Background:  In 2006, the Centers for Disease Control and Prevention (CDC) recommended routine, voluntary HIV testing for all persons aged 13 to 64 years in health care settings. Translation to emergency department practice could improve HIV diagnosis rates, enabling reductions in morbidity, mortality, and transmission. In 2007, we began evaluating 6 emergency department HIV testing programs to identify operational models, costs, barriers, and facilitators.
Methods:  We used a standardized pre-site visit survey and on-site interviews for data collection. Sites had HIV testing programs for >6 months and were chosen for diversity in geography and facility type. Operational model, process outcome, and cost-effectiveness (program costs per newly diagnosed HIV⁺ person linked to care) are reported for the first 3 sites evaluated (university hospital emergency departments in Washington, DC, and Cincinnati, Ohio; and a city hospital emergency department in New York City).

Results:  The DC emergency department used undergraduate students to offer point-of-care rapid HIV testing to medically stable patients ≥13 years on a voluntary, opt-out basis with support from department of health (DOH) and private grants. The Ohio emergency department used HIV counseling and testing staff to provide diagnostic and targeted testing using standard laboratory-based HIV testing with support from the local and state DOH. The New York City emergency department used existing nursing staff to offer laboratory-based rapid HIV testing to all patients ≥13 years with support from the city DOH. The results of testing conducted during January through June are shown in the table. All sites indicated that support from emergency department and infectious disease leadership as well as DOH funding facilitated implementation. However, staffing and resource constraints are principle barriers to sustaining and expanding testing programs.

Conclusions:  Expanded HIV testing in emergency departments will benefit individuals and public health significantly; the proportion of new HIV diagnoses ranged from 0.7 to 1.0% and most were linked to care. Considerable operational variability suggests a variety of approaches will be needed to enhance implementation of HIV testing in emergency departments and overcome significant barriers in this setting. Sources of external support such as health departments might expect a cost per newly diagnosed patient linked to care of approximately $11,000.