Impact of a Best Practice Alert Prompting HIV-1 RNA Testing on an Emergency Department HIV Screening Program

Emergency department (ED)-based opt-out HIV screening programs are effective in identifying patients with undiagnosed HIV. However, positive screening tests followed by negative HIV-1 antibody testing require an HIV-1 RNA test to determine whether a test is a false positive or acute HIV infection. HIV-1 RNA testing often requires a separate blood sample, therefore failure to complete testing during the index ED visit can result in discordant findings and additional resource utilization. We evaluated whether implementation of a best practice alert (BPA) prompting HIV-1 RNA test ordering was associated with improved index ED visit HIV-1 RNA testing.

This quality improvement initiative with retrospective analysis was conducted in an urban ED with an established opt-out HIV screening program. A BPA was implemented to prompt providers to order HIV-1 RNA testing when a 4th generation HIV screening test result was reactive. Adult ED patients with reactive screening tests were included. The primary outcome was completion of HIV-1 RNA testing during the index ED visit. A secondary analysis evaluated patients who required HIV-1 RNA testing to clarify HIV status, including those ultimately classified as false positive, acute HIV infection, or discordant. Outcomes were compared across 12-month pre- and post-BPA implementation periods using Fisher’s exact test. Effect sizes were summarized as risk ratios (RRs) with 95% confidence intervals (CIs).

Fifty-two patients with reactive HIV screening tests were identified in the pre-BPA period and 49 in the post-BPA period. Completion of HIV-1 RNA testing during the index ED visit increased from 13/52 (25.0%) pre-BPA to 26/49 (53.1%) post-BPA (RR 2.12; 95% CI 1.24–3.64; p=0.006). Among patients requiring HIV-1 RNA testing to clarify HIV status, index ED visit RNA completion increased from 6/24 (25.0%) pre-BPA to 13/27 (48.1%) post-BPA (RR 1.92; 95% CI 0.86–4.28; p=0.14).

Implementation of a HIV-1 RNA testing BPA in the context of an ED HIV screening program was associated with improved completion of HIV-1 RNA testing during the index ED visit. Avoidance of discordant results can decrease patient anxiety and lessen the burden of resources needed for follow up testing. Additional studies are needed to identify complementary strategies to further optimize ED HIV screening workflows.