December 9, 2011
American Academy of Pediatrics - Section on Emergency Medicine
Survey Application
Title of Research Project
Practices, Beliefs and Perceived Barriers of HIV Screening in Adolescent Patients in the Emergency
Department
Introduction
Despite advances in diagnosis and treatment, human immunodeficiency virus (HIV) continues to
persist among the pediatric population. Adolescents represent a particularly high risk group for HIV
infection, comprising a large percentage of all new HIV infections each year.[1] The incidence of newly
diagnosed HIV among 13-19 year olds is approximately 12 in 100,000, and the current prevalence of HIV
in adolescents is nearly 39 in 100,000.[1] The high prevalence of HIV among adolescents is largely
explained by the high-risk behaviors common among this age group, including early sexual experiences,
male-to-male sexual encounters, and illicit drug use.[2, 3]
Early knowledge of one’s HIV status has shown to increase early treatment initiation and reduce
high-risk sexual behavior, ultimately improving health and reducing transmission. [4-6] However, a large
percentage of adolescent patients with HIV are unaware they are infected, thus delaying care.[7] Almost
40% of patients first test positive for HIV less than one year before receiving a diagnosis of AIDS, yet
most of them have had multiple medical care visits prior to diagnosis. The Centers for Disease Control
and Prevention established new recommendations in 2006 regarding HIV screening based on this clear
need to improve HIV detection. These recommendations state that HIV screening should be similar to
other health measure screenings such as blood pressure monitoring, and performed in all health care
settings.[8] As of yet, there is no clear data as to how emergency departments (EDs) are implementing
these recommendations on a national level in the adolescent population and what barriers exist for such
screening.
Background
The CDC guidelines for HIV screening, introduced in 2006, recommend that voluntary screening for
HIV infection routinely be offered to patients13-64 years of age in all healthcare settings, including the
ED.[8] Per CDC recommendations, patients seeking treatment for sexually transmitted infections (STIs)
should receive HIV screening at each healthcare visit, regardless of known or suspected high-risk
behavior. Notably, a substantial proportion of patients, particularly adolescents, seek care for STIs in the
ED.[9] In addition, other patients that frequently seek care in the ED represent high-risk populations for
HIV infection, such as injection-drug users and their sex partners, and persons who exchange sex for
money or drugs. The CDC guidelines specify that health-care providers should screen for HIV in these
patients at least annually.[8] Furthermore, as of November 2011, the American Academy of Pediatrics
(AAP) has established a policy statement that encourages all pediatricians, including those in urgent care
offices and EDs, to test adolescents for HIV at least once by 16 years of age, and those who are at high
risk for HIV be tested annually.[10]
As the safety net for healthcare in the United States, the ED increasingly serves as a site of primary
care for many patients; therefore introduction of practices previously relegated to primary care physicians,
such as HIV screening, must be considered for implementation in the ED setting.[11] Despite the
increasing reliance on the ED, and the screening practices emphasized by the CDC and AAP, little is
known regarding adherence to these guidelines and current HIV screening rates for children and
adolescents seen in the ED. A single center pediatric study, conducted after publication of the CDC
recommendations, found that only 22% of respondents, consisting of ED physicians, nurses, and social
workers, were even aware of the new guidelines. Additionally, despite focused physician and nursing
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December 9, 2011
education, only 37% of eligible adolescents were approached for HIV screening.[12] Adult studies prior
to 2006 indicate emergency department providers offered HIV testing to about half of the patients
presenting to the ED with potential symptoms of HIV, and to even fewer adults at risk for STIs or
partaking in high-risk behaviors.[13-17]
Identified barriers to HIV screening from the ED include physician concerns regarding inadequate
time, insufficient resources, patient confidentiality, pretest counseling requirements, and feared loss of
follow-up.[14,18] ED providers also are concerned regarding implementation necessary for follow-up
care and post-screening, and believe adolescents would refuse to be screened if approached.[12]
Nationally representative assessments of ED provider HIV screening practices and potential barriers to
screening specific to adolescents have yet to be conducted.
Using this study, we propose to contribute to the current knowledge regarding HIV screening
practices in the ED for adolescents, provider knowledge regarding HIV testing guidelines, and barriers
against HIV screening. The results of this study will assist in targeting specific areas for improvement to
better implement universal HIV screening in the ED setting for adolescent patients.
Specific Aims
The primary objective of this study is to determine physician practices for ED-based HIV screening in
adolescents, assess physician knowledge of HIV screening guidelines and to determine any attitudes or
perceived barriers against such screening in adolescent ED patients.
