ORIGINAL ARTICLE
Practices, Beliefs, and Perceived Barriers to Adolescent Human Immunodeficiency Virus Screening in the Emergency Department Avani S. Mehta, MD,* Monika K. Goyal, MD, MSCE,† Nadia Dowshen, MD,‡ and Rakesh D. Mistry, MD, MS§ Objective: Limited data exist regarding knowledge of and compliance to the Centers for Disease Control and Prevention's universal adolescent human immunodeficiency virus (HIV) screening recommendations. Our objective was to assess current guideline knowledge, practice, and perceived barriers to emergency department (ED)–based adolescent HIV screening. Methods: We administered an anonymous Web-based cross-sectional survey from May 1, 2012, to June 30, 2012, to 1073 physicians from the American Academy of Pediatrics Section on Emergency Medicine LISTSERV. Survey participants were included if they (1) practiced as attending-level physicians, (2) practiced primarily in pediatric emergency medicine or general emergency medicine, and (3) provided clinical care for patients younger than the age of 21 years. The survey examined respondent demographics, knowledge, attitudes, beliefs, practices, and barriers to ED-based HIV screening. Standard descriptive statistics and comparative analyses were performed. Results: A total of 220 responses were obtained; 29 responses were excluded and 191 responses were included in the study. Most of the participants were from urban, free-standing children's hospitals and had an annual ED volume of more than 61,000 patient visits. Respondent knowledge of the Centers for Disease Control and Prevention guidelines was low; less than 40% of the respondents identified correct consent requirements. Only 15.4% of the respondents reported screening for HIV more than 10 times for the prior 6 months. Most frequently cited barriers included concerns for privacy (67.4%), follow-up (67%), and cost-effectiveness (65.4%). Human immunodeficiency virus screening facilitators included availability of health educators (83%), established follow-up (74.7%), and rapid HIV tests (65.2%). Conclusions: Emergency department clinicians exhibit poor knowledge of adolescent HIV screening recommendations. Current universal screening practices remain low; barriers to screening are numerous. Future efforts should disseminate guideline knowledge, increase rapid HIV testing and health educator availability, as well as reduce adolescent-specific barriers. Key Words: HIV, screening, adolescent health (Pediatr Emer Care 2015;31: 621–626)
D
espite advances in diagnosis, treatment, and prevention of human immunodeficiency virus (HIV), infection continues
From the *Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE; †Emergency Medicine and Trauma Services, Children's National Medical Center, Washington, DC; ‡Division of Adolescent Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA; and §Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO. Disclosure: The authors declare no conflict of interest. Reprints: Avani S. Mehta, MD, Division of Emergency Medicine, Nemours/ Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803 (e‐mail: [email protected]). This study was funded by the Children's Hospital of Philadelphia, Department of Pediatrics, Division of Emergency Medicine, Nicholas Crognale Chair for Emergency Medicine. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.pec-online.com). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
to occur among the pediatric population. Adolescents represent a particularly high-risk group for HIV infection, comprising approximately 26% of all new HIV infections each year.1 Early detection and treatment of HIV improve quality of life, increase life expectancy, decrease transmission of the virus,2–4 and facilitate earlier entry into medical care when diagnosed during a health care encounter.5 However, the challenge of detecting and treating HIV among adolescents is complicated by the prevalence of subclinical and undiagnosed HIV infection in this population. As of 2009, the Centers for Disease Control and Prevention (CDC) estimated that the highest percentage of undiagnosed infections is among persons aged 13 to 24 years, with almost 60% of them currently unaware of their HIV-positive status.6 Adolescents are less likely to seek routine medical care from their primary care providers, which also contributes to the high rate of undiagnosed disease in this population. Despite the episodic nature of encounters, the emergency department (ED) often serves as the lone site of medical care for many adolescents7 and is considered the preferred health care site for HIV screening by many youths.8 Recent recommendations from the CDC and the American Academy of Pediatrics (AAP) identify the ED as a strategic health care site for pediatric HIV screening. In 2006, the CDC recommended opt-out screening for HIV infection be routinely offered to all patients aged 13 to 64 years in all health care settings, including the ED.9 Similarly, the AAP suggests routine HIV screening for all adolescents at least once by the age of 16 to 18 years.10 Both the CDC and the AAP encourage active screening for adolescents, particularly those demonstrating high-risk behaviors and those seeking treatment for sexually transmitted infections.9,10 In April 2013, the United States Preventive Services Task Force (USPSTF) recommended clinicians to screen for HIV infection in adolescents and adults aged 15 to 65 years regardless of perceived HIV risk, or at younger and older ages if clinically indicated.11 Despite these numerous recommendations for routine screening, little is known about knowledge, attitudes, and practices for adolescent HIV screening in the ED. Consequently, the goal of this study was to assess knowledge of indications for HIV screening, current practice, attitudes, and perceived barriers to adolescent HIV screening among a national sample of physicians practicing in the ED.
METHODS Study Design, Setting, and Population We conducted a cross-sectional survey of the members of the AAP Section on Emergency Medicine (SoEM) LISTSERV. The SoEM includes AAP members with an interest in pediatric emergency medicine (PEM) and consists of predominantly PEM and general emergency medicine (EM) practitioners from a variety of hospital types and practice settings. Participation in the LISTSERV is voluntary, and the AAP SoEM members may “opt-out” at any time. During the study period, approximately 1073 of the 1150 members of the AAP SoEM were subscribed. The AAP
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SoEM LISTSERV is frequently used for administrative, educational, and research communications, including survey distributions. Distribution of this survey was approved and endorsed by the AAP SoEM Survey Subcommittee before administration. The study was granted exemption by the hospital's institutional review board. Inclusion criteria for participants included the following: (1) current attending-level physician, (2) primary practice in PEM or general EM, and (3) routine clinical care provided for patients aged younger than 21 years. The participants were excluded if they were not currently engaged in clinical EM practice, did not practice in the United States, or were physicians in training.
Survey Content and Development The survey questionnaire was initially designed by the investigative team, after comprehensive literature review of adult and pediatric studies of ED-based HIV testing and screening.12–16 After development, the survey was administered to 6 PEM experts for pilot testing and refinement. After pilot testing, the survey underwent content validation, using review by a multidisciplinary panel of HIV experts from adolescent medicine, general pediatrics, and infectious diseases. The members of the expert panel assessed content and relevance (or usefulness) of survey items, including question stems and responses. Items assessed as useful by at least 5 of the 6 panel members were retained in the final survey, and modifications to selected items were made on the basis of consensus expert recommendations. Construct validation was accomplished using a modified Delphi method: a panel of 5 PEM experts met with the investigators to review the clarity and completeness of each item as well as the overall survey length. A final iteration of the survey was developed, incorporating all input. Test-retest reliability and internal consistency were assessed using 2 separate survey administrations to the 5 PEM experts 1 week apart under identical conditions. The survey demonstrated excellent reliability, with a Cronbach α of 0.91 (95% confidence interval [CI], 0.84–0.95). Several domains of HIV screening were assessed: knowledge of the CDC guidelines and state laws pertaining to HIV screening; attitudes and beliefs regarding ED screening; current practice patterns; and barriers to ED-based HIV screening. The demographics of the respondents were collected, including practice setting, clinical training, and experience. The final survey questionnaire used for the study consisted of 56 items in the form of multiple-choice and Likert scale questions (Appendix, Supplemental Digital Content 1, http://links.lww.com/PEC/A88).
