Research Objective:

1
Standard and Rapid HIV Testing Practices in
Safety Net Hospitals
R. Hasnain-Wynia,1 G. Torres,1 H. Whitmore,1 J.
Pickreign, K. Stanger, 1 R. Kang, 1 and G.
Bazzoli2
1-Health Research and Educational Trust
2-Virginia Commonwealth University
Conclusions
Results
Abstract
Aims
.
Research Objective The CDC estimates that 1 in 4
people living with HIV in the U.S. are unaware of
their HIV status. The use of rapid HIV testing
in hospitals yields an opportunity to readily
identify HIV infections and refer these patients
to care. There continue to be missed
opportunities for early HIV testing in hospital
settings, which often serve as a primary access
point for many indigent at-risk or HIV-infected
patients. The U.S. health system relies on the
hospital safety net to provide care to the
uninsured and indigent, but little is known about
safety net hospitals standard and rapid HIV
testing practices. The objective of this paper is
to examine standard and rapid HIV testing
practices in safety net and non-safety net
hospitals. Study Design Surveys on HIV testing
were mailed to 4,497 non-federal, short-term
hospitals. 1,230 hospitals completed the survey
for a 27.4 response rate. Data were weighted to
adjust for non-response. We matched 623 metro
hospitals from the American Hospital Association
database to completed HIV surveys.   Population
Studied We identified and classified hospitals
into three categories by their safety net status,
core safety net, voluntary safety net and
non-safety net, focusing on the actual amount of
uncompensated care provided.   Principal
Findings 98 of core safety net hospitals offer
HIV testing compared to 94 of non-safety net
hospitals. 10 of core safety net hospitals offer
inpatient HIV testing compared to 1 of voluntary
safety-net hospitals. 10 of core safety net
hospitals offer HIV testing in their emergency
departments compared to 0 of voluntary
safety-net hospitals. 34 of labor and delivery
units in core safety net hospitals offer HIV
testing compared to 18 in non-safety net
hospitals. 7 of outpatient centers in core
safety net hospitals offer HIV testing compared
to 2 in non-safety net hospitals (all values
significant at ptesting is similar across the three hospital
categories. 47 of non-safety net hospitals dont
use rapid testing versus 28 of safety net
hospitals. 41 of emergency departments in core
safety net hospitals provide rapid testing versus
21 in non-safety net hospitals. 32 percent of
labor and delivery departments in core safety net
hospitals provide rapid testing versus 17 in
non-safety-net hospitals. 14 of outpatient
centers in safety net hospitals use rapid testing
compared to 5.5 in non-safety net hospitals (all
values significant at py net hospitals are more likely to provide
standard and rapid HIV testing compared to
non-safety net hospitals. However, given the CDC
recommendations for universal testing for (1) all
pregnant women and (2) all patients in hospitals
serving high prevalence communities (greater than
1), overall testing rates are low.
  Implications for Policy, Delivery, or
Practice HIV testing is more likely to take
place in core safety net hospitals. Given their
important role in providing care to the indigent
and to at-risk populations, policymakers should
focus on mechanisms to distribute the burden of
care by considering financial support to offset
uncompensated care costs.   Primary Funding
SourceThe Centers for Disease Control and
Prevention

• General Findings
• 98 of core safety net hospitals offer HIV
  testing compared to 94 of non-safety net
  hospitals.
• 10 of core safety net hospitals offer rapid HIV
  testing compared to 1 of voluntary safety net
  hospitals.
• 10 of core safety net hospitals offer HIV
  testing in their emergency departments compared
  to 0 of voluntary safety net and non-safety net
  hospitals.
• 34 of labor and delivery units in core safety
  net hospitals offer HIV testing compared to 18
  of labor and delivery units in non-safety net
  hospitals.
• 7 of outpatient centers in core safety net
  hospitals offer HIV testing compared to two
  percent in non-safety net hospitals.
• Knowledge of rapid HIV testing is similar across
  core, voluntary, and non-safety net hospitals.
• 47 of non-safety net hospitals do not use rapid
  testing versus 28 of safety net hospitals.
• 41 of emergency departments in core safety net
  hospitals provide rapid testing versus 21 in
  non-safety net hospitals.
• 32 of labor and delivery departments in core
  safety net hospitals provide rapid testing versus
  17 in non- safety net hospitals.
• 14 of outpatient centers in safety net hospitals
  use rapid testing compared to 5.5 in non-safety
  net hospitals.
• (All values significant at p

• Safety net hospitals are more likely to provide
  standard and rapid HIV testing compared to
  non-safety net hospitals.
• However, given the CDC recommendations for
  universal testing for (1) all pregnant women and
  (2) all patients in hospitals serving high
  prevalence communities (greater than 1), overall
  testing rates are low.

• The primary aim of this study is to examine
  standard and rapid HIV testing practices in
  safety net and non-safety net hospitals.

Methods

• Surveys sent to all non-federal, short-term
  general hospitals in the United States identified
  through the American Hospital Association
  Database.
• -Survey sent to 4,497 hospitals total
• -Surveys received from 1230 hospitals (27.4
  response)
• -Survey administered through the internet and
  mail (paper-based)
• -Data collected from March 2 through April 16,
  2004.
• Data weighted to adjust for non-response
• -Hospital ownership/control status
• -Census division
• -Metropolitan status
• Data post-stratified following a raking method to
  target population based on the AHA annual survey
• -Census division
• -Metropolitan status
• -Number of beds
• -Ownership/control
• -AIDS burden
• Population studied
• -Matched 623 metro hospitals from the American
  Hospital Association Database to completed HIV
  surveys.
• -Identified and classified hospitals into three
  categories by their safety net status based upon
  the actual amount of uncompensated care
  provided.
• (1) Core Safety NetHigh market share/high
  burdenhospitals that play a large community
  role in providing uncompensated care and
  generally have a large institutional
  commitment to providing indigent care. (n30)

Implications for Policy, Practice, or Delivery

• HIV testing is more likely to take place in core
  safety net hospitals. Given their important role
  in providing care to indigent and to at-risk
  populations, policymakers should focus on
  mechanisms to distribute the burden of care by
  considering financial support to offset
  uncompensated care costs.
• Given the role of safety net hospitals and
  emergency departments as the primary or sole
  access point to medical care for many at-risk or
  HIV-positive patients, these findings indicate
  that there continue to be many missed
  opportunities for early diagnosis.

Background

• In the United States, HIV infection is usually
  discovered at an advanced stage, usually in the
  course of medical care and often during care for
  complications of AIDS.
• 1993 MMWR RR-02 CDC recommended Hospitals with
  seroprevalence of at least 1 or an AIDS
  diagnosis rate 1.0 per 1,000 discharges should
  strongly consider adopting a policy of offering
  HIV counseling and testing routinely to patients
  15-54 years.
• 2003 MMWR, Vol 52 Increased HIV testing in
  clinical settings and routine screening in acute
  care settings in high prevalence areas.
• For the CDC to incorporate routine HIV testing in
  more clinical settings, need an understanding of
  the current state of HIV testing in hospitals
• The U.S. health system relies on hospital safety
  net to provide care to many indigent at-risk
  HIV-infected patients, but little is known about
  safety net hospitals standard and rapid HIV
  testing practices.

This project was made possible through a
cooperative agreement between the Centers for
Disease Control (CDC) and Prevention and the
Association of Teachers of Preventive Medicine
(ATPM), award number TS-0990 its contents are
the responsibility of the authors and do not
necessarily reflect the official views of the CDC
or ATPM.