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Urgent Care HIV and Viral Hepatitis Screening
A Gateway to Care: Screening for HIV and Viral Hepatitis in the Emergency Room and Urgent Care

Released: November 26, 2024

Expiration: November 25, 2025

Jordan J. Feld
Jordan J. Feld, MD, MPH
Activity Information

Activity

Progress
1
Course Completed
Key Takeaways
  • Screening for HIV, HCV, and HBV in emergency department and urgent care settings can reach marginalized populations who are at greater risk of these viral infections and may not otherwise interact with the healthcare system.
  • Effective implementation requires extensive logistical considerations, including what tests to perform, how to deliver results, and procedures for linkage to care or prevention services.

As a specialist with a role in facilitating screening for viral hepatitis and HIV, I think screening for HCV, HBV, and HIV infection in emergency and urgent care settings is crucial for achieving earlier diagnoses and improving the rate of diagnosis.

However, there are often competing priorities in the emergency department (ED).  Everyone thinks that the ED is a great place to screen for every disease, but for ED staff, this may not be a priority. Patients are coming to the ED for a reason, and it’s usually not to be screened for chronic medical conditions.  These points need to be seriously considered before making the case for why it may make sense to screen for these viral infections in the ED.

Why Screen for HCV, HBC, and HIV in the ED?
The populations most affected by HIV and viral hepatitis are often from marginalized communities who may seek healthcare in the ED or urgent care only. These patients often have less connection with the established healthcare system for numerous reasons. They may be people who are new to the country and may not speak the language. Many do not have insurance or a primary care provider, or are too focused on getting their primary needs met to consider accessing preventative healthcare. Many have also faced stigma in healthcare settings, which makes them reluctant to seek or stay engaged in care, except when it’s an emergency.  Many people from these communities only seek out care when medical needs arise, so asymptomatic conditions like the early stages of viral hepatitis and HIV infection may go unidentified for a long time.

There's clear evidence of higher rates of viral hepatitis and HIV infection among marginalized populations compared to the general population. All of these chronic viral infections disproportionately affect people that are marginalized in different ways. Injection drug use, unstable housing, incarceration, and mental health issues are all associated with higher rates of the HIV and HCV infection, while higher rates of HBV infection are associated with newcomer or immigrant status. So, screening in the ED and urgent care is very efficient in the sense that you screen fewer people to identify more infections.

That’s why I view screening for viral infections in the ED and urgent care as an opportunity. It can also be rewarding. We all seem to know a few patients who frequently need the ED and who have severe mental health issues or other challenges that can’t be easily fixed. However, viral infections are something that can be treated. If we screen for and diagnose these infections, we can cure their HCV, we can get them on treatment for HIV or HBV. And initiating treatment for those conditions can sometimes even help stabilize a patient’s other issues. That is obviously the best-case scenario, and it can be impactful and inspiring when it happens.

Meeting the Challenge
Of course, screening in the ED and urgent care has challenges. Screening must be done in a way that does not impede the reason for the urgent care visit. The key is that specialists and ED providers must work together to figure out how to make screening mutually beneficial.

One of the biggest questions is which test to do? Do you do point-of-care (POC) testing for HIV and HCV and ask the lab to prioritize the HBV test so you get an immediate diagnosis? At first glance, that seems like it makes the most sense, since without an immediate diagnosis, the patient may leave the ED or urgent care without their diagnosis.

On the flip side, if POC testing is done, then the ED physicians may need to counsel patients about HIV, HCV, or HBV in addition to addressing their chest pain or whatever the reason was for the visit. In my experience, some ED healthcare professionals preferred not using a rapid test because they were not comfortable counseling patients on these infections. Others felt that addressing screening results took away from their ability to address patients’ acute problems.

No News Is Good News?
Another major challenge is getting results to people. With POC testing, results are provided right away, but if follow-up testing is required (eg for HCV RNA or HBV tests), it can be very challenging to inform everyone of their results in an efficient manner. In the programs we have developed, I’ve asked patients whether they require notification of negative results. In my experience, about 75% of people say that they don't mind not being notified if screening tests are negative, in other words, “ no news is good news.” I also often ask if patients have a primary care provider and whether I can send the test results to their primary care provider. This ensures that, even if they don’t follow up, I can at least make sure the results are incorporated into their medical record.

The next thing to consider is a strategy for linking people to care. I believe that the best systems are ones where patients can make an appointment for linkage to care at the same time the testing is done, ideally with a low barrier facility, like a clinic with flexible hours or a drop-in clinic. In my experience, fewer patients are lost to follow-up if they are linked to care at the same time that screening is performed. Fortunately, screening in the ED is not only helpful, it’s also cost-effective.  Not surprisingly, linkage is the key determinant of cost considerations and thus needs to be a priority for program development.

Lastly, the logistics of implementing screening programs is a major undertaking. In our program, we were able to provide personnel to perform the screening, but ED and urgent care staff can also participate if they have the capacity to do so. For example, nurses can do the testing when they do their initial assessment or add screening tests to bloodwork already being sent to the lab.

Altogether, it takes multidisciplinary coordination with specialists and emergency room staff, nurses, and physicians to figure out the best system in each unique ED and urgent care setting.

Your Thoughts?
To learn more about best practices related to screening, diagnosis, and linkage to care and prevention services for HIV, HBV, and HCV, I encourage you to join an online webinar on February 6, 2025. You’ll hear from 2 expert faculty members with experience in implementing screening in emergency/urgent care.

Do you think that HIV, HCV, and HBV screening should be performed as part of routine intake procedures in ED and urgent care settings? Leave a comment to join the discussion!