The Deadliest Catch: Fishing for HIV in New Waters

In the absence of an effective HIV vaccine, case findings and treatments are the mainstay of HIV prevention. Effective treatments are available, but more than 25% of HIV-infected individuals in the United States may not know that they are infected (1). Perhaps as a result, the rate of HIV transmission in the United States seems to be holding steady (2, 3). Two years ago, the Centers for Disease Control and Prevention (CDC) responded by announcing a bold new strategy to curb HIV transmission: screening average-risk individuals in an attempt to bring more people with HIV infection into treatment and care. The new strategy proposed reaching beyond HIV voluntary counseling and testing sites (places where people who believe they are at risk for HIV can get tested) to screen for HIV in other medical settings. Additional key recommendations included simplifying requirements for obtaining written informed consent for HIV testing and increasing the use of rapid HIV tests, which would make it possible to test and deliver a preliminary positive result during a single brief visit. The vision guiding these policy recommendations was to make HIV screening a routine procedure in U.S. primary care clinics, urgent care centers, emergency departments, and hospital wards (2).

In this issue, Walensky and colleagues (4) report one emergency department's experience with implementing this type of screening. They show that these new waters can be treacherous. For their study of unselected HIV screening in a Boston, Massachusetts, emergency department, they recruited 849 study participants from a representative sample of adult emergency department patients and used an oral test approved by the U.S. Food and Drug Administration. Thirty-nine (4.6%) patients had a reactive result for HIV antibodies and were offered confirmatory testing; 8 declined and received only this “preliminary positive” result. Of the 31 patients …