Abstract
BACKGROUND AND OBJECTIVES:
Adolescents account for one-fifth of new HIV infections in the United States. Despite Centers for Disease Control and Prevention (CDC) recommendations for universal opt-out HIV screening for individuals aged 13 years or older in all health care settings, many adolescents remain undiagnosed due to limited access to testing. This study aimed to describe HIV testing rates in US pediatric emergency departments (EDs) and identify patient and hospital factors associated with testing.
METHODS:
We conducted a cross-sectional study of pediatric ED encounters for patients aged 13 to 18 years at 40 US children’s hospitals (January 2019-December 2023). Patient and hospital characteristics were analyzed using multivariable logistic regression analysis to assess associations with HIV testing.
RESULTS:
Of 2 134 464 ED encounters, 28 052 (1.3%) included HIV testing. Of these, 75% (n = 20 972) were targeted tests based on ED diagnoses, whereas 25% (n = 7080) were screening tests. Factors associated with HIV testing were female sex (adjusted odds ratio [aOR], 1.46; 95% CI, 1.42–1.51), Black/African American race (aOR, 1.71; 95% CI, 1.65–1.77), 2 or more races documented (aOR, 1.52; 95% CI, 1.38–1.66), public insurance (aOR, 1.69; 95% CI, 1.63–1.75), and living in very low Childhood Opportunity Index neighborhoods (aOR, 1.67; 95% CI, 1.59–1.75). Hispanic/Latino (aOR, 0.84; 95% CI, 0.80–0.87), Asian (aOR, 0.73; 95% CI, 0.64–0.83), and adolescents with complex chronic conditions (aOR, 0.53; 95% CI, 0.49–0.57) were less likely to have HIV testing.
CONCLUSIONS:
HIV testing during pediatric ED encounters was rare, demonstrating an opportunity to enhance pediatric HIV screening practices in accordance with recommendations from the CDC.
INTRODUCTION
In 2022, adolescents and young adults aged 13 to 24 years accounted for 20% of new HIV infections in the United States.1 On average, adolescents live with HIV for 2.7 years before diagnosis due to numerous challenges associated with HIV testing in this age group, including concerns around confidentiality, stigma, and disparities in health care access.2–5 Individuals who receive a late HIV diagnosis face worse outcomes and greater risk of severe disease and comorbidities and may unknowingly contribute to HIV transmission.6 Adolescents living with HIV face additional challenges across the care continuum, including lower rates of linkage to care, treatment adherence, and viral suppression, and are particularly vulnerable to being lost to follow-up when entering care in adolescence compared with childhood or adulthood.7,8 Furthermore, many adolescents rely on acute care settings for their medical needs.9 Thus, pediatric emergency departments (EDs) may represent an underutilized opportunity for early HIV detection and intervention in this vulnerable population.
Since 2006, the US Centers for Disease Control and Prevention (CDC) has recommended routine universal opt-out HIV screening for all individuals aged 13 years or older in all health care settings.10 Adolescents use emergency care services in lieu of primary health care at higher rates than other age groups, and those that do often engage in behaviors associated with significant health risks.11 Although HIV screening has been successfully implemented in adult EDs,12,13 it remains uncommon and inconsistent in pediatric EDs as demonstrated in prior single-center studies that have reported HIV screening rates from 2% to 37%.14–17 Contemporary knowledge of national HIV testing rates in pediatric EDs is lacking.
Prior reports from single centers have demonstrated that the majority of pediatric ED testing for HIV has been in pilot programs of limited duration, leaving a gap in understanding of real-world application of HIV screening in this setting.14 Thus, in order to provide a more comprehensive understanding of current pediatric ED HIV testing practices, we aimed to (1) determine the frequency of HIV testing and (2) identify patient- and hospital-level factors associated with HIV testing in pediatric EDs. Such an understanding can serve as a baseline to inform further implementation of CDC recommendations and reduce the spread of HIV through augmented identification of HIV among adolescents in the United States.
METHODS
Study Design and Population
We conducted a cross-sectional study of pediatric ED encounters in the Pediatric Health Information System (PHIS) database from January 2019 to December 2023. We included encounters for patients aged 13 to 18 years that were discharged from the ED. We limited our population to ED discharge encounters, as we were unable to confirm timing of an HIV test if an encounter was converted to an inpatient stay. Encounters that resulted in death were excluded. Encounters with an International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code for an HIV-related illness included in the CDC list of diagnostic criteria for AIDS, or with an ICD-10-CM code for HIV disease or infection status, were excluded because these populations would not need HIV testing if the diagnosis was already known.18
This study was exempted from review by the institutional review board at Children’s Healthcare of Atlanta. We followed the Strengthening the Reporting of Observational Studies in Epidemiology statement for observational studies.19
Study Setting
PHIS is an administrative database that contains encounter and resource utilization data for children’s hospitals in the United States.20 Quality and reliability are assured through a joint effort between the Children’s Hospital Association and participating hospitals.20 Data were included from the 40 out of 48 PHIS hospitals that had continuous contribution to the database each year of the study period.
