around the country.
Including, ahem, ours. And, since misery loves company, the situation is even worse at one of our "partner" hospitals (which will go unnamed, but is also commonly abbreviated with three letters).
Despite CDC recommendations for HIV screening in health-care settings, in our own emergency department, ironically, we do not have processes or systems in place to make HIV testing efficient. We cannot ensure that abnormal results will reach the patient. I experienced this problem over a year ago when a patient I tested for HIV was discharged from our emergency department observation unit without receiving his/her abnormal result of the initial HIV screening test. Fortunately we were able to locate this patient shortly after. Motivated both by the gap between CDC recommendations and our practice, as well as this individual case, I worked with colleagues to establish the HIV Testing in the ED Committee.
I'm confident that with Kelli's leadership, it will become a reality soon. Already I can tell that our ED clinicians are ordering more HIV tests, and we've been collaborating with them to ensure that any positive results are given an expedited evaluation by an ID doctor.
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