The CDC and other agencies have emphasized that EDs should offer HIV screening because of their high patient volume and access to vulnerable populations, says Michael S. Lyons, MD, MPH. “The problem, however, is that EDs are already overburdened and many don’t have the dedicated resources they need to increase testing rates.” Efforts to increase ED HIV screening are growing, but controversy persists about who should be tested.

HIV screening has been advocated to detect as many cases as possible, but this requires many tests and brings concerns about feasibility and effectiveness. The alternative—selectively targeting screening only to those at higher risk—may increase the chances that a test will be positive and require fewer tests, but studies show that this approach often misses cases. Prior failures in targeting may have been due to incomplete implementation or overly narrow selection criteria.

Comparing Approaches

Dr. Lyons and colleagues conducted a study, published in JAIDS, comparing the efficacy of universal and targeted screening in the context of an opt-in ED HIV screening program. In the attempt to overcome concerns about the inadequacy of targeted screening, the authors tested and implemented an exceedingly comprehensive approach to targeting—for example, any possible indication of increased risk could trigger a test offer—and implemented the strategy fully.


The study assessed 9,572 visits during which patients were approached for either targeted or universal screening. For universal screening, 40.8% consented but just 0.3% were newly diagnosed with HIV. For targeted screening, 47.4% of patients who had HIV testing indications consented but just 0.2% were newly diagnosed with HIV. “Ultimately,” Dr. Lyons says, “using this targeted screening strategy was unlikely to be different from universal screening in any clinically significant way.”

Jury Still Out

Findings of the study add to what is known but do not resolve the debate over universal and targeted patient selection strategies, according to Dr. Lyons. “Studies are needed to discover whether there are methods that can optimize the trade-off between missed HIV cases and large numbers of tests when resources are insufficient. Recent studies suggest that the Denver HIV Risk Score may be a promising instrument to enhance targeting. We should explore this approach and others, and then compare them individually with universal screening.”

The study results suggest that non-targeted approaches may result in greater increases in testing than changes in consent strategy, according to Dr. Lyons. “However,” he says, “research to improve consent rates should remain a high priority. In particular, future studies should be mindful of how patient selection methods and consent strategies interact to determine who is ultimately tested.”


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Rothman RE, Lyons MS, Haukoos JS. Uncovering HIV infection in the emergency department: a broader perspective. Acad Emerg Med. 2007; 14:653–657.

Rothman RE, Lyons MS. HIV screening in emergency departments. Introduction. Ann Emerg Med. 2011;58(Suppl 1):S1.

Haukoos JS, Hopkins E, Conroy AA, et al. Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients. JAMA. 2010;304:284–292.