Survey Administration The survey was administered to the members of the AAP SoEM LISTSERV via e-mail, and the responses were collected via the online survey program SurveyMonkey.com (Portland, Ore; author⁄owner, R. Finley). Distribution occurred during a 2-month period from May 1, 2012, to June 30, 2012. Electronic reminders were sent through e-mail via the LISTSERV at 3 and 6 weeks after initial distribution. Consent for participation was implied via initiation and completion of the survey as stated at distribution. After completion, the participants were given an option to voluntarily e-mail the investigators for a $5 gift card for participation.
Data Analysis Participants who completed less than 90% of the survey were considered as voluntary withdrawals and were not included in the final analysis. Multiple-choice questions examining knowledge were dichotomized as either “correct” or “incorrect” knowledge
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on the basis of the established AAP and CDC guidelines. Likert scale questions had 5 potential answer choices, ranging from strongly disagree to strongly agree. In data analysis, the responses were dichotomized: items rated as “strongly disagree,” “disagree,” and “neutral” were classified as “disagree” and items rated as “agree” and “strongly agree” were classified as “agree.” Descriptive data were summarized using standard descriptive statistics: continuous variables were summarized using means and SDs, and categorical variables were summarized using frequencies and proportions. Comparative analyses were performed to evaluate factors associated with HIV screening, specifically knowledge, attitudes to screening, and resource availability. Comparisons of categorical variables of interest were accomplished using the χ2 test, and the magnitude of these associations was analyzed using odds ratios. Descriptive and comparative analyses were reported with 95% CIs, where appropriate. Interrater agreement between reported and actual state consent procedures was analyzed using the κ statistic and 95% CIs. A P value of less than 0.05 was considered statistically significant. All analyses were performed via the Statistical Package for the Social Sciences version 20.0 (IBM SPSS Inc, Chicago, Ill).
RESULTS Demographics The survey was distributed to the members of the AAP SoEM LISTSERV; the participants needed to be attending physicians practicing medicine in the United States and care for patients younger than the age of 21 years. A total of 220 responses were obtained. Of these, 29 respondents were excluded: 20 respondents were not attending physicians (1 resident, 19 fellows), 5 respondents did not practice medicine in the United States, 3 respondents did not practice clinically, and 1 respondent did not care for children younger than the age of 21 years. There were 191 eligible responses, which comprised the study population. Most of the respondents practiced in urban, free-standing children's hospitals (71.8%) and evaluated patients in high-volume EDs with more than 61,000 visits annually (45.8%). A true response rate could not be calculated because the actual denominator of the attending-level ED physicians who care for children and practice in the United States was not available via the AAP SoEM LISTSERV. When comparing the respondent demographics to the aggregate AAP SoEM demographics, irrespective of LISTSERV participation, our study population was nearly identical to that of the overall AAP SoEM membership (Table 1; AAP Section on Emergency Medicine membership database, available via Sue Tellez).
Knowledge of Recommendations and State Laws Regarding HIV Screening Overall, respondent knowledge of the CDC guidelines for HIV screening was poor (Table 2). Specifically, knowledge of the target populations for screening and frequency of HIV screening were answered correctly by less than half of the respondents. In addition, fewer than 40% of the respondents reported that they were aware of the correct CDC consent requirements for HIV screening; a separate consent form is not required for HIV screening as per the CDC guidelines. Many participants reported that they were aware of their individual state consent procedures (68.1%); however, when measured against the actual state legal requirements for consent,17 agreement between the respondents and the actual state recommendations was extremely poor (κ = −0.02; 95% CI, −0.19 to 0.16). Most of the respondents answered correctly regarding at which health care sites HIV screening should © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Barriers to Adolescent HIV Screening in the ED
TABLE 1. Demographics of the Survey Respondents Compared With the Overall AAP SoEM Characteristic
Overall AAP SoEM (n = 1143)
Male sex Region of practice Northwest Midwest South West Hospital type University based/affiliated Community hospital Hospital setting Urban Suburban Rural Years as a practicing physician in EM, mean (SD) PEM board certified/eligible
Survey Respondents (n = 191), n (%)
46.8%
83 (48.3)
28.0 22.3 31.9 17.9
54 (31.4) 40 (23.3) 59 (34.3) 19 (11.0)
80.7 19.3
150 (84.7) 27 (15.3)
86.3 11.8 1.9 12.1 ± 6.9 88.8
140 (79.5) 33 (18.8) 3 (1.7) 12.2 ± 7.96 154 (87.0)
take place. Confidence in knowledge of indications and procedures for testing was reported by only 44.4% of the respondents. Of note, respondent knowledge was not associated with academic (P = 0.53) or urban practice setting (P = 0.94).
screening. Fewer than 1 in 5 (19.8%) respondents stated that they would offer ED-based HIV screening to all adolescents regardless of chief complaint, even if a full complement of resources were available in their ED.
Attitudes and Beliefs About ED-Based HIV Screening
Resources and Current Practices for HIV Screening
Although the respondents reported agreement with recommendations to screen adolescents for HIV, attitudes toward screening procedures did not correspond. Most (73.5%) of the respondents agreed that adolescents are at high risk for contracting HIV, and most (84.4%) believed that ED screening helps increase access to HIV testing for adolescents. Despite these beliefs, only 44.2% of the ED physicians acknowledge HIV screening as their responsibility. Many (45.8%) believed that those with nonsexual health complaints are more likely to refuse HIV
Reported resources for HIV screening in the ED were limited among the survey respondents. Rapid HIV testing, an ED-based health educator, well-defined HIV screening protocols, and ability for nonphysicians to initiate ED-based HIV screening were available to the minority (Fig. 1). Of note, 15.2% of the respondents were not aware of which testing methods were available in their own ED. A small percentage (15.4%) of the respondents reported screening for HIV more than 10 times for the prior 6 months. Of the HIV tests obtained, 33.1% of the respondents reported that
TABLE 2. Knowledge Assessment of the CDC HIV Screening Recommendations (n = 191) Knowledge Item
n (% Response)
Age recommended for HIV Screening
Recommended practice site
Requirement of separate written consent
Recommended frequency of HIV screening
All > age 13 y* All > age 18 y Sexually active adolescents and adults None of the above Do not know PCP office STI testing clinics All health care settings* Do not know Yes No* Do not know At least every 3 mo At least annually* At least every 2 y Do not know
52 (28.3)* 7 (3.8) 70 (38.0) 10 (5.4) 45 (24.5) 7 (3.8) 1 (0.5) 138 (75.0)* 38 (20.7) 57 (31.3) 71 (39.0)* 54 (29.7) 39 (21.2) 79 (42.9)* 2 (1.1) 64 (34.8)
*Correct answer. PCP indicates primary care physician; STI, sexually transmitted infection.
