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Keywords:

  • HIV;
  • STI;
  • public health;
  • emergency department;
  • screening; surveillance;
  • consensus;
  • recommendations;
  • research;
  • nominal group technique

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. References
  9. Supporting Information

This article describes the results of the human immunodeficiency virus (HIV) and sexually transmitted infections (STI) prevention in the emergency department (ED) component of the 2009 Academic Emergency Medicine Consensus Conference entitled “Public Health in the ED: Surveillance, Screening, and Intervention.” The objectives were to use experts to define knowledge gaps and priority research questions related to the performance of HIV and STI surveillance, screening, and intervention in the ED. A four-step nominal group technique was applied using national and international experts in HIV and STI prevention. Using electronic mail, an in-person meeting, and a Web-based survey, specific knowledge gaps and research questions were identified and prioritized. Through two rounds of nomination and refinement, followed by two rounds of election, consensus was achieved for 11 knowledge gaps and 14 research questions related to HIV and STI prevention in EDs. The overarching themes of the research priority questions were related to effectiveness, sustainability, and integration. While the knowledge gaps appear disparate from one another, they are related to the research priority questions identified. Using a consensus approach, we developed a set of priorities for future research related to HIV and STI prevention in the ED. These priorities have the potential to improve future clinical and health services research and extramural funding in this important public health sector.

Steadily rising annual emergency department (ED) patient visits, coupled with lack of access to traditional medical care, has spurred ED-based public health initiatives ranging from alcohol and substance abuse intervention, to human immunodeficiency virus (HIV) and sexually transmitted infections (STI) screening.1 EDs are known to disproportionately serve populations that are more susceptible to infectious diseases, including HIV and STIs.1,2 Screening for STIs in the ED has particular theoretical appeal from both medical and public health standpoints, because they may be subtle and indolent, yet result in significant morbidity and mortality when detection is delayed or missed. Early identification of STIs, unlike many other potential public health interventions, may also mitigate or prevent community transmission.

Previous studies have reported surprisingly high rates of HIV and STIs in EDs in the United States. Among urban ED patients screened for gonorrhea and chlamydia, the combined prevalence of infection has ranged from 10% to 16%,3–7 and the prevalence of previously undiagnosed HIV has ranged from 2% to 3%.8–14 Effective screening and treatment for HIV and STIs in the ED could substantially reduce disease burden and transmission in the general population, as well as lower overall health care costs.15–18

In 2000, the Society for Academic Emergency Medicine (SAEM) Public Health and Education Task Force conducted a thorough review of existing initiatives to identify primary and secondary preventive interventions appropriate for inclusion in routine emergency care.19 Screening for HIV infection received an Alpha rating, i.e., recommended by the United States Preventive Services Task Force (USPSTF) with evidence sufficient to support offering this intervention in the ED (assuming sufficient resources are available), for prevention of morbidity and mortality based on more than a decade of prior work demonstrating significant disease burden, feasibility, and crude cost analysis.19 Although other STI screening programs were not specifically evaluated, similar evidence exists in the literature for this intervention.20 In 2006, the Centers for Disease Control and Prevention (CDC) announced new national recommendations for HIV testing in health care settings with the intention of expanding the role of testing to less traditional clinical sites, including EDs.21 Designed to improve case identification from all testing venues, the recommendations gave specific emphasis to episodic care settings, including EDs, by streamlining the process of informed consent and separating prevention counseling from testing. Similar guidelines have been issued by the USPSTF for STIs, which recommends that all sexually active women under 25 years be routinely screened and that in high-risk areas screening should be expanded based on populations served.22 Like the CDC recommendations for HIV testing, the USPSTF recommendations recognize the ED as an important clinical setting for STI screening.

In response to the evolving and growing interest in public health and preventive emergency medicine, Academic Emergency Medicine (AEM), the journal of the SAEM, convened a consensus conference entitled “Public Health in the ED: Surveillance, Screening, and Intervention” as part of its 2009 annual meeting. The conference goals included 1) development of consensus statements to establish priorities and highlight opportunities in public health research in emergency medical care, 2) development of recommendations to advance an agenda for public health research in emergency medical care, and 3) development of a framework for building a research network related to public health research in emergency medicine (EM). This article describes the results of the HIV and STI prevention breakout session of the consensus conference. The objectives of this session were to use experts to define knowledge gaps and priority research questions related to the performance of HIV and STI surveillance, screening, and intervention in the ED. The resultant work summarizes the consensus-based recommendations made by this expert group and should help inform future research and funding in these areas.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. References
  9. Supporting Information

This evaluation was approved by the Colorado Multiple Institutional Review Board and a waiver of written informed consent was granted. Participants provided consent through voluntary response to the surveys.

