Screening of HIV based on indicator conditions and risk behaviors at the emergency departments

Dear Editor,

In relation to the letter addressed to the editor by Argelich-Ibáñez and Juan-Serra¹ referring to a study carried out by our research group² on HIV screening in an emergency department (ED), we agree with the authors that the availability of HIV testing—using rapid diagnosis techniques—in EDs aimed at the population with risk factors and/or indicator conditions is necessary. This is because routine HIV testing in non-specialist environments has the potential to significantly reduce both late diagnosis and treatment access barriers.³ Furthermore, it increases the likelihood of identifying the number of undiagnosed infections, thereby requiring less testing and improving the efficiency of testing, which makes the strategy cost-effective.^3,4

Nevertheless, the feasibility of including screening programmes in EDs largely depends on the ability to integrate HIV testing in the EDs, and on how the programmes are funded.⁵ The most cost-effective strategy described by other authors is to include an HIV screening programme within the ED with new personnel, especially nursing personnel, which ensures a relatively immediate guided transition of patients with a positive diagnosis to the specialist services³ and helps to gain patients’ trust in the healthcare provider and in the healthcare system by providing support and direct comprehensive HIV care.³ These programmes can offer detection tests to all potential patients, with a wide testing coverage and with lower costs per test.⁶ However, this staffing model, parallel to that of the ED, requires multidisciplinary collaboration (ED personnel, HIV units and public health professionals), which involves resources and investment in infrastructure.³ In addition, it results in a limited evaluation of HIV due to the lack of availability of personnel to carry out HIV testing 24 hours a day.⁶

Therefore, the ideal situation is to have an HIV screening programme in EDs targeted at the population with risk factors, using appropriate criteria which increase the sensitivity of the programme, through a programme implemented in EDs with nursing staff that guarantees: the screening of individuals; proper performing of the test; and the introduction of patients newly diagnosed with HIV to specialist care. Given the limited resources in our setting, creating a programme with these characteristics would be quite complex. Therefore, in line with Argelich-Ibáñez and Juan-Serra,¹ and in our current setting, it is not possible to implement a screening programme given the limited resources, but we believe that HIV testing using rapid diagnostic techniques should be available in EDs, where HIV should be ruled out based on the indicator conditions and risk behaviours.

In terms of the low prevalence of new diagnoses of HIV found in our study, we believe that it is: (1) secondary to the possible absence of a hidden epidemic in the low-risk population; (2) due to the low efficiency of universal screening in this department,^3,6 and (3) due to the study's operational constraints, as there was only one nurse offering the test in an ED with a very high number of visits, and in which screening depended on the availability of the nurse.