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Revising Expectations from Rapid HIV Tests in the Emergency Department

Rochelle P. Walensky, MD, MPH; Christian Arbelaez, MD, MPH; William M. Reichmann, MA; Ron M. Walls, MD; Jeffrey N. Katz, MD, MSc; Brian L. Block, BA; Matthew Dooley, BA; Adam Hetland, BA; Simeon Kimmel, BA; Jessica D. Solomon, BS; and Elena Losina, PhD
[+] Article and Author Information

ClinicalTrials.gov registration number: NCT00502944.


From Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, and Partners AIDS Research, Boston, Massachusetts.


Acknowledgment: The authors thank the co-investigators and staff of the USHER Trial, including Carrie Braverman, Susan Larrabee, Regina Mikulinsky, Paul Sax, and Elizabeth Wright. They also thank the faculty and staff of Brigham and Women's Hospital emergency department for their participation in the USHER Trial and for their dedication to the identification of undiagnosed HIV infection, especially the emergency service assistants and focus group members. Finally, they thank Kenneth A. Freedberg, MD, MSc, and A. David Paltiel, PhD, for critical review of the manuscript; Doug Owens, MD, for advice and study critique; and Mariam Fofana for technical assistance.

Grant Support: By the National Institute of Mental Health (R01 MH073445, R01 MH65869) and the Doris Duke Charitable Foundation, Clinical Scientist Development Award (Dr. Walensky).

Potential Financial Conflicts of Interest: None disclosed.

Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Walensky (e-mail, rwalensky@partners.org).

Requests for Single Reprints: Rochelle P. Walensky, MD, MPH, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114; e-mail, rwalensky@partners.org.

Current Author Addresses: Dr. Walensky: Division of General Medicine, Massachusetts General Hospital, 50 Staniford Street, 9th Floor, Boston, MA 02114.

Drs. Arbelaez and Walls: Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

Mr. Reichmann and Drs. Katz and Losina: Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, 75 Francis Street, BC 4-4016, Boston, MA 02115.

Mr. Block: Partners AIDS Research Center, 149 13th Street, Room 5234k, Charlestown, MA 02129.

Mr. Dooley, Mr. Hetland, Mr. Kimmel, and Ms. Solomon: Department of Emergency Medicine, USHER Trial Research Assistant, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

Author Contributions: Conception and design: R.P. Walensky, E. Losina.

Analysis and interpretation of the data: R.P. Walensky, W.M. Reichmann, J.N. Katz.

Drafting of the article: R.P. Walensky, C. Arbelaez, E. Losina.

Critical revision of the article for important intellectual content: R.P. Walensky, C. Arbelaez, W.M. Reichmann, R.M. Walls, J.N. Katz, B.L. Block, M. Dooley, A. Hetland, S. Kimmel, J.D. Solomon, E. Losina.

Final approval of the article: R.P. Walensky, C. Arbelaez, W.M. Reichmann, J.N. Katz, B.L. Block, M. Dooley, A. Hetland, S. Kimmel, J.D. Solomon, E. Losina.

Provision of study materials or patients: R.P. Walensky, R.M. Walls.

Statistical expertise: W.M. Reichmann, J.N. Katz, E. Losina.

Obtaining of funding: R.P. Walensky.

Administrative, technical, or logistic support: R.M. Walls, B.L. Block, M. Dooley, A. Hetland, S. Kimmel, J.D. Solomon.

Collection and assembly of data: R.P. Walensky, W.M. Reichmann, B.L. Block, M. Dooley, A. Hetland, S. Kimmel, J.D. Solomon.


Ann Intern Med. 2008;149(3):153-160. doi:10.7326/0003-4819-149-3-200808050-00003
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The USHER Trial screened 849 patients in the emergency department with an oral OraQuick HIV test. The estimated prevalence of newly identified HIV infection was 0.6%, which supports continued screening in the emergency department in compliance with the CDC guidelines (1). During this study, 39 patients (4.6%) had reactive results on rapid oral HIV tests; the estimated specificity of these tests was 96.9% (CI, 95.7% to 98.1%). Depending on assumptions about test sensitivity (33.3% to 100%), the positive likelihood ratio ranged from 8.2 to 32.2. Thus, patients with a reactive oral OraQuick HIV screening test in the emergency department have an 8- to 32-fold increased odds of HIV infection relative to the pretest odds.

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Figure 2.
Posterior probability of HIV infection under alternative assumptions about the true infection status of patients with unconfirmed test results.

Assumptions about the frequency of false-negative results (sensitivity) do not affect the posterior probability of infection after a positive test result.

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Comments

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Post-test probability only 16% for rapid HIV test
Posted on August 21, 2008
james r korb
Southern California Permanente Medical Group
Conflict of Interest: None Declared
In the abstract, Wallensky et.al reported that the rapid HIV test, when used in the emergency room had specificity of 96.9%. The chance that a person with a positive rapid test actually had HIV was 16% (5/31). It would be more helpful to cite this post-test probability of 16% in the abstract rather than the specificity of the test. Conflict of Interest:

None declared

Revising expectations from rapid HIV tests in the emergency department.
Posted on August 26, 2008
Hadi Meeran Hussain
Department Of Internal Medicine,combined military hospital,lahore
Conflict of Interest: None Declared

In this study by Walensky et al,the authors report on the experience of implementing a rapid oral HIV screening test in 849 unselected patients in Massachusetts.(1) Before we start promoting rapid, non-invasive HIV screening in the emergency department and perhaps in other health care settings, we must have evidence that the proposed screening method is fully reliable. Thirty-nine patients had a reactive result, but of the 31 patients who allowed a confirmatory serum testing, only five (16%) were HIV-infected. The specificity of the rapid oral test was lower than anticipated. Although the study clearly shows that the specificity of the oral test utilized is low in this setting, the sensitivity was not assessed because the non-reactive test results were not confirmed.

References:

1.Walensky RP, Arbelaez C, Reichmann WM, Walls RM, Katz JN, Block BL, Dooley M, Hetland A, Kimmel S, Solomon JD, Losina E.Revising expectations from rapid HIV tests in the emergency department.Ann Intern Med 2008;149(3):153-60

Conflict of Interest:

None declared

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Summary for Patients

Rapid Oral Testing for HIV Infection

The summary below is from the full report titled “Revising Expectations from Rapid HIV Tests in the Emergency Department.” It is in the 5 August 2008 issue of Annals of Internal Medicine (volume 149, pages 153-160). The authors are R.P. Walensky, C. Arbelaez, W.M. Reichmann, R.M. Walls, J.N. Katz, B.L. Block, M. Dooley, A. Hetland, S. Kimmel, J.D. Solomon, and E. Losina.

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