Nominal Group Technique

The work described in this article represents the results of both an electronic survey and a breakout session related to HIV and STI prevention in the ED and the AEM consensus conference. A nominal group technique (NGT) was applied to develop a set of agreed upon knowledge gaps and priority research questions for future investigations related to HIV and STI prevention in the ED. NGT is a group-based method through which information is gathered from experts in a structured way, and consensus on a particular topic is facilitated.23 This technique allows for continued refinement of individual ideas related to a specific content area so that coherent solutions or themes may emerge.

The four steps of the NGT include 1) silent generation of ideas, in which the problem is introduced to the group and each individual has the opportunity to independently generate ideas related to the problem; 2) sharing ideas, in which group members engage in round-robin feedback to concisely record each idea without debate; 3) discussion of ideas, in which each recorded item is discussed to determine clarity and importance, allowing participants to express their understanding of the logic and relative importance of each item; and 4) voting and ranking, in which independent prioritization of ideas relative to the objective is undertaken. Because the consensus conference was held on a single day, the NGT was applied in stages prior to, during, and after the conference.

Participants

National and international experts in HIV and STI prevention were invited to participate in the nominal group approach. Potential participants were identified from 1) the membership of the National Emergency Department HIV Testing Consortium;24 2) authorship on recent scientific abstracts related to HIV or STIs in the ED from the annual meetings of SAEM, the American College of Emergency Physicians (ACEP), the Conference on Retroviruses and Opportunistic Infections (CROI), the Infectious Diseases Society of America (IDSA), and the 2008 National Summit on HIV Diagnosis, Prevention, and Access to Care; 3) authors of recently published peer-reviewed articles on HIV or STIs in the ED; and 4) direct contact of specific HIV and STI experts. We used the different approaches described above to ensure that a maximal number of key stakeholders were contacted and invited to participate.

Data Collection

Stage 1 consisted of generating ideas related specifically to knowledge gaps and priority research questions prior to the consensus conference. This was accomplished using electronic mail to ask the following two open-ended questions to the group of identified experts: what are the current knowledge gaps related to HIV or STI surveillance, screening, or intervention in the ED and what are the highest priority research questions related to HIV or STI surveillance, screening, or intervention in the ED? All responses were anonymous during Stage 1.

Stage 2 consisted of sharing and discussing the ideas generated in Stage 1 during the 1-hour breakout session on HIV and STI prevention in the ED at the 2009 AEM consensus conference. This process allowed group members to engage in an interactive feedback session to clarify each knowledge gap and priority research question and to allow participants to express their understanding of the logic and relative importance of each item. All proposed knowledge gaps and priority research questions were reviewed and participants were allowed to provide additional knowledge gaps or priority research questions not previously described. Each list was then finalized prior to Stage 3.

Stage 3 was also performed during the breakout session at the 2009 AEM consensus conference. Its goal was to generate a streamlined priority list of knowledge gaps and research questions for presentation to the entire group during Stage 4. Development of these streamlined priority lists was accomplished by each breakout session participant independently voting on whether he or she agreed or disagreed that the proposed knowledge gap was actually a knowledge gap using the following four-level Likert-type scale: completely agree, generally agree, generally disagree, or completely disagree. Additionally, each participant independently voted on whether he or she agreed or disagreed that the proposed priority research questions were actually research priorities using the same Likert-type scale and then rank-ordered them from highest priority to lowest priority. Finally, each participant independently voted on whether he or she thought each priority research question should be led primarily by EM or be primarily collaborative. All voting during Stage 3 was performed using closed-response data collection instruments and completed prior to the end of the breakout session held during the consensus conference.

Stage 4 consisted of distributing a revised survey related to knowledge gaps and priority research questions to all the experts identified to participate from the beginning. This survey incorporated revisions and refinement generated during Stage 3 and represented a focused list of knowledge gaps and research priorities resulting from Stage 3 voting. All responses were anonymous during this stage. This stage was accomplished by generating an electronic survey instrument (Zoomerang, MarketTools, Inc., San Francisco, CA) and requesting responses via electronic mail.

