Making Opt-Out HIV Testing Routine in the Emergency Department

A critical first step toward ending the HIV epidemic is making sure that all HIV infections are diagnosed as early as possible, so people with HIV can quickly access the care and treatment they need to stay healthy. Effective treatment reduces the level of virus in the body to an undetectable level, which prevents HIV transmission to sexual partners. However, many HIV infections are not detected early, often because testing is not routine or patients and providers are uncomfortable talking about HIV. Missed opportunities for testing result in some people with HIV living for many years without knowing their HIV status. This can reduce their quality of life and options for successful treatment, while also having the risk of unknowingly transmitting the virus to others through sex.

That’s why the Centers for Disease Control and Prevention (CDC) recommends that hospital emergency departments and other health care settings offer routine opt-out HIV screening. This means that everyone ages 13-64 years who comes in for care is automatically offered an HIV test, without having to ask for one. These broad, age-based testing criteria increase the number of tests performed and also help to reduce the stigma sometimes associated with HIV.

Some hospitals have had difficulty putting CDC’s recommendation into practice because of concerns that it will increase workload in an already overburdened emergency department or require time-consuming training. In East Baton Rouge Parish, Louisiana, dedicated funding—along with teamwork and ingenuity—helped overcome these barriers. Through a remarkable parish-wide collaboration led by Baton Rouge Mayor-President Sharon Weston Broome’s office and including state and local health officials, federally funded health clinics, private local hospitals, and Gilead Sciences, opt-out HIV testing is now available in two local emergency departments — Our Lady of the Lake and Ochsner Medical Center – Baton Rouge. The routine opt-out HIV testing program was first launched at Our Lady of the Lake in 2015, through funding and on-the-ground support from Gilead Sciences. Largely due to these efforts, from 2016 to 2018, the parish’s rate of late-stage HIV diagnoses — until recently the highest in the nation — was cut in half. Lessons learned from this partnership served as a model for Ochsner Medical Center – Baton Rouge, which began its opt-out testing program in 2019 and receives support for testing through the Ending the HIV Epidemic initiative.

“A lot of people — and that includes doctors and nurses as well as patients — may be uncomfortable talking about HIV,” says Dianne Teal, chief nursing officer at Ochsner Medical Center – Baton Rouge. “Some patients are uncomfortable talking about their weight, for example, but they understand we still expect them to get on the scale and put on that blood pressure cuff. It’s the same with HIV. We want to make it part of the regular conversation — the test is just one more tool we can use to get a clearer picture of the patient’s health.”

According to Susan Green, who heads Ochsner’s emergency department, cultivating staff champions was a key ingredient for making routine opt-out testing a success. She says the program has benefitted from remarkable leadership from her team. “We rolled out staff education months in advance. Right off the bat, our emergency department team was eager to take this program in — to understand everything from how common undiagnosed HIV is here in Baton Rouge to how screening would become a part of their day-to-day workflow. As soon as they saw how great the need was, our nurses were more than ready to make routine HIV testing available for everyone.”

In addition to education, minimizing burden on emergency department staff was critical. Hospitals in East Baton Rouge worked with their electronic medical record (EMR) providers to integrate a testing flag so that triage nurses are automatically notified when a patient is between the ages of 13-64 years and should be tested. They also developed a clear path to link people with HIV to follow-up care: through the Ending the HIV Epidemic initiative, a Rapid Start Navigator was brought on board to connect people with HIV to appropriate care and treatment services within 7 days of a new HIV diagnosis. Nathan Freeman, M.D., an emergency department physician at Ochsner, emphasizes the importance of following up with each patient who tests positive — even if the patient has already checked out of the emergency department.

“Our care for a person we screen for HIV doesn’t stop at the test — it begins there,” says Dr. Freeman, “It can be a real shock for someone to find out they’re living with this virus, so it’s that much more important for us to make sure every person with newly diagnosed HIV is connected to care. That one small step dramatically increases the odds that someone can get their virus down to undetectable levels and have effectively no risk of sexually transmitting HIV.”

The emergency department HIV testing partnership in East Baton Rouge is poised for continued success, with current Ending the HIV Epidemic initiative investments in HIV testing kits supporting the expansion of Ochsner’s program. The parish plans to integrate rapid HIV testing into even more healthcare locations like specialty health clinics and correctional facilities as additional resources allow. Lessons learned from this program will extend far beyond East Baton Rouge Parish, potentially serving as an example for other jurisdictions nationwide that want to initiate opt-out HIV testing in emergency departments. In fact, Ochsner has already expanded testing to its emergency department in Iberville Parish, southwest of East Baton Rouge.