Research Objective:

1. Standard and Rapid HIV Testing Practices in Safety Net Hospitals R. Hasnain-Wynia,1 G. Torres,1 H. Whitmore,1 J. Pickreign, K. Stanger, 1 R. Kang, 1 and G. Bazzoli2 1-Health Research and Educational Trust 2-Virginia Commonwealth University Conclusions Results Abstract Aims . • General Findings • 98% of core safety net hospitals offer HIV testing compared to 94% of non-safety net hospitals. • 10% of core safety net hospitals offer rapid HIV testing compared to 1% of voluntary safety net hospitals. • 10% of core safety net hospitals offer HIV testing in their emergency departments compared to 0% of voluntary safety net and non-safety net hospitals. • 34% of labor and delivery units in core safety net hospitals offer HIV testing compared to 18% of labor and delivery units in non-safety net hospitals. • 7% of outpatient centers in core safety net hospitals offer HIV testing compared to two percent in non-safety net hospitals. • Knowledge of rapid HIV testing is similar across core, voluntary, and non-safety net hospitals. • 47% of non-safety net hospitals do not use rapid testing versus 28% of safety net hospitals. • 41% of emergency departments in core safety net hospitals provide rapid testing versus 21% in non-safety net hospitals. • 32% of labor and delivery departments in core safety net hospitals provide rapid testing versus 17% in non- safety net hospitals. • 14% of outpatient centers in safety net hospitals use rapid testing compared to 5.5% in non-safety net hospitals. • (All values significant at p<.05). Research Objective: The CDC estimates that 1 in 4 people living with HIV in the U.S. are unaware of their HIV status. The use of rapid HIV testing in hospitals yields an opportunity to readily identify HIV infections and refer these patients to care. There continue to be missed opportunities for early HIV testing in hospital settings, which often serve as a primary access point for many indigent at-risk or HIV-infected patients. The U.S. health system relies on the hospital safety net to provide care to the uninsured and indigent, but little is known about safety net hospitals’ standard and rapid HIV testing practices. The objective of this paper is to examine standard and rapid HIV testing practices in safety net and non-safety net hospitals. Study Design: Surveys on HIV testing were mailed to 4,497 non-federal, short-term hospitals. 1,230 hospitals completed the survey for a 27.4% response rate. Data were weighted to adjust for non-response. We matched 623 metro hospitals from the American Hospital Association database to completed HIV surveys. Population Studied: We identified and classified hospitals into three categories by their safety net status, core safety net, voluntary safety net and non-safety net, focusing on the actual amount of uncompensated care provided. Principal Findings: 98% of core safety net hospitals offer HIV testing compared to 94% of non-safety net hospitals. 10% of core safety net hospitals offer inpatient HIV testing compared to 1% of voluntary safety-net hospitals. 10% of core safety net hospitals offer HIV testing in their emergency departments compared to 0% of voluntary safety-net hospitals. 34% of labor and delivery units in core safety net hospitals offer HIV testing compared to 18% in non-safety net hospitals. 7% of outpatient centers in core safety net hospitals offer HIV testing compared to 2 % in non-safety net hospitals (all values significant at p<.05). Knowledge of rapid HIV testing is similar across the three hospital categories. 47% of non-safety net hospitals don’t use rapid testing versus 28% of safety net hospitals. 41% of emergency departments in core safety net hospitals provide rapid testing versus 21% in non-safety net hospitals. 32% percent of labor and delivery departments in core safety net hospitals provide rapid testing versus 17% in non-safety-net hospitals. 14% of outpatient centers in safety net hospitals use rapid testing compared to 5.5% in non-safety net hospitals (all values significant at p<.05). Conclusions: Safety net hospitals are more likely to provide standard and rapid HIV testing compared to non-safety net hospitals. However, given the CDC recommendations for universal testing for (1) all pregnant women and (2) all patients in hospitals serving high prevalence communities (greater than 1%), overall testing rates are low. Implications for Policy, Delivery, or Practice: HIV testing is more likely to take place in core safety net hospitals. Given their important role in providing care to the indigent and to at-risk populations, policymakers should focus on mechanisms to distribute the burden of care by considering financial support to offset uncompensated care costs. Primary Funding Source:The Centers for Disease Control and Prevention* • Safety net hospitals are more likely to provide standard and rapid HIV testing compared to non-safety net hospitals. • However, given the CDC recommendations for universal testing for (1) all pregnant women and (2) all patients in hospitals serving high prevalence communities (greater than 1%), overall testing rates are low. • The primary aim of this study is to examine standard and rapid HIV testing practices in safety net and non-safety net hospitals. Methods • Surveys sent to all non-federal, short-term general hospitals in the United States identified through the American Hospital Association Database. • -Survey sent to 4,497 hospitals total • -Surveys received from 1230 hospitals (27.4% response) • -Survey administered through the internet and mail (paper-based) • -Data collected from March 2 through April 16, 2004. • Data weighted to adjust for non-response • -Hospital ownership/control status • -Census division • -Metropolitan status • Data post-stratified following a raking method to target population based on the AHA annual survey • -Census division • -Metropolitan status • -Number of beds • -Ownership/control • -AIDS burden • Population studied • -Matched 623 metro hospitals from the American Hospital Association Database to completed HIV surveys. • -Identified and classified hospitals into three categories by their safety net status based upon the actual amount of uncompensated care provided. • (1) Core Safety Net:High market share/high burden—hospitals that play a large community role in providing uncompensated care and generally have a large institutional commitment to providing indigent care. (n=30) • (2) Voluntary Safety Net: High burden only—hospitals that have a high uncompensated care burden but not high market share. May serve as a safety net for immediate communities but do not treat a large number of indigent patients in the broader market, or high market share hospitals that play a major role in the community in providing uncompensated care but have paying patients who generate revenues that cover a large proportion of their expense; (n=99) • (3) Non-Safety Net Hospitals (n=494) • Analytic Approach: • -Conducted descriptive and bivariate analyses Implications for Policy, Practice, or Delivery • HIV testing is more likely to take place in core safety net hospitals. Given their important role in providing care to indigent and to at-risk populations, policymakers should focus on mechanisms to distribute the burden of care by considering financial support to offset uncompensated care costs. • Given the role of safety net hospitals and emergency departments as the primary or sole access point to medical care for many at-risk or HIV-positive patients, these findings indicate that there continue to be many missed opportunities for early diagnosis. Background • In the United States, HIV infection is usually discovered at an advanced stage, usually in the course of medical care and often during care for complications of AIDS. • 1993 MMWR RR-02: CDC recommended: “Hospitals with seroprevalence of at least 1% or an AIDS diagnosis rate ≥ 1.0 per 1,000 discharges should strongly consider adopting a policy of offering HIV counseling and testing routinely to patients 15-54 years.” • 2003 MMWR, Vol 52: Increased HIV testing in clinical settings and routine screening in acute care settings in high prevalence areas. • For the CDC to incorporate routine HIV testing in more clinical settings, need an understanding of the current state of HIV testing in hospitals • The U.S. health system relies on hospital safety net to provide care to many indigent at-risk HIV-infected patients, but little is known about safety net hospitals standard and rapid HIV testing practices. *This project was made possible through a cooperative agreement between the Centers for Disease Control (CDC) and Prevention and the Association of Teachers of Preventive Medicine (ATPM), award number TS-0990; its contents are the responsibility of the authors and do not necessarily reflect the official views of the CDC or ATPM.