Data Management and Statistical Analyses

Data were either entered manually or transferred electronically into an electronic spreadsheet (Microsoft Excel, Microsoft Corporation, Redmond, WA) and then transferred into native SAS or Stata formats using translational software (df/Power DBMS/Copy, DataFlux Corporation, Cary, NC). Analyses were performed using SAS Version 9.2 (SAS Institute, Inc., Cary, NC) or Stata SE Version 10 (StataCorp, College Station, TX). Data are reported using descriptive statistics.

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. References
  9. Supporting Information

Stage 1

A total of 184 potential participants were identified. Of these, 39 responded to the initial invitation, providing 54 potential knowledge gaps and 27 potential research priorities. Potential knowledge gaps were broadly categorized into the following nine areas (listed in descending order of frequency): 1) enhanced use or availability of epidemiologic and prevalence data (eight items); 2) comparison of HIV testing options (e.g., opt-out screening, targeted screening, or diagnostic testing [seven items]); 3) rapid STI testing (six items); 4) cost and cost-effectiveness of HIV and STIs (six items); 5) follow-up care for HIV infection (six items); 6) laboratory or computerized technological aids for HIV and STI testing (five items); 7) detailed understanding of acceptability and feasibility in patients and staff (four items); 8) consent processes for HIV testing (three items); and 9) initiation and implementation of new testing and screening programs (two items). There were seven items that could not be grouped into one of these categories.

Potential research priorities were broadly categorized into the following seven areas (listed in descending order of frequency): 1) sustainability of ED-based HIV and STI testing (seven items); 2) follow-up care for those identified with HIV infection (five items); 3) comparison of HIV testing or screening (four items); 4) enhanced data collection, integration, and utilization for both HIV and STIs (four items); 5) funding and legislation for HIV and STI testing and screening (three items); 6) rapid tests for STIs (two items); and 7) implementing prevention interventions (two items). Knowledge gaps and research priorities were generally similar with regard to content areas, although individual responses to research priorities were more precisely defined.

It was noted from individual responses that respondents were more likely to specify HIV than STIs. However, many responses were applicable to both HIV and STIs and were presented as such in Stage 2. Some individual responses were redundant or closely related; therefore, a streamlined list of 35 knowledge gaps and 28 research priorities was presented in Stage 2 (see Data Supplement S1, available as supporting information in the online version of this paper). The knowledge gaps that were most commonly repeated were related to cost-effectiveness and comparison of screening or testing strategies.

Stage 2

Knowledge gaps and research priorities identified from Stage 1 were presented to the 21 attendees of the HIV and STI prevention breakout session of the 2009 AEM Consensus Conference. Of the 21 attendees, 14 were members of the original cohort from Stage 1. As a result of discussion and clarification during the round-robin format, two additional knowledge gaps and one additional priority research question were added, resulting in 37 total knowledge gaps and 29 total research questions. Two additional knowledge gaps were significantly modified to clarify meaning, and minor revisions were made to three other research questions.

Stage 3

Of the 37 knowledge gaps, 11 distinguished themselves as having the highest complete agreement, highest agreement overall, and lowest disagreement among participant voting during Stage 3. These 11 items were then presented to the original cohort during Stage 4 (Table 1).

Table 1.    Results From Stage 4: Most Agreed Upon Knowledge Gaps (N = 38)
The 11 Priority Knowledge Gaps Identified During Stage 3 and Re-presented During Stage 4Agreement, n (%)
  1. Priority items identified during Stage 3 were re-presented to participants in Stage 4. Results of Stage 4 election are presented in this table. “Agreement” includes responses “completely agree” and “generally agree.” Not all cells sum to 38 due to missing responses.

  2. HIV = human immunodeficiency virus; STI = sexually transmitted infection.

 1. Optimal utilization of ancillary staff to support HIV or STI screening in the ED.33 (94)
 2. Utility of rapid HIV testing algorithms to improve the predictive value of HIV testing in the ED.32 (91)
 3. Cost-effectiveness of different HIV testing or screening strategies in the ED.34 (89)
 4. Detailed understanding of the differences between opt-out and opt-in consent methods as a part of HIV screening in the ED.31 (82)
 5. Interface between technological innovations and HIV or STI screening in the ED.31 (82)
 6. Influence of the consent processes on acceptance of HIV or STI screening in the ED.28 (80)
 7. Lack of true benchmarks to measure the effectiveness of HIV or STI testing in EDs.28 (80)
 8. Utility of a multicentered consortium to streamline methods for evaluation of HIV and STI surveillance, screening, and intervention in the ED.27 (77)
 9. Differences between pediatric and adult EDs regarding HIV and STI prevalence and testing strategies.27 (77)
10. Impact of repeat ED visits on HIV surveillance.26 (74)
11. Prevalence and risk factors for coinfection of HIV and STIs among patients in the ED.27 (71)

