Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2016 4 16() doi 10.1111/acem.12987
An increasing number of U.S. emergency departments (EDs) have implemented ED-based HIV testing programs since the Centers for Disease Control and Prevention issued revised HIV testing recommendations for clinical settings in 2006. In 2010, the National HIV/AIDS Strategy (NHAS) set an LTC rate goal of 85% within 90 days of HIV diagnosis. Linkage to care (LTC) rates for newly diagnosed HIV-infected patients vary markedly by site, and many are suboptimal. The optimal approach for LTC in the ED setting remains unknown.
To perform a brief descriptive analysis of the LTC methods practiced in EDs across the United States in order to determine the overall linkage rate of ED-based HIV testing programs.
We conducted a systematic review of literature related to U.S. ED HIV testing in the adult population using PubMed, Embase, Web of Science, Scopus and Cochrane. There were 333 articles were identified; 31 articles were selected after a multiphasic screening process. We analyzed data from the 31 articles to assess LTC methods and rates. LTC methods that involved physical escort of the newly diagnosed patient to an HIV/infectious disease (ID) clinic or interaction with a specialist health care provider at the ED were operationally defined as ‘intensive" LTC protocol. "Mixed" LTC protocol was defined as a program that employed intensive linkage only part of the coverage hours. All other forms of linkage was defined as "non-intensive" LTC protocol. An LTC rate of ≥85% was used to identify characteristics of ED-based HIV testing program associated with a higher LTC rate.
There were 37 ED-based HIV testing programs in the 31 articles. The overall LTC rate was 74.4%. Regarding type of protocol, 9 (24.3%) employed intensive LTC protocols, 25 (67.6%) non-intensive, 2 (5.4%) mixed, and 1 (2.7%) had unclear protocols. LTC rates for programs with intensive and non-intensive LTC protocols were 80.0% and 72.7%, respectively. Four (44.4%) with intensive protocols and nine (36.0%) with the non-intensive protocols had LTC rates >85%. The linkage staff employed was different between ED programs. Among them, 25 (67.6%) programs used exogenous staff, ten (27.0%) used the ED staff, and 2 had no information. All the programs in the non-intensive group utilized drop-in HIV/ID clinic or medical appointments while seven out of nine of the programs in the intensive group physically escorted the patients to the initial medical intake appointment. There were no significant differences in characteristics of ED-based HIV testing programs between those with ≥85% LTC rate versus those with <85% within the intensive or non-intensive group. CONCLUSION
Intensive LTC protocols had a higher LTC rate and a higher proportion of programs that surpassed the >85% NHAS goal as compared to non-intensive methods, suggesting that, when possible, ED-based HIV testing programs should adopt intensive LTC strategies to improve LTC outcomes. However, intensive LTC protocols most often required involvement of multidisciplinary non-ED professionals and external research funding. Our findings provide a foundation for developing best practices for ED-based HIV LTC programs. This article is protected by copyright. All rights reserved.