Researchers Study Strategies to Increase HIV Testing, Prevention via the Emergency Department

The CDC recommends routine, universal HIV screening for patients who are 13 years of age and older in all healthcare settings, including the Emergency Department. However, experts say the ED is being underutilized as an access point for HIV screening and prevention.

ingeno [at] chop.edu (By Lauren Ingeno)

While more than half of new HIV diagnoses were among patients ages 13 to 34 in 2021, the Centers for Disease Control and Prevention (CDC) estimates that only half of adolescents and young adults living with HIV are aware of their status.

For young people, the Emergency Department (ED) represents an ideal access point for HIV testing and linkage to preventive medicine, particularly because many adolescents report using it for non-urgent medical care. However, the ED is being underutilized for HIV prevention, according to Nadia Dowshen, MD, MSHP, a pediatrician and adolescent medicine specialist at Children's Hospital of Philadelphia.

"When it comes to HIV prevention, the U.S. healthcare system has largely failed young people," said Dr. Dowshen, who directs Adolescent HIV Services at CHOP. "The CDC has recommended for over 15 years that everyone over the age of 13 receive an HIV test in any healthcare setting including when they come into the Emergency Department, but we know that kind of routine testing just isn't happening across the country."

Barriers like a lack of HIV education among healthcare professionals, concerns about following up after results, and increased workloads have prevented many hospitals from implementing universal HIV screening.

Now, with funding from the National Institutes of Health, Dr. Dowshen will co-lead two new studies to determine the best strategies for increasing HIV screening in pediatric EDs, while using digital health tools to link patients to prevention and treatment services.

"We're comparing different strategies," Dr. Dowshen said, "so that we can inform Pediatric Emergency Departments about what methods might be best for them to adhere to the CDC guidelines to do HIV screenings in the ED."

Dr. Dowshen will serve as a principal investigator for both studies, along with

Two CHOP-led studies are seeking to increase universally-offered, opt-out HIV screening in the pediatric ED. The trials will also use digital health tools to identify and link at-risk youth to ongoing PrEP care. (Credit: Adolescent Medicine Trials Network for HIV/AIDS Interventions)

Monika Goyal, MD, of Children's National Hosptial, and Jennifer Reed, of Cincinatti Children's Hospital. The CHOP ED will serve as a site for one of the studies, while the second study — a research project of the Adolescent Medicine Trials Network (ATN) for HIV/AIDS Interventions — will take place at five other pediatric EDs throughout the U.S.

The ATN is the only multicenter research network in the United States devoted to the health and well-being of adolescents and young adults living with or at risk for HIV. CHOP has been a part of the network since its launch in 2001.

During the studies, researchers will investigate the effectiveness of different strategies, including a universally-offered "opt-out" approach and a universally-offered opt-in option.

All patients ages 14 to 24 years old who come though the CHOP ED during the study period will be offered a tablet to complete a survey. Within the survey, patients will be notified that they will be tested for HIV unless they choose to opt out, and their decision will be relayed to the ED clinician through their electronic medical record.

Patients also will answer survey questions about their sexual health, and their ED doctor will be notified if a participant could benefit from Pre-exposure Prophylaxis (PrEP). When taken as prescribed (either an oral pill or an injectable), PrEP is highly effective for preventing HIV, which is why connecting adolescents to the medication early is so important, said Marné Castillo PhD, MEd, clinical and research director of the Adolescent Initiative at CHOP.

"For us, the goal is all about prevention. How can we put ourselves out of business?" said Dr. Castillo, who is serving as a co-investigator on the HIV screening studies. "We want to do this in a sex-positive way by giving young people options and choices to express themselves while staying healthy."

For study participants who indicate during their ED visit that they might qualify for PrEP, they will be offered the opportunity to enroll in a text messaging-based digital health platform to learn more. If the patient decides to begin PrEP medication, the texting tool will connect them directly with a health navigator from the Adolescent Initiative (AI) at CHOP. The Adolescent Initiative offers multidisciplinary HIV prevention and treatment services as well as education to youth in the community.

In addition to investigating whether giving out the tablet and making recommendations to clinicians will increase HIV testing in the ED, the studies will identify the best and most cost-effective ways to implement the strategy.

"Adolescents are a unique group," Dr. Castillo said. "And so it's really important to be able to have research that's appropriate for youth, that is engaging them from where they're at and understanding what their needs are."

Additional investigators on the CHOP study team include Cynthia Mollen, MD, MSCE, Joseph Zorc, MD, MSCE, and Sarah Wood, MD, MSHP.