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and time. Although most respondents agreed that pretest and posttest counseling significantly lengthened the time to screen, only 29.2% of the respondents felt that HIV screening in the ED was overall too time-consuming. In addition, a lack of confidence in the ability to identify HIV screening candidates was a barrier for 58.1% of the respondents. Facilitators to HIV screening were identified by the respondents. Most of the respondents reported that they would be more likely to offer HIV screening from the ED if established followup (74.7% of the respondents), point-of-care HIV tests (65.2%), and health educators (83%) were available.
DISCUSSION
FIGURE 1. Resource availability for ED-based HIV screening.
most of these tests were obtained for sexual assault concerns, rather than routine screening.
Attitudes Toward and Characteristics Associated With Universal Screening Specific factors were associated with reported increased screening practices as well as agreement with universal screening (Table 3). Frequent HIV screening practice (reported >10 HIV tests ordered in the past 6 months) was most strongly associated with the availability of nonphysicians to initiate HIV screening in the ED, availability of rapid HIV testing, and presence of a health educator. In addition, existence of well-defined ED protocols (P < 0.001) and possessing correct knowledge of CDC consent requirements (P = 0.001) were associated with reported frequent HIV screening. Frequent HIV screening was 10 times more likely for respondents reporting confidence in screening or correct knowledge of appropriate screening indications and procedures. Agreement with universal ED-based HIV screening was most strongly associated with correct knowledge of screening indications, procedures, populations, and locations (Table 3). Existence of well-defined protocols (P = 0.002) and knowledge of CDC consent requirements (P = 0.031) were also significantly associated with reported agreement with universal screening. Type of practice, US region of practice, or PEM board certification/ eligibility were not associated with reported agreement with universal screening.
Perceived Barriers and Facilitators The 5 most commonly cited barriers to ED-based HIV screening are presented in Table 4. The most frequently cited barriers included concerns of privacy, follow-up, cost-effectiveness,
The most recent recommendations published by the CDC, the AAP, and the USPSTF advocate for universal opt-out HIV screening for appropriate-aged patients in all health care settings, including the ED. The results of our study, which is among the first national examinations of adolescent HIV screening practices from the ED, suggest that ED-based adolescent HIV screening rates are suboptimal. We found that ED physician knowledge of CDC screening guidelines remains poor and that current reported practice of universal screening for adolescents is not concordant with the national recommendations. In addition, our results suggest that numerous adolescent-specific barriers exist to universal HIV testing. However, reported universal HIV screening in the prior 6 months was substantially improved with availability of resources (including rapid HIV testing), allowance for nonphysicians (specifically health educators) to initiate screening and the existence of well-defined screening protocols. Our findings indicate limited knowledge of the CDC guidelines among ED practitioners, which is consistent with previously published studies. In a single-center pediatric study from 2009, just 22% of respondents, consisting of ED physicians, nurses, and social workers, were even aware of the new guidelines.12 This degree of limited knowledge was present among our study population, where few EM physicians correctly identified appropriate age, screening frequency, and consent criteria. Although many respondents were aware that the ED is a recommended HIV-testing location and supports routine ED-based testing, knowledge and positive attitudes were not associated with increased screening rates—a discordance that has been demonstrated previously.14 Emergency department physicians reported that most of the HIV tests sent were for sexual assault concerns, rather than for routine screening purposes. Unfortunately, reported screening practices in our study mirror other studies at individual institutions, where pediatric screening rates were low, varying from 2% to 37%.12,14,18
TABLE 3. Factors Associated With Increased Screening and Agreement for Universal Screening Odds Ratio (95% CI) Factor
Frequent HIV Screening* Agreement With Universal HIV Screening
Rapid HIV test availability Health educator availability Non-MD allowed to initiate screening Confidence in knowledge for screening indications and procedures Correct knowledge of populations to screen Correct knowledge of screening locations
8.2 (2.7–24.9) 4.7 (1.9–11.6) 8.3 (3.2–21.1) 10.2 (3.3–31.0) 3.9 (1.7–9.1) 11.0 (1.4–83.6)
4.2 (1.8–9.6) 2.8 (1.3–6.2) 2.2 (1.0–4.6) 9.4 (3.6–24.1) 5.4 (2.5–11.9) 7.2 (1.6–31.2)
*Frequent HIV screening is defined as more than 10 tests ordered in the past 6 months. Non-MD indicates nonphysician.
