The State of HIV Screening in Emergency Departments: A Q&A with Michael Lyons, MD
Thirty years after the first reported cases of HIV/AIDS in the United States, the medical community is still looking for ways to control the continued spread of the disease. This July, assistant professor of emergency medicine Michael Lyons, MD, served as co-guest editor of a landmark Centers for Disease Control and Prevention (CDC) publication, a supplement to the July issue of the Annals of Emergency Medicine, covering the state of HIV screening programs in the country’s emergency departments.
The supplement, which includes seven papers by UC faculty including Carl Fichtenbaum, MD, of the division of infectious diseases, and Christopher Lindsell, PhD, and Alexander Trott, MD, of emergency medicine, describes research and practice in all aspects of emergency department (ED)-based HIV testing, from how testing programs can reach new patients to how hospitals can identify better ways to deliver testing.
In addition to overseeing the HIV Early Intervention Program within the department of emergency medicine, Lyons focuses his research on HIV screening programs and the challenges of increasing HIV testing rates.
What is the current state of HIV screening in the U.S.? Historically, health care providers have not done much HIV screening. Although many individuals were diagnosed in health care settings, these diagnoses were often made because of illness occurring during later stages of infection.
In 2006, the CDC recommended that health care settings start doing more HIV screening, and these recommendations are gradually being adopted. Now, many more providers are screening for HIV before the onset of late-stage illness, leading to more cases being detected and detection at an earlier stage. As a result, the percentage of individuals who are infected with HIV but unaware of their infection appears to be decreasing.
This is encouraging, but progress has been slow and there are many missed opportunities for earlier diagnosis. There is also some worry that progress will slow further if financial support from the CDC for increased testing comes to an end.
How many emergency departments conduct regular HIV screening? There has been a dramatic increase in the number of emergency departments that allow HIV testing, and there are now some that screen large volumes of patients. However, these are still only a small fraction of the number of emergency departments in the country. Much more progress will be required before HIV screening is a broadly accepted and commonly practiced activity in the majority of our nation's emergency departments.
Why are the advantages of hosting screening programs in emergency departments? Many Americans don’t have access to health care, and those that do still often go to the emergency department for care. The number of patients seen in emergency departments every year is huge. This means that screening in emergency departments makes testing available to a broad segment of society, including many disadvantaged persons.
Research also shows that many undiagnosed people have had recent visits to emergency departments before they are eventually diagnosed with HIV. In the time period between their visit and their diagnosis, these people might have infected others unknowingly and their illness might have become worse. Testing in emergency departments could help to avoid these bad outcomes by diagnosing HIV earlier.
What do you see as the biggest challenges to reaching the CDC recommendations for universal testing? The good news is that the current CDC recommendations help remove some of the biggest barriers by letting us change the testing process so that it is more like ordering any other test in health care.
The bad news is that changing the practice of individual doctors, as well as whole emergency departments, is often a difficult and lengthy process. Emergency departments care for very large numbers of patients and doing anything reliably tens of thousands of times per year is a significant challenge.
As well, emergency departments have typically avoided non-emergency activities like screening in favor of carrying out their primary mission to stabilize emergent illness and injury. Expanding the clinical mission at a time when emergency departments are faced with a crisis of severe overcrowding is difficult and controversial. Last but not least, many ED administrators are unsure of how the costs of screening will be paid for.
The most powerful way to increase HIV testing would involve changing our health care system to encourage prevention for all illnesses. We also need to continue with research on making screening programs as cost-effective as possible—that includes finding ways to implement programs, allocate resources and efficiently identify individuals with undiagnosed HIV. The more screening programs in place, the more impact we can have on slowing the ongoing epidemic.