Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You and Your Team.

Learn More →

Nontargeted HIV Screening in Emergency Departments—Reply

Nontargeted HIV Screening in Emergency Departments—Reply In reply The first remark by Yazdanpanah et al applied the undiagnosed-infection prevalence observed in the metropolitan Paris emergency departments (EDs) (0.14%) to all persons aged 18 to 64 years in France and claimed that national undetected human immunodeficiency virus (HIV) infections reach 56 000. Because the number of diagnoses per Paris-area inhabitant is 4 times higher than in other regions, that calculation largely overestimates the national prevalence. We would rather conclude that the undiagnosed infection prevalence in France is far below the Centers for Disease Control and Prevention–recommended 0.10% threshold for performing nontargeted screening.1 Second, we do not question that there are HIV cases in lower-risk individuals. However, our results clearly showed that most ED-consulting patients with undiagnosed HIV infections belonged to high-risk groups. Third, it can reasonably be considered that the 4 patients hospitalized for AIDS-related symptoms or symptomatic primary HIV infections would have been tested diagnostically. We agree on the difficulty of integrating risk assessment into routine ED care. Nevertheless, we think that the use of a screening tool based on very few and relevant demographic or behavioral characteristics should be feasible, more effective, and less resource-consuming than nontargeted screening. Finally, our results are consistent with those of Haukoos et al,2 who reported that 11 of 15 patients diagnosed via nontargeted screening had CD4 cell counts below 350/μL. Taken together, these results show that nontargeted screening in EDs did not favor early HIV diagnosis. Sowah et al highlighted the need for caution in generalizing our results. We agree that the impact of nontargeted HIV screening might be different in other health care systems, settings, or epidemic patterns, as emphasized in our article's Comment section.3 Pertinently, similar undiagnosed infection prevalences in EDs were reported in the United States and United Kingdom, 2 other low-prevalence countries with concentrated epidemics.2,4 Unfortunately, we cannot respond to their reported 0.53% prevalence of newly diagnosed individuals in the 3 Baltimore EDs because the authors did not provide detailed data on the proportion and characteristics of the tested population. To our knowledge, our study was the first to evaluate the impact of nontargeted HIV screening of a very large sample of individuals reflecting the general population of an 11.7 million–inhabitant region. Our results clearly suggest that nontargeted HIV screening is poorly effective. However, we think that HIV-rapid tests should ideally be available in EDs, and health care teams should offer testing to high-risk patients. We are currently planning a study to assess the impact of a targeted HIV-screening strategy based on demographic/behavioral characteristics and symptoms in EDs. Back to top Article Information Correspondence: Dr Crémieux, Département de Médecine Aiguë et Spécialisée, Hôpital Raymond-Poincaré, 104 Boulevard Raymond-Poincaré, 93380 Garches, France (anne-claude.cremieux@rpc.aphp.fr). Financial Disclosure: None reported. References 1. Branson BM, Handsfield HH, Lampe MA, et al; Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-1716988643PubMedGoogle Scholar 2. Haukoos JS, Hopkins E, Conroy AA, et al; Denver Emergency Department HIV Opt-Out Study Group. Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients. JAMA. 2010;304(3):284-29220639562PubMedGoogle ScholarCrossref 3. d’Almeida KW, Kierzek G, de Truchis P, et al; Emergency Department HIV-Screening Group. Modest public health impact of nontargeted human immunodeficiency virus screening in 29 emergency departments. Arch Intern Med. 2012;172(1):12-2022025095PubMedGoogle ScholarCrossref 4. Rayment M, Thornton A, Mandalia S, et al. HIV testing in non-traditional settings—the HINTS study. Poster session presented at: 18th International AIDS Conference; July 18-23, 2010; Vienna, Austria http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Nontargeted HIV Screening in Emergency Departments—Reply

Loading next page...
 
/lp/american-medical-association/nontargeted-hiv-screening-in-emergency-departments-reply-tODkmJoVq0
Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.52
Publisher site
See Article on Publisher Site

Abstract

In reply The first remark by Yazdanpanah et al applied the undiagnosed-infection prevalence observed in the metropolitan Paris emergency departments (EDs) (0.14%) to all persons aged 18 to 64 years in France and claimed that national undetected human immunodeficiency virus (HIV) infections reach 56 000. Because the number of diagnoses per Paris-area inhabitant is 4 times higher than in other regions, that calculation largely overestimates the national prevalence. We would rather conclude that the undiagnosed infection prevalence in France is far below the Centers for Disease Control and Prevention–recommended 0.10% threshold for performing nontargeted screening.1 Second, we do not question that there are HIV cases in lower-risk individuals. However, our results clearly showed that most ED-consulting patients with undiagnosed HIV infections belonged to high-risk groups. Third, it can reasonably be considered that the 4 patients hospitalized for AIDS-related symptoms or symptomatic primary HIV infections would have been tested diagnostically. We agree on the difficulty of integrating risk assessment into routine ED care. Nevertheless, we think that the use of a screening tool based on very few and relevant demographic or behavioral characteristics should be feasible, more effective, and less resource-consuming than nontargeted screening. Finally, our results are consistent with those of Haukoos et al,2 who reported that 11 of 15 patients diagnosed via nontargeted screening had CD4 cell counts below 350/μL. Taken together, these results show that nontargeted screening in EDs did not favor early HIV diagnosis. Sowah et al highlighted the need for caution in generalizing our results. We agree that the impact of nontargeted HIV screening might be different in other health care systems, settings, or epidemic patterns, as emphasized in our article's Comment section.3 Pertinently, similar undiagnosed infection prevalences in EDs were reported in the United States and United Kingdom, 2 other low-prevalence countries with concentrated epidemics.2,4 Unfortunately, we cannot respond to their reported 0.53% prevalence of newly diagnosed individuals in the 3 Baltimore EDs because the authors did not provide detailed data on the proportion and characteristics of the tested population. To our knowledge, our study was the first to evaluate the impact of nontargeted HIV screening of a very large sample of individuals reflecting the general population of an 11.7 million–inhabitant region. Our results clearly suggest that nontargeted HIV screening is poorly effective. However, we think that HIV-rapid tests should ideally be available in EDs, and health care teams should offer testing to high-risk patients. We are currently planning a study to assess the impact of a targeted HIV-screening strategy based on demographic/behavioral characteristics and symptoms in EDs. Back to top Article Information Correspondence: Dr Crémieux, Département de Médecine Aiguë et Spécialisée, Hôpital Raymond-Poincaré, 104 Boulevard Raymond-Poincaré, 93380 Garches, France (anne-claude.cremieux@rpc.aphp.fr). Financial Disclosure: None reported. References 1. Branson BM, Handsfield HH, Lampe MA, et al; Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-1716988643PubMedGoogle Scholar 2. Haukoos JS, Hopkins E, Conroy AA, et al; Denver Emergency Department HIV Opt-Out Study Group. Routine opt-out rapid HIV screening and detection of HIV infection in emergency department patients. JAMA. 2010;304(3):284-29220639562PubMedGoogle ScholarCrossref 3. d’Almeida KW, Kierzek G, de Truchis P, et al; Emergency Department HIV-Screening Group. Modest public health impact of nontargeted human immunodeficiency virus screening in 29 emergency departments. Arch Intern Med. 2012;172(1):12-2022025095PubMedGoogle ScholarCrossref 4. Rayment M, Thornton A, Mandalia S, et al. HIV testing in non-traditional settings—the HINTS study. Poster session presented at: 18th International AIDS Conference; July 18-23, 2010; Vienna, Austria

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Mar 26, 2012

Keywords: emergency service, hospital,hiv screening

References