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Barriers to Adolescent HIV Screening in the ED
TABLE 4. Most Commonly Cited Barriers Barriers to ED-Based Adolescent HIV Screening
Agreed/Strongly Agreed, %
Concern for discrete HIV screening Ensuring appropriate follow-up for HIV tests sent from ED Cost-effectiveness of universal ED-based HIV screening Increased time requirement due to pretest/posttest counseling Inability to identify which adolescents should be screened
Emergency department physicians report concern that adolescent HIV is a serious problem and that they can potentially play a role in capturing a population, which otherwise does not seek routine care. However, these same physicians feel that they are unable to identify which adolescents should be screened and often feel that HIV screening is not their responsibility. As found in our study, most practitioners stated that they would not offer ED-based screening, despite having a full complement of resources in their ED. In the current era of ED overcrowding, practitioners wish to focus on true “emergency care”19 and often cite concerns that HIV screening will require increased time and resource burden. Additional barriers to ED-based HIV screening identified in several studies, including ours, include concerns for patient confidentiality and feared loss of follow-up.13,14 Previously described concerns for insufficient resources12,16 were affirmed because we found that a minority of ED physicians had rapid HIV testing or health educators available to them. Our findings support several potential areas for intervention to improve adherence to ED-based HIV screening. Perhaps, most important is improving knowledge of indications and current guidelines for HIV screening among ED physicians. In fact, higher screening rates have been reported at programs where opt-out screening and focused education are established.12,18 As such, formalized education directed at trainees and current practitioners as well as quality improvement initiatives have a potential to make significant impact. Further, ED physicians should receive specific training to help improve comfort in conducting confidential sexual health discussions with adolescents presenting to the ED with their caregivers because this was the most frequently cited barrier to testing. Use of information technology, such as automatic prompts to consider HIV screening in the electronic health record, may also be a promising strategy to improve screening rates. Our study as well as prior investigations20 suggest that access to well-defined screening protocols may improve screening rates in the ED, but increased awareness of and access to this kind of guidance are needed.18,20 Initiation of ED-based HIV screening by nonphysicians was significantly associated with increased screening in our study. Although the use of social workers and nurses may assist screening, the availability of dedicated health educators can decrease the burden placed on emergency providers in the ED environment. Health educators are able to address posttest counseling, establish follow-up for post–ED visit care, and provide referrals to appropriate resources.21 Although the benefits of health educators are greatly appreciated in our own institution, access to such a resource may not be feasible in all health care settings because of costs. Our study found that the availability of rapid, point-of-care HIV testing also facilitated increased HIV screening. Similar to previously reported data,20 less than half of the ED physicians reported availability of rapid HIV testing and many reported concern for lack of follow-up; therefore, institution of rapid HIV testing represents another potential target for intervention to increase adherence to the national guidelines. Although concerns
67.4 67.0 65.4 64.2 58.1
of cost exist, rapid HIV testing is increasingly likely to be covered by insurance companies with the new USPSTF grade A recommendation and other provisions in the Affordable Care Act to support reimbursement of routine screening.22,23
Limitations There are limitations to our study. Our response rate was unable to be calculated, and therefore, the survey results may not represent the practice of all pediatric ED physicians. Data for nonresponders could not be identified through our survey mechanism. However, our study respondent characteristics are congruent to the overall AAP SoEM LISTSERV demographics, thus allowing greater confidence in the survey results. Selection bias is possible because those consenting to the survey may be more or less motivated to screen than the general population. Most respondents were university-based, academic physicians with training in PEM, which may affect the generalizability of our results. Recall bias may affect reported screening practice, and as is the case with surveys, responses may not reflect true practice.
CONCLUSIONS Timely diagnosis and treatment of adolescent HIV are a national public health priority. Although the ED often serves as the only source of health care for many adolescents, improved EDbased HIV screening is vital. Our study demonstrates that ED clinicians exhibit poor knowledge of HIV screening recommendations for adolescents and that reported screening rates remain low despite the well-established guidelines. This study also identified several potential barriers and facilitators in screening in the ED setting. Future studies should develop and test interventions to disseminate knowledge, increase availability of rapid HIV testing and health educators, as well as reduce adolescentspecific barriers by educating providers about how to conduct confidential sexual health discussions in the ED. ACKNOWLEDGMENTS The authors would like to thank Drs Jason Kim, Yesh Kulasekaran, Elizabeth Lowenthal, and Richard Rutstein as well as Ms Chris Ambrose for their content expertise; Drs Mercedes Blackstone, James Callahan, Joel Fein, Frances Nadel, Richard Scarfone, and Mark Zonfrillo for their assistance in refining the survey; and Ms Sue Tellez for her assistance in obtaining the AAP SoEM demographic data. REFERENCES 1. HIV incidence. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/hiv/statistics/surveillance/incidence/ index.html. Updated May 22, 2013. Accessed June 5, 2013. 2. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med. 2000;342:921–929.
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3. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39:446–453. 4. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20:1447–1450. 5. Grant AM, Jamieson DJ, Elam-Evans LD, et al. Reasons for testing and clinical and demographic profile of adolescents with non-perinatally acquired HIV infection. Pediatrics. 2006;117:e468–e475. 6. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 U.S. dependent areas—2010. HIV Surveillance Supplemental Report. 2012;17(no. 3, part A). Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/ hiv/pdf/statistics_2010_HIV_Surveillance_Report_vol_17_no_3.pdf. Published June 2012. Accessed May 31, 2013. 7. Wilson KM, Klein JD. Adolescents who use the emergency department as their usual source of care. Arch Pediatr Adolesc Med. 2000; 154:361–365. 8. Haines CJ, Uwazuoke K, Zussman B, et al. Pediatric emergency department-based rapid HIV testing: adolescent attitudes and preferences. Pediatr Emerg Care. 2011;27:13–16.
13. Fincher-Mergi M, Cartone KJ, et al. Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs. AIDS Patient Care STDS. 2002;16:549–553. 14. Arbelaez C, Wright EA, Losina E, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med. 2012;42:7–14. 15. Burke RC, Sepkowitz KA, Bernstein KT, et al. Why don't physicians test for HIV? A review of the US literature. AIDS. 2007;21:1617–1624. 16. Haukoos JS, Hopkins E, Hull A, et al. HIV testing in emergency departments in the United States: a national survey. Ann Emerg Med. 2011;58:S10–S16.e8. 17. Minors' access to STI services. State policies in brief, Guttmacher Institute Web site. Available at: http://www.guttmacher.org/statecenter/spibs/ spib_MASS.pdf. Accessed April 1, 2013. 18. Hack CM, Scarfi CA, Sivitz AB, et al. Implementing routine HIV screening in an urban pediatric emergency department. Pediatr Emerg Care. 2013;29:319–323. 19. Schnall R, Clark S, Olender S, et al. Providers' perceptions of the factors influencing the implementation of the New York state mandatory HIV testing law in two urban academic emergency departments. Acad Emerg Med. 2013;20:279–286.
9. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55:1–16.
20. Akhter S, Gorelick M, Beckmann K. Rapid human immunodeficiency virus testing in the pediatric emergency department. A national survey of attitudes among pediatric emergency practitioners. Pediatr Emerg Care. 2012;28:1257–1262.
10. American Academy of Pediatrics, Committee on Pediatric AIDS. Adolescents and HIV infection: the pediatrician's role in promoting routine testing. Pediatrics. 2011;128:1023–1029.
21. Mollen C, Lavelle J, Hawkins L, et al. Description of a novel pediatric emergency department-based HIV screening program for adolescents. AIDS Patient Care STDS. 2008;22:505–512.
11. U.S. Preventive Services Task Force. Screening for HIV: Final Recommendation Statement. AHRQ. Publication no. 12-05173-EF-3. Available at: http://www.uspreventiveservicestaskforce.org/uspstf13/hiv/ hivfinalrs.htm. Accessed June 12, 2013.
22. Healthcare.gov. What are my preventive benefits? Available at: https:// www.healthcare.gov/what-are-my-preventive-care-benefits/. Accessed August 27, 2013.
12. Minniear TD, Gilmore B, Arnold SR, et al. Implementation of and barriers to routine HIV screening for adolescents. Pediatrics. 2009;124:1076–1084.