Of the 29 priority research questions, 14 were also presented during Stage 4 (Table 2). Of the 14 priority research questions, eight distinguished themselves as having an overall agreement, rank, and proportion identified as EM-led greater than the median response. Additionally, we included the only item that was voted 100% EM-led (“Would empirically derived clinical prediction instruments to assess risk for HIV infection improve the effectiveness of targeted screening in the ED?”) and five items for which there was significant disagreement among participants during Stage 3 (i.e., a similar proportion of respondents agreeing and disagreeing as to the item’s importance as a research priority).

Table 2.    Results from Stage 4: Most Agreed Upon and Highest Ranked Research Priorities (N = 38)
The 14 Priority Research Questions Identified During Stage 3 and Re-presented During Stage 4Agreement, n (%)Priority Rank 1st, 2nd, 3rd, n (%)Primarily EM-led, n (%)
  1. Priority items identified during Stage 3 were re-presented to participants in Stage 4. Results of Stage 4 election are presented in this table. “Agreement” includes responses “completely agree” and “generally agree.” Not all cells sum to 38 due to missing responses.

  2. HIV = human immunodeficiency virus; STI = sexually transmitted infection.

 1. How can HIV testing be incorporated into a broader public health approach in the ED (e.g., would it be effective to integrate HIV and STI testing with other needed screenings with dedicated workers)?33 (94)7 (30)23 (72)
 2. What are the main factors influencing staff acceptance of HIV and or STI screening in the ED?32 (91)4 (14)7 (22)
 3. Is HIV testing sustainable as a permanent part of clinical care in the ED relative to other competing clinical priorities?31 (89)10 (40)12 (37)
 4. What is the cost-effectiveness of HIV testing in the ED relative to other clinical venues?31 (89)10 (38)21 (66)
 5. What are the key factors that contribute to sustainability of ED-based HIV testing? 31 (89)5 (21)11 (34)
 6. To what extent do technological innovations (e.g., automated or streamlined consent or order sets, rapid turnaround conventional HIV testing, etc.) improve the effectiveness and or efficiency of performing HIV screening in the ED?31 (89)3 (12)16 (50)
 7. What is the most effective approach to linking newly diagnosed HIV-infected patients into medical care from the ED?30 (86)11 (42)25 (78)
 8. How many additional ED visits (and other health care visits) are prevented by earlier diagnosis of HIV infection?30 (86)9 (33)17 (53)
 9. Can a national (ED-centric) HIV testing registry or databank improve outcomes (e.g., update of HIV testing by other sites, more rapid data exchange, and leveraging of funding)?30 (86)4 (17)12 (37)
10. What are the main factors influencing patient acceptance of HIV and or STI screening in the ED?29 (83)5 (22)9 (28)
11. What is the optimal frequency of HIV and or STI testing in the ED?29 (83)4 (16)20 (63)
12. What are the acceptance rates by patients of different HIV testing methods (e.g., diagnostic, targeted, and nontargeted)?28 (80)3 (13)15 (47)
13. Would empirically derived clinical prediction instruments to assess risk for HIV infection improve the effectiveness of targeted screening in the ED?27 (77)5 (19)12 (37)
14. How does obtaining separate informed consent impact effectiveness of HIV screening in the ED?24 (69)4 (15)11 (34)

Stage 4

There were 38 respondents during Stage 4. Three items emerged as being the most agreed upon knowledge gaps related to HIV and STI prevention in the ED. The knowledge gaps were disparate and did not have an overarching theme. Knowledge was thought to be most lacking regarding optimal utilization of ancillary staff to support HIV or STI screening in the ED, the utility of rapid HIV testing algorithms to improve the predictive value of HIV testing in the ED, and cost-effectiveness of different HIV testing or screening strategies in the ED (Table 1). The items with the highest proportion of participants disagreeing that they were important knowledge gaps were the prevalence and risk factors for coinfection of HIV and STIs among patients in the ED, the impact of repeat ED visits on HIV surveillance, the utility of a multicentered consortium to streamline methods for evaluation of HIV and STI surveillance, and differences between pediatric and adult EDs regarding HIV and STI prevalence and testing strategies. These disagreements, however, do not indicate that these knowledge gaps are unimportant, rather that they were less important relative to other items on the list.

