Section 5: Frequently Asked Questions on Rapid HIV Testing and Prevention Services in Hospital Emergency Departments
What is the role of the emergency medicine in HIV prevention?
Since the beginning of the HIV epidemic, emergency departments (EDs) have played a critical role in diagnosing and treating HIV-related illness. More recently, EDs are emerging as front-line providers of key public health and prevention services, including HIV screening, the diagnosis of Acute HIV Infection (AHI), and the provision of non-occupational post-exposure prophylaxis (nPEP).
Patients with AHI frequently seek treatment in emergency departments. AHI is a flu-like illness, which often goes undiagnosed. The AIDS Institute recommends that ED clinicians maintain a high level of suspicion for AHI in patients presenting with HIV risk and a compatible clinical syndrome or a sexually transmitted infection (STI). When AHI is suspected, a plasma HIV RNA (viral load) assay should be used in conjunction with an HIV-antibody test to diagnose AHI. (See www.hivguidelines.org.)
Undiagnosed AHI may have significant public health consequences. Patients with AHI are likely to be highly infectious and may continue to engage in high risk behavior. For pregnant women, the consequences of undiagnosed AHI are extremely serious. A recent Department of Health study of residual mother-to-child HIV transmission (MTCT) found that undiagnosed AHI was responsible for 23% of statewide MTCT cases in 2002-2004. The transmission rate for mothers with undiagnosed AHI during pregnancy was 37% compared to 25% for untreated HIV infection in pregnancy. In many of these cases, the pregnant woman was unaware of her risk for HIV infection.
Persons who have been exposed to HIV through voluntary sexual activity, sexual assault, injection drug use, and human bites typically present in the emergency department. AIDS Institute guidelines (www.hivguidelines.org) recommend post-exposure prophylaxis in cases where the HIV risk is significant and the patient presents within 36 hours of exposure. To improve performance in providing nPEP, the AIDS Institute recommends that emergency departments: (1) assign nPEP responsibilities to staff trained in managing all types of HIV exposures, (2) develop mechanisms for tracking seroconversion and follow up on ED recommendations, (3) establish a system for providing a 30-day supply of medication, and (4) develop a protocol for providing prevention and risk-reduction counseling to patients presenting with exposure from voluntary sexual activity or injection drug use. For guidance on providing nPEP, contact the Clinical Education Initiative Line. See Section 7 for regional contact information.
Why provide HIV testing in hospital EDs?
Both the Centers for Disease Control and Prevention and the New York State Department of Health are recommending that HIV testing become a routine part of medical care in a variety of settings, including EDs. Rapid HIV testing in emergency settings has proven an effective means to increase the number of persons who are identified as HIV-positive and transitioned into appropriate care. The CDC estimates that approximately 25% of the 850,000 to 950,000 people living with HIV in the United States do not yet know they are infected. In fact, many already have weakened immune systems when they first test positive and are concurrently diagnosed with HIV and AIDS. There are several benefits to early knowledge of HIV infection. The first is early entry into treatment and access to highly effective antiretroviral treatments. In addition to these personal benefits, knowledge of one's infection can help prevent the spread of HIV to others.
What reimbursement is available for HIV testing in hospital EDs?
Effective November 1, 2006, the New York State Department of Health has extended Medicaid billing for two HIV testing visits - HIV Testing and HIV Counseling (Positive) - to EDs located in hospitals enrolled in the HIV Primary Care Medicaid program. The HIV Testing visit may only be billed when rapid tests are used. Same-day billing of one or both HIV testing visits with an ED visit is allowable provided that both HIV testing and emergency services are fully documented in the patient's medical record.
What issues should hospitals consider in establishing rapid HIV Testing in the ED?
Successful rapid HIV testing in the ED involves a team approach. Buy in and support from all levels of staff is critical along with solid support and direction from hospital and ED leadership and from the laboratory director. Getting started with HIV testing in the ER requires obtaining the necessary laboratory permits, conducting an assessment of the need for staff training, developing policies and procedures, delineating staff roles and responsibilities, and developing a plan for ongoing evaluation and quality improvement. Issues to be considered include how testing will be integrated into ED work flow, staff availability for conducting the test while the patient is receiving medical care, and space allocation for conducting the tests.
See Section 6, Tools and Resources, for information on implementing rapid HIV testing, including laboratory requirements and guidelines for staff training and quality assurance.
Which ED patients should receive a recommendation for HIV testing?
The New York State Department of Health encourages ED health care teams to recommend testing to adults and adolescent patients who present with non-critical conditions and have the capacity to consent to testing, particularly those who present with sexually transmitted infections (STIs). The ED rapid HIV Testing program should not supplant established HIV Testing programs at the hospital and should be used only for persons receiving other ED care. HIV antibody and viral load testing should be strongly recommended to persons presenting in the ED with symptoms suggestive of acute HIV infection.
