HIV Testing Programs in Emergency Departments
The use of voluntary HIV testing programs in emergency departments remains a matter of professional and public concerns. Current paper proposes a research idea to analyze the demographic factors, which may or may not influence patients’ decision to opt out for a free HIV testing program when admitted to the emergency department. The proposal includes a detailed review of the problem, justification of the proposed idea, sampling and data collection recommendations. The most relevant ethical issues are being discussed.
Keywords: HIV testing, emergency department, screening, demographic
The Human Immunodeficiency Virus remains one of the greatest public health problems facing the developed world. According to Sankoff, Hopkins, Sasson, Al-Tayyib, Bender, and Haukoos, despite numerous efforts made by public health officials to reduce the incidence and prevalence of HIV, it remains one of the chief causes of preventable deaths in America. At least 230,000 people are unaware of being infected with HIV. No less than 56,300 new cases are registered annually in the U.S. In most situations, new infections emerge as a result of contacting someone, who is unaware or aware of his/her infection.
In this problematic situation, the need for mandatory or at least voluntary HIV testing is becoming more urgent. Emergency departments represent a convenient space for implementing HIV testing recommendations. As Freeman, Sattin, Miller, Dias and Wilde write, emergency departments in America not only provide patients with a wide range of health services but also ensure easy and quick access to the basic medical care for those, who are considered as uninsured or underserved. Hundreds of persons who are at risk of being HIV-infected pass through emergency departments on a daily basis. “Persons with undiagnosed HIV infection access the ED prior to their diagnosis, but are not often tested”. Emergency departments have the potential to become the key elements in reducing the scope, prevalence, and incidence of HIV infection. However, in order to meet the goals of public health and enhance the quality of preventive efforts in the long run, they should increase the number of patients undergoing voluntary HIV testing.
Several emergency departments have successfully implemented free HIV-testing programs for their patients on voluntary basis. These screening methods are offered to patients, based on their clinical symptoms and the initial analysis of their behavioral risks. In most cases, professionals in emergency departments target those, who are considered high-risk populations, including women, ethnic and racial minorities, and other individuals and groups that may not be aware of their diagnosis. Meanwhile, the Centers for Disease Control and Prevention (CDC) have implemented new HIV testing recommendations to increase the frequency of HIV testing in emergency departments. According to Hecht, Smith, Radonich, Kozlovskaya and Totten, in 2008, only every second emergency department offered free HIV screening options to their patients. For years, many EDs intentionally avoided offering free HIV testing to patients for a variety of reasons, including costs, consent requirements, the novelty of testing approaches, reliability concerns, as well as privacy, confidentiality, and the risks of patients’ resistance. Thus, instead of offering a viable solution to the problem of HIV in America, emergency departments impede the implementation of effective screening strategies for patients who may be unaware of their HIV diagnosis.
Lack of patient acceptance is one of the primary obstacles to implementing free HIV screening strategies in emergency departments. Low rates of acceptance of HIV testing in EDs question the efficacy of the counseling and persuasion approaches used by medical professionals to justify the necessity and safety of such tests. Meanwhile, despite the growing body of empirical and theoretical literature, most professionals are unaware of the factors that drive utilization of free HIV screening procedures in different settings. More specifically, clinicians and researchers are still unaware of the factors, which could encourage patients admitted to emergency departments to opt out for a free HIV screening program.
Current prospective cohort study is designed to understand the factors behind patients’ decision to opt out for a free HIV-testing program, when admitted to an emergency department. The need for such study is justified by the growing incidence and prevalence of HIV in the United States, coupled with the poor understanding of the factors which encourage or keep patients admitted to EDs from using free HIV screening options. The research question to be answered is: do demographic factors influence the decision to opt out for free HIV testing programs in the emergency department? The following hypotheses are to be tested:
H0: A variety of demographic factors influence patients’ decision to opt out for free HIV screening in the emergency department.
H1: Race and ethnicity are the most important demographic factors behind patients’ decision to opt out for free HIV screening in the emergency department.
Sampling Selection Plan
The earlier studies into the use of HIV testing in emergency departments offer some recommendations in relation to sampling procedures. Borrowing some information from Trillo, Merchant, Baird, Ladd, Liu and Nirenberg (2009), the proposed research will rely on random sampling techniques, with the sample being randomly selected from at least 1,000 patients admitted to several different emergency departments across the United States. Given that the proposed study is based on the prospective cohort design, all study groups will be organized in present time and be followed into the future to predict the factors that may or may not lead them to opting out for a free HIV testing program in the emergency department. The sample will consist of patients admitted to at least four different emergency departments in different hospitals across the United States. They will be organized in groups according to the emergency department, from which the participants are recruited. Potential research participants will have to meet the following criteria: (a) age between 20 and 45; (b) no previous HIV diagnosis; (c) admitted to the ED without any serious psychological or psychiatric crisis. Patients with life-threatening traumas, traumas that make informed consent difficult or impossible or those who report too much pain will be excluded from the study. Independent variables will include a variety of demographic characteristics, such as age, ethnicity, marital status, etc., whereas the decision to opt out for free HIV testing in the ED will be treated as the dependent variable. The range and scope of the independent variables may change, as the study progresses.
Data Collection Plan
The data will be collected with the help of a standard questionnaire that includes questions related to patients’ demographic characteristics, their history of HIV testing, and the amount of time passed after the last HIV testing (if applicable). The questionnaire will be presented in English and Spanish. All questionnaires will be self-administered. Patients are expected to spend no more than 10 minutes filling out the questionnaire.
According to Smith (2009), “in any research on human beings, each potential subject must be adequately informed of the aims, methods, anticipated benefits and potential hazards of the study” (p. 57). Problems with obtaining informed consent in HIV research are widely documented. Resnik (1998) claims, that the efficacy of informed consent in HIV research is doubtful. The situation is further complicated by the fact that the study will take place in the emergency department, and the amount of time given to obtain informed consent will be limited. In addition, anonymity and confidentiality of the questionnaire and HIV testing results must be guaranteed. Respondents may not agree to participate in the study, fearing that the results of their HIV tests will be made public. Solid policies and recommendations will have to be developed to secure the research participants from possible risks.