Nurse-Led Pilot Program Boosts HIV, Hepatitis C Diagnosis Rates

Ryan Anson, Erica Ivans, and Kara Vassily at the 2018 Association of Nurses in AIDS Care conference in Denver, Colorado
Sony Salzman

Today in the U.S., one out of seven people living with HIV isn't aware of their status, and a staggering 50% of people living with hepatitis C have never been diagnosed.

Because emergency departments are often where the country's most vulnerable populations seek primary care, they're a perfect place to bolster screening rates for infectious diseases like HIV and hepatitis C.

In May 2017, the emergency department staff at Alta Bates Summit Medical Center in California launched a pilot program for opt-out screening, meaning all eligible emergency room patients would be tested unless they specifically declined.

A few months later, the nursing staff banded together and requested they be given the authority to screen patients as part of their routine assessment and intake process. Incorporating HIV and hepatitis C screening into their existing workflow would help get more patients diagnosed, the nursing staff reasoned.

"We're already triaging people," said Kara Vassily, RN, "so for us, this is another series of things we can do to get the rapid HIV and hepatitis C screening done."

Hospital directors agreed, giving Vassily and her colleagues permission to implement a nursing standardized procedure for HIV and hepatitis C testing. Over 17 months, the nurses and other clinical staff screened 10,024 patients for HIV and 9,236 for hepatitis C, according to a Nov. 8 poster presentation at the 2018 Association of Nurses in AIDS Care conference in Denver, Colorado.

The opt-out system helped reduce stigma, Vassily explained. When "you just frame it in a non-judgmental way," almost everyone participates, she said.

Ultimately, 47 patients were diagnosed with HIV, and 279 were diagnosed with chronic hepatitis C. The number of acute HIV infections exceeded expectations, with 52% of patients living with the virus displaying symptomatic acute HIV. Another surprise was the large number of young patients diagnosed with hepatitis C, a disease that is five times more likely to be found among members of the baby boom generation than any other age group.

Emergency department nurses found that 36% of patients diagnosed with chronic hepatitis C were born after 1965 -- the cutoff year for the baby boom generation -- offering more support for the theory that disease prevalence is growing in younger generations because of the opioid epidemic.

Related: "Caring at Its Essence": HIV Nurses Recall Pivotal Moments With Patients

Overall, this research demonstrated that a nurse-led screening program can improve diagnosis rates without negatively impacting other emergency department operations or lengthening patient stays, the study team said. Done correctly, with the backing of hospital administrators and in close coordination with other hospital staff, HIV and hepatitis C screening can be incorporated into nursing workflows even in a busy emergency department, they assert.

"Nurses and [physician assistants] spend a lot more time at the bedside, providing that care and discussing a lot of sensitive health history," said Ryan Anson, NP-C, of East Bay Advanced Care in Oakland. "That's the unique skill set [nurses] can bring to a potentially vulnerable population."

Today, the screening program is no longer a pilot -- it's been fully incorporated into the emergency department's operations. Grant money was only extended for one year, but the program is now self-sustaining, because tests are billed to patient insurance plans, which almost always cover the cost of these medically necessary tests, Anson said.

Next, Anson, Vassily, and their colleagues want to focus on the next stage in the cascade of care: treatment. As part of their 17-month pilot project, the Alta Bates emergency department nurses developed a strong relationship with an outpatient HIV clinic, where patients with diagnosed HIV were handed off to continue receiving care. All 14 patients diagnosed with acute HIV in the emergency department were successfully linked to care.

"Of those 14 cases, I would say everyone started [treatment] within three to four days -- most within 24 to 48 hours," said Anson.

Hepatitis C linkage to care was not as successful, with the authors noting in their poster that about 30% of those individuals could not be contacted. But in May 2018, they realized their strategy of calling people on the phone wasn't enough, so they began to send letters in the mail in addition to a phone call -- bolstering the linkage rate from 21% to 32%.

According to Anson, "this [pilot] is easy to replicate" for emergency departments that are considering a nurse-led, opt-out screening program that saves lives.