What is the process for recommending HIV testing in the ED?
Emergency Departments should follow the New York State Department of Health’s 2005 Guidance for HIV Testing . ED staff may present the availability of rapid HIV testing during intake or initial triage. The staff member performing the streamlined counseling may give Part A of the Informed Consent for HIV Testing (the informational section) to the patient for review along with an explanation that the ED physician recommends testing for HIV to all adolescent and adult patients, regardless of risk factors. Individuals who have no questions should be asked to sign the signature page (Part B) of the form. Other ways to provide information on testing may include a verbal review of the form and/or the use of print and/or audiovisual materials in a waiting area. More extensive counseling should be provided upon patient request or upon assessment that this is required. Educational brochures can help patients understand the benefits of HIV testing. The rapid screening result will be available in 10 to 30 minutes (depending on the type of test used). No further testing is required when the HIV screening result is non reactive (negative).
What if the rapid HIV screening result is positive?
A reactive screening result is considered a preliminary (unconfirmed) HIV positive and must be confirmed through clinical laboratory testing. In these cases, two HIV Counseling (Positive) Visits are provided - the first to deliver the preliminary result and the second, at a later date, to deliver the results of confirmatory testing. See Section 1 for a comprehensive description of the HIV Counseling (Positive) Visit.
In order to ensure seamless entry into care, some facilities provide both HIV Counseling (Positive) visits in the HIV clinic. In this model, the ED staff member providing the rapid test escorts the patient to the HIV clinic and introduces him or her to a member of the HIV clinic team, who arranges for confirmatory testing and schedules the patient's return for confirmatory testing.
Some facilities emphasize continuity in counseling by providing both HIV Counseling (Positive) visits in the ER. In these cases, the ED staff member or counselor delivers the preliminary positive test result, provides counseling on the meaning of the test result, arranges for confirmatory testing, and schedules the return visit for the confirmatory test result. In this model, the ED staff member is responsible for ensuring that the patient is linked to care and services if the confirmatory test is positive.
What models are currently used for rapid HIV testing in the ED?
HIV testing in the ED requires flexible models that are designed to fit the patient flow in the ED. When deciding on a model of care, the ED should examine patient volume, community risk factors and other HIV testing resources in the hospital. The following is a summary of available models.
Low-volume settings may choose to integrate HIV testing into routine ED care. Discussion of HIV testing may be initiated by triage nurse with follow up during the nursing assessment in the general exam room. In the integrated model, health care providers deliver HIV testing results.
Counselor on Call Model
Some medium volume ED settings have implemented a team approach, which includes the use of "counselor on call" who serves as facility expert. The counselor on call is responsible for training other ED staff on rapid HIV testing, counseling patients who test positive, arranging for confirmatory testing, and ensuring that HIV-infected patients are engaged in care.
Dedicated Counseling Staff
In high volume EDs, dedicated HIV counselors are often used to initiate discussion of testing, answer detailed questions, conduct the tests, address the needs of those who receive positive test results, and provide prevention counseling to high-risk individuals whose test results are negative.
Are there training requirements for staff providing rapid testing in EDs?
Training for staff who provide rapid HIV testing visits is recommended rather than required. The Department of Health recommends that at least one staff member receive intensive HIV counselor training. Additional information on training is available on the Department of Health's website.
Current rapid HIV tests are classified as "waived" and therefore free from many of the requirements of the Clinical Laboratory Improvement Act (CLIA). A waived test must be conducted in compliance with the manufacturer's product insert instructions. There are no specific federal or state educational requirements concerning who can perform a waived test.
The hospital's clinical laboratory (if any) is responsible for the quality of rapid HIV testing in the ED and will conduct competency assessments of an ED staff member's ability to perform the test. Competency assessments are recommended at periodic intervals after initial training.
What billing rules apply to HIV testing in EDs?
The following is a summary of rules which apply to billing for HIV testing by EDs.
- EDs may bill the HIV Testing Visit only when rapid tests, which provide results in a single visit, are used. The costs of the rapid test kit and controls are included in the visit rate.
- Same-day billing is allowed for the HIV Testing Visit and an ED visit.
- The ED must provide HIV counseling and linkage to medical services, including confirmatory testing, when a patient's test result is a preliminary positive. In these cases, the hospital may bill an ED visit, an HIV Testing Visit, and an HIV Counseling (Positive) Visit on the same day.
- EDs may not bill the HIV Primary Care Medicaid Program visits for patients who are admitted for inpatient services.