Methods
A cross-sectional internet-based survey via SurveyMonkey.com will be implemented to members of the
American Academy of Pediatrics Section on Emergency Medicine (AAP SOEM). The survey has been
pilot-tested with six pediatric emergency medicine colleagues.
Inclusion Criteria
1. Physicians belonging to the AAP SOEM email list-serv
2. Attending-level physicians whose primary practice is in emergency medicine
3. Practice consists of patients < 21 years of age
Exclusion Criteria
1. Physicians not practicing clinically
2. Physicians not practicing in the United States of America
3. Physicians in training, including residents and fellows
Incentives
As an incentive for participation, a five-dollar gift card will be offered to respondents. To prevent any
influence of answers to our queries, the gift card will be offered only at the completion of the survey.
After completion of the survey, subjects will be asked to provide their name and mailing address to a
separately created e-mail account if they wish to receive the gift card. However, the respondents’ emails
with personal information will be separate from survey responses, and will not be able to be linked with
each other in any fashion. Therefore we will maintain the confidentiality of the responses.
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Impact
The goal of this study is to learn the current knowledge regarding HIV screening, actual screening rates
and what barriers exist. With a better understanding of all this, we can devise specific programs for
improved HIV detection from the Emergency Department, whether these involve educational sessions for
care providers, improved electronic medical record reminders for screening or establishing a health
educator per hospital to facilitate HIV testing.
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References
1.
HIV Surveillance Report, 2009. 2009, Centers for Disease Control and Prevention.
2.
Mehta, S.D., et al., Adult and pediatric emergency department sexually transmitted disease and
HIV screening: programmatic overview and outcomes. Acad Emerg Med, 2007. 14(3): p. 250-8.
3.
Eaton, D.K., et al., Youth risk behavior surveillance - United States, 2009. MMWR Surveill
Summ, 2010. 59(5): p. 1-142.
4.
Quinn, T.C., et al., Viral load and heterosexual transmission of human immunodeficiency virus
type 1. Rakai Project Study Group. N Engl J Med, 2000. 342(13): p. 921-9.
5.
Marks, G., et al., Meta-analysis of high-risk sexual behavior in persons aware and unaware they
are infected with HIV in the United States: implications for HIV prevention programs. J Acquir
Immune Defic Syndr, 2005. 39(4): p. 446-53.
6.
Marks, G., N. Crepaz, and R.S. Janssen, Estimating sexual transmission of HIV from persons
aware and unaware that they are infected with the virus in the USA. AIDS, 2006. 20(10): p.
1447-50.
7.
Prevention, C.f.D.C.a., HIV Surveillance — United States, 1981–2008. 2011, MMWR 2011. p.
689-693.
8.
Branson BM, H.H., Lampe MA, et al, Revised recommendations for HIV testing of adults,
adolescents, and pregnant women in health-care settings. MMWR Recommendations and
Reports, 2006. 55: p. 1-17.
9.
Beckmann, K.R., M.D. Melzer-Lange, and M.H. Gorelick, Emergency department management
of sexually transmitted infections in US adolescents: Results from the National Hospital
Ambulatory Medical Care Survey. Annals of Emergency Medicine, 2004. 43(3): p. 333-338.
10.
Committee on Pediatric AIDS. Adolescents and HIV infection: The pediatrician’s role in
promoting routine testing. Pediatrics, 2011. 128(5): p. 1023-9.
11.
Wilson, K.M. and J.D. Klein, Adolescents who use the emergency department as their usual
source of care. Arch Pediatr Adolesc Med, 2000. 154(4): p. 361-5.
12.
Minniear, T.D., et al., Implementation of and barriers to routine HIV screening for adolescents.
Pediatrics, 2009. 124(4): p. 1076-84.
13.
Wilson, S.R., et al., Testing for HIV: current practices in the academic ED. Am J Emerg Med,
1999. 17(4): p. 354-6.
14.
Fincher-Mergi, M., et al., Assessment of emergency department health care professionals'
behaviors regarding HIV testing and referral for patients with STDs. AIDS Patient Care STDS,
2002. 16(11): p. 549-53.
15.
Burke, R.C., et al., Why don't physicians test for HIV? A review of the US literature. AIDS, 2007.
21(12): p. 1617-24.
16.
Hardwicke, R., et al., HIV testing in emergency departments: a recommendation with missed
opportunities. J Assoc Nurses AIDS Care, 2008. 19(3): p. 211-8.
17.
Merchant, R.C. and B.M. Catanzaro, HIV testing in US EDs, 1993-2004. Am J Emerg Med, 2009.
27(7): p. 868-74.
18.
Arbelaez, C., et al., Emergency Provider Attitudes and Barriers to Universal HIV Testing in the
Emergency Department. J Emerg Med, 2009.
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