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23. U.S. Preventive Services Task Force. USPSTFA and B Recommendations. Available at: http://www.uspreventiveservicestaskforce.org/uspstf/ uspsabrecs.htm. Accessed August 27, 2013.
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Practices, Beliefs, and Perceived Barriers to Adolescent Human Immunodeficiency Virus Screening in the Emergency Department Avani S. Mehta, MD,* Monika K. Goyal, MD, MSCE,† Nadia Dowshen, MD,‡ and Rakesh D. Mistry, MD, MS§ Objective: Limited data exist regarding knowledge of and compliance to the Centers for Disease Control and Prevention's universal adolescent human immunodeficiency virus (HIV) screening recommendations. Our objective was to assess current guideline knowledge, practice, and perceived barriers to emergency department (ED)–based adolescent HIV screening. Methods: We administered an anonymous Web-based cross-sectional survey from May 1, 2012, to June 30, 2012, to 1073 physicians from the American Academy of Pediatrics Section on Emergency Medicine LISTSERV. Survey participants were included if they (1) practiced as attending-level physicians, (2) practiced primarily in pediatric emergency medicine or general emergency medicine, and (3) provided clinical care for patients younger than the age of 21 years. The survey examined respondent demographics, knowledge, attitudes, beliefs, practices, and barriers to ED-based HIV screening. Standard descriptive statistics and comparative analyses were performed. Results: A total of 220 responses were obtained; 29 responses were excluded and 191 responses were included in the study. Most of the participants were from urban, free-standing children's hospitals and had an annual ED volume of more than 61,000 patient visits. Respondent knowledge of the Centers for Disease Control and Prevention guidelines was low; less than 40% of the respondents identified correct consent requirements. Only 15.4% of the respondents reported screening for HIV more than 10 times for the prior 6 months. Most frequently cited barriers included concerns for privacy (67.4%), follow-up (67%), and cost-effectiveness (65.4%). Human immunodeficiency virus screening facilitators included availability of health educators (83%), established follow-up (74.7%), and rapid HIV tests (65.2%). Conclusions: Emergency department clinicians exhibit poor knowledge of adolescent HIV screening recommendations. Current universal screening practices remain low; barriers to screening are numerous. Future efforts should disseminate guideline knowledge, increase rapid HIV testing and health educator availability, as well as reduce adolescent-specific barriers. Key Words: HIV, screening, adolescent health (Pediatr Emer Care 2015;31: 621–626)
D
espite advances in diagnosis, treatment, and prevention of human immunodeficiency virus (HIV), infection continues
From the *Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE; †Emergency Medicine and Trauma Services, Children's National Medical Center, Washington, DC; ‡Division of Adolescent Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA; and §Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO. Disclosure: The authors declare no conflict of interest. Reprints: Avani S. Mehta, MD, Division of Emergency Medicine, Nemours/ Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803 (e‐mail: [email protected]). This study was funded by the Children's Hospital of Philadelphia, Department of Pediatrics, Division of Emergency Medicine, Nicholas Crognale Chair for Emergency Medicine. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.pec-online.com). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
to occur among the pediatric population. Adolescents represent a particularly high-risk group for HIV infection, comprising approximately 26% of all new HIV infections each year.1 Early detection and treatment of HIV improve quality of life, increase life expectancy, decrease transmission of the virus,2–4 and facilitate earlier entry into medical care when diagnosed during a health care encounter.5 However, the challenge of detecting and treating HIV among adolescents is complicated by the prevalence of subclinical and undiagnosed HIV infection in this population. As of 2009, the Centers for Disease Control and Prevention (CDC) estimated that the highest percentage of undiagnosed infections is among persons aged 13 to 24 years, with almost 60% of them currently unaware of their HIV-positive status.6 Adolescents are less likely to seek routine medical care from their primary care providers, which also contributes to the high rate of undiagnosed disease in this population. Despite the episodic nature of encounters, the emergency department (ED) often serves as the lone site of medical care for many adolescents7 and is considered the preferred health care site for HIV screening by many youths.8 Recent recommendations from the CDC and the American Academy of Pediatrics (AAP) identify the ED as a strategic health care site for pediatric HIV screening. In 2006, the CDC recommended opt-out screening for HIV infection be routinely offered to all patients aged 13 to 64 years in all health care settings, including the ED.9 Similarly, the AAP suggests routine HIV screening for all adolescents at least once by the age of 16 to 18 years.10 Both the CDC and the AAP encourage active screening for adolescents, particularly those demonstrating high-risk behaviors and those seeking treatment for sexually transmitted infections.9,10 In April 2013, the United States Preventive Services Task Force (USPSTF) recommended clinicians to screen for HIV infection in adolescents and adults aged 15 to 65 years regardless of perceived HIV risk, or at younger and older ages if clinically indicated.11 Despite these numerous recommendations for routine screening, little is known about knowledge, attitudes, and practices for adolescent HIV screening in the ED. Consequently, the goal of this study was to assess knowledge of indications for HIV screening, current practice, attitudes, and perceived barriers to adolescent HIV screening among a national sample of physicians practicing in the ED.
METHODS Study Design, Setting, and Population We conducted a cross-sectional survey of the members of the AAP Section on Emergency Medicine (SoEM) LISTSERV. The SoEM includes AAP members with an interest in pediatric emergency medicine (PEM) and consists of predominantly PEM and general emergency medicine (EM) practitioners from a variety of hospital types and practice settings. Participation in the LISTSERV is voluntary, and the AAP SoEM members may “opt-out” at any time. During the study period, approximately 1073 of the 1150 members of the AAP SoEM were subscribed. The AAP
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SoEM LISTSERV is frequently used for administrative, educational, and research communications, including survey distributions. Distribution of this survey was approved and endorsed by the AAP SoEM Survey Subcommittee before administration. The study was granted exemption by the hospital's institutional review board. Inclusion criteria for participants included the following: (1) current attending-level physician, (2) primary practice in PEM or general EM, and (3) routine clinical care provided for patients aged younger than 21 years. The participants were excluded if they were not currently engaged in clinical EM practice, did not practice in the United States, or were physicians in training.
