Randomized Comparison of Universal and Targeted HIV Screening in the Emergency Department
Randomized Comparison of Universal and Targeted HIV Screening in the Emergency Department
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DOI：
10.1097/qai.0b013e3182a21611
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发表时间：
2013-11-01
影响因子：
3.6
通讯作者：
Fichtenbaum, Carl J.
中科院分区：
文献类型：
--
作者：
Lyons, Michael S.;Lindsell, Christopher J.;Fichtenbaum, Carl J.
目标：建议进行全民艾滋病毒筛查，但实施起来具有挑战性。有选择地针对高危人群被认为会漏掉病例，但之前的研究受到风险标准狭窄、实施不完整和缺乏直接比较的限制。我们假设，当全面实施并使用最广泛的风险标准时，有针对性的艾滋病毒筛查可以通过更少的检测检测出几乎与普遍筛查一样多的病例。 方法：这项单中心集群随机试验比较了在流行率较低的城市急诊室进行艾滋病毒筛查的普遍和有针对性的患者选择。患者因年龄（64 岁）、已知的 HIV 感染或当天之前进行过 HIV 检测的方法而被排除。针对从图表、员工推荐或自我披露中发现的任何风险指标进行有针对性的筛查。无论风险如何，都提供普遍筛查。基线血清阳性率是根据连续的未识别血样估计的。结果：有 9572 次符合条件的就诊期间接触过患者。对于普遍筛查，40.8% (1915/4692) 同意，其中 6 人是新诊断的 [0.31%，95% 置信区间 (CI)：0.13% 至 0.65%]。对于针对性筛查，37% (1813/4880) 没有检测指征。在剩下的 3067 名患者中，47.4%（1454 名）同意，其中 3 名是新诊断的（0.22%，95% CI：0.06% 至 0.55%）。估计血清阳性率为 0.36%（95% CI：0.16% 至 0.70%）。针对性筛查的同意比例较高（47.4% vs. 40.8%，P < 0.002），但 ED 接受检测的比例较低（29.7% vs. 40.7%，P < 0.002）。结论：针对性筛查，即使完全实施最大允许选择，也不会显着提高阳性率或减少进行的检测。尽管同意率略低，但普遍筛查诊断出更多病例，因为接受了更多检测。
Objective: Universal HIV screening is recommended but challenging to implement. Selectively targeting those at risk is thought to miss cases, but previous studies are limited by narrow risk criteria, incomplete implementation, and absence of direct comparisons. We hypothesized that targeted HIV screening, when fully implemented and using maximally broad risk criteria, could detect nearly as many cases as universal screening with many fewer tests.Methods: This single-center cluster-randomized trial compared universal and targeted patient selection for HIV screening in a lower prevalence urban emergency department. Patients were excluded for age (64 years), known HIV infection, or previous approach for HIV testing that day. Targeted screening was offered for any risk indicator identified from charts, staff referral, or self-disclosure. Universal screening was offered regardless of risk. Baseline seroprevalence was estimated from consecutive deidentified blood samples.Results: There were 9572 eligible visits during which the patient was approached. For universal screening, 40.8% (1915/4692) consented with 6 being newly diagnosed [0.31%, 95% confidence interval (CI): 0.13% to 0.65%]. For targeted screening, 37% (1813/4880) had no testing indication. Of the 3067 remaining, 47.4% (1454) consented with 3 being newly diagnosed (0.22%, 95% CI: 0.06% to 0.55%). Estimated seroprevalence was 0.36% (95% CI: 0.16% to 0.70%). Targeted screening had a higher proportion consenting (47.4% vs. 40.8%, P < 0.002), but a lower proportion of ED encounters with testing (29.7% vs. 40.7%, P < 0.002).Conclusions: Targeted screening, even when fully implemented with maximally permissive selection, offered no important increase in positivity rate or decrease in tests performed. Universal screening diagnosed more cases, because more were tested, despite a modestly lower consent rate.