Screening test of HIV in Emergency Departments: How? When? Who?

Dear Editor,

We read with great interest the article published by Reyes-Urueña et al., which documents, in a cohort of 2140 patients treated in an Accident and Emergency Department (A&E) in Barcelona during the period 2011–2013, that the prevalence of HIV was 0.15%, and the acceptance rate of a rapid HIV test was 95%.¹ During the same study period, Pizarro Portillo et al. carried out a similar investigation, although they differed in the sampling method (subjects aged from 15 to 75 with criteria of blood extraction for analysis in A&E at the discretion of the attending physician, rather than subjects aged from 15 to 64 at the discretion of research nurses in triage) and the screening test (fourth generation enzyme immunoassay test rather than an oral fluid test), which showed a prevalence of 0.6% and a rejection percentage of 1.2% in an A&E department in Madrid.

Although these studies differ in the prevalence of HIV, which may be related to sociodemographic aspects or to the type of sampling carried out, it is evident that the screening test for HIV could be a cost-effective measure in the adult population treated in the A&E departments in our area. This would be justified both by the prevalence in A&E—as it is above 0.1%—and by the high prevalence of late diagnosis in Spain.^2–4 Nevertheless, we believe that there are many aspects still to be clarified in the environment of A&E.

First of all, the available data come from research studies that do not reflect real life, and there is therefore little information about the logistical capacity of personnel and the time necessary to carry out the test routinely on all patients seen in A&E, or to be able to give the information in an appropriate way in the event of a positive result.⁵

Secondly, despite the high rates of acceptance of the screening test in the studies discussed above,^1,6 it is known that there are barriers between physicians and patients in relation to performing the test in A&E; one of the most important being the desire to focus on the actual reason for consultation.⁷ In these terms, the best strategy for offering the test is unclear; whether by the doctor responsible for patient care, nursing staff in triage or in a parallel process, or on the patient's own initiative after learning that they have free access to the test.^8,9

Thirdly, it is known that the prevalence of HIV in Spain is 0.4%,⁵ but what we do not know is the prevalence in the areas covered by the different A&E departments or whether, within these areas, there are unknown populations at increased risk of HIV infection. Pizarro Portillo et al. documented that being male, coming from other countries, having a history of hepatitis or tattooing, and infection as a reason for consultation, were all factors associated with having a positive HIV test.⁶

Bearing in mind that one in every two new diagnoses in Spain is a late diagnosis, in order to improve outcomes, it seems logical to adapt the prevention programmes to groups at the highest risk, such as young people and immigrants, especially if they report high-risk practices.¹⁰ In view of the above, and knowing that at times the only contact this group has with the healthcare system is A&E, we believe it is necessary to create a series of standardised recommendations for carrying out the HIV screening test in A&E, in order to establish the how, when and who.