Survey Content and Development The survey questionnaire was initially designed by the investigative team, after comprehensive literature review of adult and pediatric studies of ED-based HIV testing and screening.12–16 After development, the survey was administered to 6 PEM experts for pilot testing and refinement. After pilot testing, the survey underwent content validation, using review by a multidisciplinary panel of HIV experts from adolescent medicine, general pediatrics, and infectious diseases. The members of the expert panel assessed content and relevance (or usefulness) of survey items, including question stems and responses. Items assessed as useful by at least 5 of the 6 panel members were retained in the final survey, and modifications to selected items were made on the basis of consensus expert recommendations. Construct validation was accomplished using a modified Delphi method: a panel of 5 PEM experts met with the investigators to review the clarity and completeness of each item as well as the overall survey length. A final iteration of the survey was developed, incorporating all input. Test-retest reliability and internal consistency were assessed using 2 separate survey administrations to the 5 PEM experts 1 week apart under identical conditions. The survey demonstrated excellent reliability, with a Cronbach α of 0.91 (95% confidence interval [CI], 0.84–0.95). Several domains of HIV screening were assessed: knowledge of the CDC guidelines and state laws pertaining to HIV screening; attitudes and beliefs regarding ED screening; current practice patterns; and barriers to ED-based HIV screening. The demographics of the respondents were collected, including practice setting, clinical training, and experience. The final survey questionnaire used for the study consisted of 56 items in the form of multiple-choice and Likert scale questions (Appendix, Supplemental Digital Content 1, http://links.lww.com/PEC/A88).
Survey Administration The survey was administered to the members of the AAP SoEM LISTSERV via e-mail, and the responses were collected via the online survey program SurveyMonkey.com (Portland, Ore; author⁄owner, R. Finley). Distribution occurred during a 2-month period from May 1, 2012, to June 30, 2012. Electronic reminders were sent through e-mail via the LISTSERV at 3 and 6 weeks after initial distribution. Consent for participation was implied via initiation and completion of the survey as stated at distribution. After completion, the participants were given an option to voluntarily e-mail the investigators for a $5 gift card for participation.
Data Analysis Participants who completed less than 90% of the survey were considered as voluntary withdrawals and were not included in the final analysis. Multiple-choice questions examining knowledge were dichotomized as either “correct” or “incorrect” knowledge
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on the basis of the established AAP and CDC guidelines. Likert scale questions had 5 potential answer choices, ranging from strongly disagree to strongly agree. In data analysis, the responses were dichotomized: items rated as “strongly disagree,” “disagree,” and “neutral” were classified as “disagree” and items rated as “agree” and “strongly agree” were classified as “agree.” Descriptive data were summarized using standard descriptive statistics: continuous variables were summarized using means and SDs, and categorical variables were summarized using frequencies and proportions. Comparative analyses were performed to evaluate factors associated with HIV screening, specifically knowledge, attitudes to screening, and resource availability. Comparisons of categorical variables of interest were accomplished using the χ2 test, and the magnitude of these associations was analyzed using odds ratios. Descriptive and comparative analyses were reported with 95% CIs, where appropriate. Interrater agreement between reported and actual state consent procedures was analyzed using the κ statistic and 95% CIs. A P value of less than 0.05 was considered statistically significant. All analyses were performed via the Statistical Package for the Social Sciences version 20.0 (IBM SPSS Inc, Chicago, Ill).
RESULTS Demographics The survey was distributed to the members of the AAP SoEM LISTSERV; the participants needed to be attending physicians practicing medicine in the United States and care for patients younger than the age of 21 years. A total of 220 responses were obtained. Of these, 29 respondents were excluded: 20 respondents were not attending physicians (1 resident, 19 fellows), 5 respondents did not practice medicine in the United States, 3 respondents did not practice clinically, and 1 respondent did not care for children younger than the age of 21 years. There were 191 eligible responses, which comprised the study population. Most of the respondents practiced in urban, free-standing children's hospitals (71.8%) and evaluated patients in high-volume EDs with more than 61,000 visits annually (45.8%). A true response rate could not be calculated because the actual denominator of the attending-level ED physicians who care for children and practice in the United States was not available via the AAP SoEM LISTSERV. When comparing the respondent demographics to the aggregate AAP SoEM demographics, irrespective of LISTSERV participation, our study population was nearly identical to that of the overall AAP SoEM membership (Table 1; AAP Section on Emergency Medicine membership database, available via Sue Tellez).
Knowledge of Recommendations and State Laws Regarding HIV Screening Overall, respondent knowledge of the CDC guidelines for HIV screening was poor (Table 2). Specifically, knowledge of the target populations for screening and frequency of HIV screening were answered correctly by less than half of the respondents. In addition, fewer than 40% of the respondents reported that they were aware of the correct CDC consent requirements for HIV screening; a separate consent form is not required for HIV screening as per the CDC guidelines. Many participants reported that they were aware of their individual state consent procedures (68.1%); however, when measured against the actual state legal requirements for consent,17 agreement between the respondents and the actual state recommendations was extremely poor (κ = −0.02; 95% CI, −0.19 to 0.16). Most of the respondents answered correctly regarding at which health care sites HIV screening should © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Barriers to Adolescent HIV Screening in the ED
TABLE 1. Demographics of the Survey Respondents Compared With the Overall AAP SoEM Characteristic
Overall AAP SoEM (n = 1143)
Male sex Region of practice Northwest Midwest South West Hospital type University based/affiliated Community hospital Hospital setting Urban Suburban Rural Years as a practicing physician in EM, mean (SD) PEM board certified/eligible
Survey Respondents (n = 191), n (%)
46.8%
83 (48.3)
28.0 22.3 31.9 17.9
54 (31.4) 40 (23.3) 59 (34.3) 19 (11.0)
80.7 19.3
150 (84.7) 27 (15.3)
86.3 11.8 1.9 12.1 ± 6.9 88.8
140 (79.5) 33 (18.8) 3 (1.7) 12.2 ± 7.96 154 (87.0)
take place. Confidence in knowledge of indications and procedures for testing was reported by only 44.4% of the respondents. Of note, respondent knowledge was not associated with academic (P = 0.53) or urban practice setting (P = 0.94).
screening. Fewer than 1 in 5 (19.8%) respondents stated that they would offer ED-based HIV screening to all adolescents regardless of chief complaint, even if a full complement of resources were available in their ED.
