Jacob et al. argue in favour of universal HIV screening in hospital emergency departments (EDs), which, as they point out, is cost-effective.1 In fact, a universal screening strategy has been established in the UK with government support and is proving successful.2 However, we believe that its implementation in Spain is very complex in clinical practice, for two main reasons.
The first is logistical, as EDs handle 20 million episodes per year,3 which indicates the number of serological tests that would need to be performed. In addition, this strategy would also require some automation, in order to avoid repeating HIV tests for patients who have already had a previous test, and bearing in mind that in some circumstances, such as a sexually transmitted infection, a repeat test may be indicated despite a previous test having been performed.
Secondly, the need to request verbal consent to perform the test and record it in the patient's medical record affects the development of a universal strategy. This is a major barrier given the characteristics of emergency care, which is performed in situations of time constraints, overcrowding and high caseload, making it difficult to obtain optimal informed consent for patients coming for a non-HIV-related reason.4
Considering these difficulties, we believe that a targeted strategy is currently the best option for screening for HIV infection in EDs. This intervention is showing good results in terms of number of serological tests (81,360) and number of new diagnoses established (1124).5 A very notable aspect of the programme's results is that half of the new diagnoses are being established in situations different from the six entities included in the SEMES [Spanish Society of Emergency Medicine] recommendations.6 This may be related to increased awareness among emergency department professionals, a cultural change that makes them more aware of HIV in their daily care activities.
However, the study of adherence to recommendations shows that there is still room for improvement to increase the number of serological tests,6 for which we are actively working to establish analytical profiles and computer alerts to ensure that no patient at risk of presenting HIV goes unnoticed by an emergency department,7 as recommended by Jacob et al. In addition, the alert strategy is based on computer algorithms that include all diseases for which there is an increased risk of HIV, and not only the six that are included in the current programme recommendations, as well as demographic factors, such as being born in countries with a very high prevalence of HIV infection, in which case serological testing is recommended.
In any case, we think that EDs are an ideal setting for performing serological tests and, more than what strategy to establish, the most important thing is to have a strategy, as studies show the efficacy of an intervention in this setting and the potential savings for the healthcare system,8 in addition to the obvious benefits both for the diagnosed patient and in terms of public health.9
FundingNo funding was received for this study.
Conflicts of interestThere are no conflicts of interest in this study.