The items that had the greatest proportion of complete agreement and highest rank for priority research questions had some similarities to one another (Table 2). Two of these items related to sustainability. Participants thought it was yet to be determined whether HIV testing is sustainable as a permanent part of clinical care in the ED relative to other clinical priorities (item 3) and that it was a high priority to determine what the key factors are that contribute to the sustainability of ED-based HIV testing (item 5). Related to sustainability, the item that almost all participants agreed with was to determine how HIV testing can be incorporated into a broader public health approach in the ED (item 1). Items 3 and 5 were thought to be primarily collaborative research priorities rather than primarily EM-led, although item 1, which more specifically discusses integration of HIV testing with other public health EM concerns, was frequently indicated as being a primarily EM-led initiative (72%). Just as items 1 and 3 consider integration with other ED services, item 4, the cost-effectiveness of HIV testing relative to other clinical venues, was one of the items given more importance by rank, and two-thirds of respondents classified this as a primarily EM-led research priority. Effectiveness was incorporated in the final two items that were important research priorities: determining the most effective approach to linking newly diagnosed HIV-infected patients into medical care from the ED (item 7) and the extent to which technological innovations might improve the effectiveness and/or efficiency of performing HIV screening in the ED (item 6). Item 7 was classified as principally an EM-led activity, while item 6 was evenly split between being a collaborative or an EM-led activity.

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. References
  9. Supporting Information

Through two rounds of nomination and refinement followed by two rounds of election, consensus was achieved for several knowledge gaps and priority research questions related to HIV and STI prevention in EDs. The overarching themes of the research priority questions were related to effectiveness, sustainability, and integration; knowledge gaps, as expected, were related to the research priority questions identified. Careful evaluation of consent processes, and learning how to maximize the utility of ancillary staff, may have direct applications to improving effectiveness, by streamlining procedures and improving the efficiency of resource utilization.

Research and program proposals aimed at producing sustainable HIV and STI testing and screening should define and incorporate generalizable measures of effectiveness. As noted in some individual responses through the NGT (see Data Supplement S1), to determine the sustainability of HIV and STI testing in the ED would require comparison of other ED public health priorities and services and also comparison of ED HIV and STI testing to other ED clinical priorities. These types of comparisons, with a standardized and well-designed approach, would help determine factors that contribute to the success or failure of an ED HIV or STI testing program, relative to other public health and clinical priorities. Effectively linking newly diagnosed HIV-infected patients into medical care may be a part of the definition of a successful testing program and may contribute to its sustainability. Technological innovations may be evaluated in the same manner—as contributors to effectiveness, sustainability, or integration. However, while discrete questions may be posed, the overall measures of success and sustainability that will lead to broad implementation of programs will require rigorous methodology and significant financial and resource support.

Based on the results of our process, we recommend at least two global research foci for HIV and STI testing in the ED that are primarily EM-led initiatives: 1) comparative assessment of methods for incorporation of ED HIV and STI testing into a broader public health approach in the ED and 2) identifying the key determinants of a sustainable ED HIV testing program as part of routine clinical care. These two global research priorities will likely encompass numerous other research questions, but it will take more than one, two, or a few studies to provide deeper insight into these initiatives. Comparability and generalizability will require ongoing HIV and STI testing and input from numerous EDs serving a variety of populations.

The consensus-based recommendations reported in this article are potentially limited in several ways. Although several attempts were made to identify and contact key stakeholders, participation and response rates were potentially biasing. Results from Stage 4 were anonymous, yet only 38 individuals responded. By definition, NGT aims to determine stakeholder priorities through a participatory process. While participants in the four stages were meant to represent the key stakeholders by the nature of the process itself, it is impossible to know this with certainty. Additionally, key stakeholders were primarily individual investigators and not individuals from funding agencies. It is therefore unknown whether the identified knowledge gaps or priority research questions reflect the priorities of stakeholders from agencies that fund investigations within this content area.

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. References
  9. Supporting Information

Using a consensus approach, we developed a set of priorities for future research related to HIV and STI prevention in the ED. These priorities have the potential to improve future clinical and health services research and extramural funding in this important public health sector.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. References
  9. Supporting Information

The authors thank Steve Bernstein, MD, and Gail D’Onofrio, MD, MS, who served as co-chairs of the 2009 Academic Emergency Medicine Consensus Conference. The authors also thank Emily Hopkins, MSPH, who provided invaluable assistance with data collection related to Stage 4 of the nominal group process.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. References
  9. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. References
  9. Supporting Information

Data Supplement S1. Appendix.

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