Attitudes and Beliefs About ED-Based HIV Screening
Resources and Current Practices for HIV Screening
Although the respondents reported agreement with recommendations to screen adolescents for HIV, attitudes toward screening procedures did not correspond. Most (73.5%) of the respondents agreed that adolescents are at high risk for contracting HIV, and most (84.4%) believed that ED screening helps increase access to HIV testing for adolescents. Despite these beliefs, only 44.2% of the ED physicians acknowledge HIV screening as their responsibility. Many (45.8%) believed that those with nonsexual health complaints are more likely to refuse HIV
Reported resources for HIV screening in the ED were limited among the survey respondents. Rapid HIV testing, an ED-based health educator, well-defined HIV screening protocols, and ability for nonphysicians to initiate ED-based HIV screening were available to the minority (Fig. 1). Of note, 15.2% of the respondents were not aware of which testing methods were available in their own ED. A small percentage (15.4%) of the respondents reported screening for HIV more than 10 times for the prior 6 months. Of the HIV tests obtained, 33.1% of the respondents reported that
TABLE 2. Knowledge Assessment of the CDC HIV Screening Recommendations (n = 191) Knowledge Item
n (% Response)
Age recommended for HIV Screening
Recommended practice site
Requirement of separate written consent
Recommended frequency of HIV screening
All > age 13 y* All > age 18 y Sexually active adolescents and adults None of the above Do not know PCP office STI testing clinics All health care settings* Do not know Yes No* Do not know At least every 3 mo At least annually* At least every 2 y Do not know
52 (28.3)* 7 (3.8) 70 (38.0) 10 (5.4) 45 (24.5) 7 (3.8) 1 (0.5) 138 (75.0)* 38 (20.7) 57 (31.3) 71 (39.0)* 54 (29.7) 39 (21.2) 79 (42.9)* 2 (1.1) 64 (34.8)
*Correct answer. PCP indicates primary care physician; STI, sexually transmitted infection.
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and time. Although most respondents agreed that pretest and posttest counseling significantly lengthened the time to screen, only 29.2% of the respondents felt that HIV screening in the ED was overall too time-consuming. In addition, a lack of confidence in the ability to identify HIV screening candidates was a barrier for 58.1% of the respondents. Facilitators to HIV screening were identified by the respondents. Most of the respondents reported that they would be more likely to offer HIV screening from the ED if established followup (74.7% of the respondents), point-of-care HIV tests (65.2%), and health educators (83%) were available.
DISCUSSION
FIGURE 1. Resource availability for ED-based HIV screening.
most of these tests were obtained for sexual assault concerns, rather than routine screening.
Attitudes Toward and Characteristics Associated With Universal Screening Specific factors were associated with reported increased screening practices as well as agreement with universal screening (Table 3). Frequent HIV screening practice (reported >10 HIV tests ordered in the past 6 months) was most strongly associated with the availability of nonphysicians to initiate HIV screening in the ED, availability of rapid HIV testing, and presence of a health educator. In addition, existence of well-defined ED protocols (P < 0.001) and possessing correct knowledge of CDC consent requirements (P = 0.001) were associated with reported frequent HIV screening. Frequent HIV screening was 10 times more likely for respondents reporting confidence in screening or correct knowledge of appropriate screening indications and procedures. Agreement with universal ED-based HIV screening was most strongly associated with correct knowledge of screening indications, procedures, populations, and locations (Table 3). Existence of well-defined protocols (P = 0.002) and knowledge of CDC consent requirements (P = 0.031) were also significantly associated with reported agreement with universal screening. Type of practice, US region of practice, or PEM board certification/ eligibility were not associated with reported agreement with universal screening.
Perceived Barriers and Facilitators The 5 most commonly cited barriers to ED-based HIV screening are presented in Table 4. The most frequently cited barriers included concerns of privacy, follow-up, cost-effectiveness,
The most recent recommendations published by the CDC, the AAP, and the USPSTF advocate for universal opt-out HIV screening for appropriate-aged patients in all health care settings, including the ED. The results of our study, which is among the first national examinations of adolescent HIV screening practices from the ED, suggest that ED-based adolescent HIV screening rates are suboptimal. We found that ED physician knowledge of CDC screening guidelines remains poor and that current reported practice of universal screening for adolescents is not concordant with the national recommendations. In addition, our results suggest that numerous adolescent-specific barriers exist to universal HIV testing. However, reported universal HIV screening in the prior 6 months was substantially improved with availability of resources (including rapid HIV testing), allowance for nonphysicians (specifically health educators) to initiate screening and the existence of well-defined screening protocols. Our findings indicate limited knowledge of the CDC guidelines among ED practitioners, which is consistent with previously published studies. In a single-center pediatric study from 2009, just 22% of respondents, consisting of ED physicians, nurses, and social workers, were even aware of the new guidelines.12 This degree of limited knowledge was present among our study population, where few EM physicians correctly identified appropriate age, screening frequency, and consent criteria. Although many respondents were aware that the ED is a recommended HIV-testing location and supports routine ED-based testing, knowledge and positive attitudes were not associated with increased screening rates—a discordance that has been demonstrated previously.14 Emergency department physicians reported that most of the HIV tests sent were for sexual assault concerns, rather than for routine screening purposes. Unfortunately, reported screening practices in our study mirror other studies at individual institutions, where pediatric screening rates were low, varying from 2% to 37%.12,14,18
TABLE 3. Factors Associated With Increased Screening and Agreement for Universal Screening Odds Ratio (95% CI) Factor
Frequent HIV Screening* Agreement With Universal HIV Screening
Rapid HIV test availability Health educator availability Non-MD allowed to initiate screening Confidence in knowledge for screening indications and procedures Correct knowledge of populations to screen Correct knowledge of screening locations
8.2 (2.7–24.9) 4.7 (1.9–11.6) 8.3 (3.2–21.1) 10.2 (3.3–31.0) 3.9 (1.7–9.1) 11.0 (1.4–83.6)
4.2 (1.8–9.6) 2.8 (1.3–6.2) 2.2 (1.0–4.6) 9.4 (3.6–24.1) 5.4 (2.5–11.9) 7.2 (1.6–31.2)
*Frequent HIV screening is defined as more than 10 tests ordered in the past 6 months. Non-MD indicates nonphysician.
