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One Way to Curb an Epidemic
In the emergency department, routine HIV testing has long been part of the picture
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In the ED, Heather Hairston administers a routine HIV test.

In September 2006, the Centers for Disease Control and Prevention issued new guidelines recommending testing for HIV for all patients ages 13 to 64 during routine physical exams or hospital visits. Previously, federal guidelines had recommended testing only those at risk.

To be sure, the guidelines represented a major shift in policy, but in The Johns Hopkins Hospital’s emergency department, they seemed more like business as usual. That’s because the ED has been offering free, rapid HIV testing to everyone who wants it since early 2006, and it was the first in the nation to do so.

Research coordinator Heather Hairston, along with ED staff, handles HIV testing and referral services. Offering the test to every admission, she explains what’s involved and obtains written informed consent from those who express an interest. “Most are very aware of HIV and AIDS and are eager to be tested,” Hairston says, noting that even those who don’t consent receive materials about HIV. The test is done with an oral swab; results are made available to the health care team within an hour.

 If the result indicates the presence of HIV, a follow-up test is ordered to confirm the finding. Those who test positive are referred for treatment and counseling to the Moore Clinic, an outpatient clinic for people with HIV/AIDS. According to Hairston, up to 4 percent of those tested for the virus in the Hopkins ED have a positive result. Those patients, she adds, likely would not have learned they had a problem until much later.

HIV testing in the ED has its roots in the early years of the AIDS epidemic when, in 1985, Gabor Kelen, then a young assistant professor of emergency medicine, started conducting large research studies involving patients in the ED. The work was labor-intensive and slow, as was the HIV test itself, but his findings, published in 1987, showed the extent of HIV in ED settings.

Today, Kelen is chairman of emergency medicine, but his premise still holds true: Every day, the Emergency Department draws large numbers of patients from Baltimore City, where 50 percent of Maryland’s HIV cases originate. “The ED is the perfect venue for helping us understand epidemics and reach thousands who might otherwise never be tested,” says Kelen.

In 1996, Rich Rothman, an M.D./ Ph.D. who was working on developing novel diagnostic tests to identify people with various infectious diseases, joined Kelen to strengthen the HIV testing program and oversee the department’s research efforts. Last year, Rothman and his expanded team of emergency medicine faculty won the only state grant that provides funds to coordinate ED-based testing efforts.

Some 1 million to 1.2 million people in the United States living with HIV are unaware of their status. Universal testing could give thousands vital information that could save their lives and the lives of those they might infect, Rothman points out. “Now that testing is more acceptable and available, I think we need to make it a part of our responsibility.”

But obstacles remain, says Rothman, beginning with cumbersome paperwork. When Hairston isn’t available to explain the test and obtain consent, the job falls on physicians. “It seems ridiculously simple,” says Rothman, “but for busy ED physicians, it just can’t be as high a priority as stabilizing sick patients.”

The CDC proposal urges removing separate, signed consent forms, but some states, including Maryland, require them. Rothman and his colleagues are working to address such issues at the state legislature.

Because of state laws, all who administer the test in this program, including physicians, must be certified. According to Rothman, co-investigator Julianna Jung has built a simplified, condensed  training course that meets requirements of Maryland state laws but is also practical for doctors in the ED.

“It can be an uphill battle, and it might take five years to get the kinks out,” acknowledges Rothman, “but the only way to have an impact on this epidemic is to make the test routine.”

—Judy Minkove

 

 

Johns Hopkins Medicine

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