No HIV Diagnosis Differences Seen Between Targeted, Nontargeted Screening

Findings of a randomized controlled trial revealed no differences among HIV diagnosis rates between targeted screening practices when compared with nontargeted practices.

In emergency departments (EDs), targeted HIV screening was not superior to nontargeted HIV screening, according to results of a randomized clinical trial published in JAMA Network Open. Although all strategies identified relatively low numbers of new HIV diagnoses, nontargeted screening resulted in significantly more tests performed, authors wrote.

A significant number of individuals living HIV remain undiagnosed in the United States, while the CDC and US Preventive Services Task Force (USPSTF) recommend routine nontargeted screening in most medical settings. In the past, both groups supported the practice of targeted (risk-based) HIV screening as well.

To compare targeted and nontargeted HIV screening strategies when integrated into practice across several EDs, researchers conducted a multicenter, prospective, pragmatic, 3-arm randomized clinical trial. The HIV Testing using Enhanced Screening Techniques in Emergency Departments (TESTED) trial was carried out in 4 high-volume EDs in Baltimore, Maryland; Cincinnati, Ohio; Denver, Colorado; and Oakland, California.

A total of 76,561 patient visits between April 2014 and January 2016 were randomized, while any individual younger than 16, unable to provide consent for HIV testing, known to be living with HIV, was a victim of sexual assault, had occupational exposure to HIV or had an anticipated ED stay length under 30 minutes was excluded from analyses.

Visit randomization was incorporated into each location’s electronic health record system via a computer-generated random number algorithm.

“Real-time randomization occurred 24 hours per day, providing concealed allocation with equal probability assignment to 1 of the 3 HIV screening arms,” authors wrote, which included nontargeted HIV screening, enhanced targeted HIV screening, and traditional targeted HIV screening.

Those in the enhanced arm underwent screening using the Denver HIV Risk Score, which includes 6 variables and yields a composite score indicating risk. Meanwhile, those in the traditional arm underwent screening using the Behavioral Risk Screening Tool, whereby 1 affirmative response to any question prompted automatic testing by a nurse.

Data from 67,964 unique individuals with a median age of 40 were included in final analyses. A slim majority (51.2%) were women, while 39.4% were Black, 32.6% were non-Hispanic White, and 21.4% were Hispanic. In addition, 25,469 were randomized to nontargeted screening; 25,453 to enhanced targeted screening; and 25, 639 to traditional targeted screening. Most participants were insured through Medicaid.

Analyses revealed:

  • Of the nontargeted group, 6744 participants (26.5%) completed testing and 10 (0.15%) were newly diagnosed
  • Of the enhanced targeted group, 13,883 participants (54.5%) met risk criteria, 4488 (32.3%) completed testing, and 7 (0.16%) were newly diagnosed
  • Of the traditional targeted group, 7099 participants (27.7%) met risk criteria, 3173 (44.7%) completed testing, and 7 (0.22%) were newly diagnosed
  • When compared with nontargeted screening, targeted strategies were not associated with a higher rate of new diagnoses (enhanced targeted and traditional targeted combined: difference, −0.01%; 95% CI, −0.04% to 0.02%; RR, 0.7; 95% CI, 0.30 to 1.56; P = .38; and enhanced targeted only: difference, −0.01%; 95% CI, −0.04% to 0.02%; RR, 0.70; 95% CI, 0.27 to 1.84; P = .47)
  • Of the 24 new diagnoses, the median (interquartile range [IQR]) initial CD4 cell count and viral load were 339 (197-529) cells/μL and 28,959 (5359-106,000) copies/mL, respectively, with 1 case identified as acute (4.2%; 95% CI, 1.1% to 21.1%) and 4 (16.7%; 95% CI, 4.7% to 37.4%) as AIDS

Results indicated targeted screening may be more efficient as less tests were used among these individuals. “Notably, all 3 screening strategies exceeded the 0.1% HIV test prevalence threshold for performing routine screening as suggested by the CDC and supported by cost analyses,” researchers wrote. One year after diagnosis the majority of AIDS-defined patients also had improved CD4 cell counts.

“Despite not identifying a clearly superior approach, this trial does support the importance of routine screening for HIV in EDs,” authors said. However, additional understanding of how screening interventions affect ED operational efficiency, their cost effectiveness, and acceptance by patients and staff warrants additional research.

“As progress toward ending the HIV epidemic in the US has stalled over the past few years, it is now especially critical to utilize all diagnostic approaches and venues, leveraging EDs in ways that are pragmatic and sustainable to decrease undiagnosed HIV,” researchers stressed.

Because all EDs included in this analysis had experience performing HIV screening, results may not be generalizable to community EDs, marking a limitation to the study. In addition, as the number of new HIV diagnoses was smaller than anticipated, this may have limited researchers’ ability to identify significant differences.


Haukoos JS, Lyons MS, Rothman RE, et al. Comparison of HIV screening strategies in the emergency department a randomized clinical trial. JAMA Netw Open. Published online July 26, 2021. doi: 0.1001/jamanetworkopen.2021.17763