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Barriers to Adolescent HIV Screening in the ED
TABLE 4. Most Commonly Cited Barriers Barriers to ED-Based Adolescent HIV Screening
Agreed/Strongly Agreed, %
Concern for discrete HIV screening Ensuring appropriate follow-up for HIV tests sent from ED Cost-effectiveness of universal ED-based HIV screening Increased time requirement due to pretest/posttest counseling Inability to identify which adolescents should be screened
Emergency department physicians report concern that adolescent HIV is a serious problem and that they can potentially play a role in capturing a population, which otherwise does not seek routine care. However, these same physicians feel that they are unable to identify which adolescents should be screened and often feel that HIV screening is not their responsibility. As found in our study, most practitioners stated that they would not offer ED-based screening, despite having a full complement of resources in their ED. In the current era of ED overcrowding, practitioners wish to focus on true “emergency care”19 and often cite concerns that HIV screening will require increased time and resource burden. Additional barriers to ED-based HIV screening identified in several studies, including ours, include concerns for patient confidentiality and feared loss of follow-up.13,14 Previously described concerns for insufficient resources12,16 were affirmed because we found that a minority of ED physicians had rapid HIV testing or health educators available to them. Our findings support several potential areas for intervention to improve adherence to ED-based HIV screening. Perhaps, most important is improving knowledge of indications and current guidelines for HIV screening among ED physicians. In fact, higher screening rates have been reported at programs where opt-out screening and focused education are established.12,18 As such, formalized education directed at trainees and current practitioners as well as quality improvement initiatives have a potential to make significant impact. Further, ED physicians should receive specific training to help improve comfort in conducting confidential sexual health discussions with adolescents presenting to the ED with their caregivers because this was the most frequently cited barrier to testing. Use of information technology, such as automatic prompts to consider HIV screening in the electronic health record, may also be a promising strategy to improve screening rates. Our study as well as prior investigations20 suggest that access to well-defined screening protocols may improve screening rates in the ED, but increased awareness of and access to this kind of guidance are needed.18,20 Initiation of ED-based HIV screening by nonphysicians was significantly associated with increased screening in our study. Although the use of social workers and nurses may assist screening, the availability of dedicated health educators can decrease the burden placed on emergency providers in the ED environment. Health educators are able to address posttest counseling, establish follow-up for post–ED visit care, and provide referrals to appropriate resources.21 Although the benefits of health educators are greatly appreciated in our own institution, access to such a resource may not be feasible in all health care settings because of costs. Our study found that the availability of rapid, point-of-care HIV testing also facilitated increased HIV screening. Similar to previously reported data,20 less than half of the ED physicians reported availability of rapid HIV testing and many reported concern for lack of follow-up; therefore, institution of rapid HIV testing represents another potential target for intervention to increase adherence to the national guidelines. Although concerns
67.4 67.0 65.4 64.2 58.1
of cost exist, rapid HIV testing is increasingly likely to be covered by insurance companies with the new USPSTF grade A recommendation and other provisions in the Affordable Care Act to support reimbursement of routine screening.22,23
Limitations There are limitations to our study. Our response rate was unable to be calculated, and therefore, the survey results may not represent the practice of all pediatric ED physicians. Data for nonresponders could not be identified through our survey mechanism. However, our study respondent characteristics are congruent to the overall AAP SoEM LISTSERV demographics, thus allowing greater confidence in the survey results. Selection bias is possible because those consenting to the survey may be more or less motivated to screen than the general population. Most respondents were university-based, academic physicians with training in PEM, which may affect the generalizability of our results. Recall bias may affect reported screening practice, and as is the case with surveys, responses may not reflect true practice.
CONCLUSIONS Timely diagnosis and treatment of adolescent HIV are a national public health priority. Although the ED often serves as the only source of health care for many adolescents, improved EDbased HIV screening is vital. Our study demonstrates that ED clinicians exhibit poor knowledge of HIV screening recommendations for adolescents and that reported screening rates remain low despite the well-established guidelines. This study also identified several potential barriers and facilitators in screening in the ED setting. Future studies should develop and test interventions to disseminate knowledge, increase availability of rapid HIV testing and health educators, as well as reduce adolescentspecific barriers by educating providers about how to conduct confidential sexual health discussions in the ED. ACKNOWLEDGMENTS The authors would like to thank Drs Jason Kim, Yesh Kulasekaran, Elizabeth Lowenthal, and Richard Rutstein as well as Ms Chris Ambrose for their content expertise; Drs Mercedes Blackstone, James Callahan, Joel Fein, Frances Nadel, Richard Scarfone, and Mark Zonfrillo for their assistance in refining the survey; and Ms Sue Tellez for her assistance in obtaining the AAP SoEM demographic data. REFERENCES 1. HIV incidence. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/hiv/statistics/surveillance/incidence/ index.html. Updated May 22, 2013. Accessed June 5, 2013. 2. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med. 2000;342:921–929.
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3. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39:446–453. 4. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20:1447–1450. 5. Grant AM, Jamieson DJ, Elam-Evans LD, et al. Reasons for testing and clinical and demographic profile of adolescents with non-perinatally acquired HIV infection. Pediatrics. 2006;117:e468–e475. 6. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 U.S. dependent areas—2010. HIV Surveillance Supplemental Report. 2012;17(no. 3, part A). Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/ hiv/pdf/statistics_2010_HIV_Surveillance_Report_vol_17_no_3.pdf. Published June 2012. Accessed May 31, 2013. 7. Wilson KM, Klein JD. Adolescents who use the emergency department as their usual source of care. Arch Pediatr Adolesc Med. 2000; 154:361–365. 8. Haines CJ, Uwazuoke K, Zussman B, et al. Pediatric emergency department-based rapid HIV testing: adolescent attitudes and preferences. Pediatr Emerg Care. 2011;27:13–16.
13. Fincher-Mergi M, Cartone KJ, et al. Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs. AIDS Patient Care STDS. 2002;16:549–553. 14. Arbelaez C, Wright EA, Losina E, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med. 2012;42:7–14. 15. Burke RC, Sepkowitz KA, Bernstein KT, et al. Why don't physicians test for HIV? A review of the US literature. AIDS. 2007;21:1617–1624. 16. Haukoos JS, Hopkins E, Hull A, et al. HIV testing in emergency departments in the United States: a national survey. Ann Emerg Med. 2011;58:S10–S16.e8. 17. Minors' access to STI services. State policies in brief, Guttmacher Institute Web site. Available at: http://www.guttmacher.org/statecenter/spibs/ spib_MASS.pdf. Accessed April 1, 2013. 18. Hack CM, Scarfi CA, Sivitz AB, et al. Implementing routine HIV screening in an urban pediatric emergency department. Pediatr Emerg Care. 2013;29:319–323. 19. Schnall R, Clark S, Olender S, et al. Providers' perceptions of the factors influencing the implementation of the New York state mandatory HIV testing law in two urban academic emergency departments. Acad Emerg Med. 2013;20:279–286.
9. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55:1–16.
20. Akhter S, Gorelick M, Beckmann K. Rapid human immunodeficiency virus testing in the pediatric emergency department. A national survey of attitudes among pediatric emergency practitioners. Pediatr Emerg Care. 2012;28:1257–1262.
10. American Academy of Pediatrics, Committee on Pediatric AIDS. Adolescents and HIV infection: the pediatrician's role in promoting routine testing. Pediatrics. 2011;128:1023–1029.
21. Mollen C, Lavelle J, Hawkins L, et al. Description of a novel pediatric emergency department-based HIV screening program for adolescents. AIDS Patient Care STDS. 2008;22:505–512.
11. U.S. Preventive Services Task Force. Screening for HIV: Final Recommendation Statement. AHRQ. Publication no. 12-05173-EF-3. Available at: http://www.uspreventiveservicestaskforce.org/uspstf13/hiv/ hivfinalrs.htm. Accessed June 12, 2013.
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