Outcomes
The primary outcome was documentation of laboratory testing for HIV as determined by the presence of clinical transaction classification codes (Supplemental Table 1). Encounters with ICD-10-CM codes related to (a) pregnancy, (b) sexual health and sexually transmitted infection (STI) or disease (STD) including STI-referable symptoms (eg, lower abdominal pain, dysuria, etc), (c) symptoms of HIV or diagnoses associated with HIV, or (d) a combination of 1 or more of these were classified as targeted HIV tests (Supplemental Table 2). All other encounters with an HIV test were classified as having HIV screening.
Variables
The following characteristics were extracted from the database as coded by PHIS: patient age, sex, race, ethnicity, insurance type (private, public, or other), Childhood Opportunity Index (COI),21 and presence of complex chronic condition.22 Hospitals within PHIS record race and ethnicity by hospital-specific practices, which includes caregiver report during registration.23 We included race and ethnicity, conceptualized as social constructs, to assess potential disparities in testing practices that could reflect bias or discrimination.24 COI measures neighborhood conditions affecting child development using 29 weighted indicators across education, health, and socioeconomic domains; scores range from 1 to 5, with 1 representing the bottom 20% of neighborhoods nationally.21 Hospital locations were categorized according to US Census regions.25
Analyses
Categorical data were summarized with counts and percentages. Continuous variables were summarized as medians and interquartile ranges (IQRs). We performed univariate and multivariable mixed-effect logistic regression analyses, clustering on hospitals, to identify demographic, clinical, and hospital factors during pediatric ED encounters with HIV testing compared with those without HIV testing. Candidate variables were selected a priori based on hypotheses that stemmed from published literature that age, sex, race, ethnicity, insurance coverage, socioeconomic status, medical complexity, and hospital region would impact the decision to obtain an HIV test.26–29 Additionally, referent groups were selected a priori based on hypothesized low likelihood of HIV testing. Temporal trends in HIV testing rates, overall and by encounter type, were assessed using the Cochran-Armitage trend test. All statistical analyses were performed in R Statistical Software (version 4.2.1; R Core Team 2022).
RESULTS
There were 2 331 902 pediatric ED encounters during the study period; 197 339 (9%) were excluded, leaving 2 134 563 analyzed encounters (Figure 1). The median patient age was 15 years (IQR, 14–16); 55% (n = 1 182 064) were female, 52% (n = 1 106 625) were white, 30% (n = 616 834) were Hispanic or Latino, 58% (n = 1 241 042) were publicly insured, 29% (n = 614 666) had a COI score of 1 (very low), and 6% (n = 118 513) had a complex chronic condition (Table 1); and 38% (n = 813 708) of pediatric ED encounters were in the Southern United States.
FIGURE 1.
Study population flow diagram.
Abbreviations: ED, emergency department; ICD-10-CM, International Classification of Diseases, 10th Revision, Clinical Modification; PHIS, Pediatric Health Information System; STD, sexually transmitted disease.
TABLE 1.
Descriptive Characteristics of Included Pediatric Emergency Department Encounters
| Characteristic | Overall N = 2 134 563, n (%) |
Had HIV Testing | No HIV Testing N = 2 106 511, n (%) |
|||||
|---|---|---|---|---|---|---|---|---|
| All Encounters N = 28 052, n (%) |
Encounters With ICD-10 Codes Related to: | |||||||
| (a) Pregnancy N = 348, n (%) | (b) Sexual Health and/or STIs N = 15 209, n (%) | (c) HIV Symptom and/or Associated HIV Diagnosis N = 1125, n (%) | Combination of a, b, c N = 15 209, n (%) | Other Encounters N = 7080, n (%) |
||||
| Age, median (IQR) | 15 (14–16) | 16 (15–17) | 16 (15–17) | 16 (15–17) | 17 (16–17) | 16 (15–17) | 16 (15–17) | 15 (14–16) |
| Sex | ||||||||
| Female | 1 182 064 (55) | 21 784 (78) | 348 (100) | 11 915 (78) | 601 (53) | 4094 (95) | 4826 (68) | 1 160 280 (55) |
| Male | 952 100 (45) | 6258 (22) | 0 | 3292 (22) | 524 (47) | 196 (5) | 2246 (32) | 945 842 (45) |
| Missing | 399 (0) | 10 (0) | 0 | 2 (0) | 0 (0) | 0 | 8 (0) | 389 (0) |
| Race | ||||||||
| American Indian or Alaskan Native | 5231 (0) | 54 (0) | 1 (0) | 32 (0) | 1 (0) | 5 (0) | 15 (0) | 5177 (0) |
| Asian | 41 155 (2) | 232 (1) | 3 (1) | 105 (1) | 10 (1) | 33 (1) | 81 (1) | 40 923 (2) |
| Black or African American | 554 103 (26) | 14 405 (51) | 219 (63) | 7963 (52) | 441 (39) | 2370 (55) | 3412 (48) | 539 698 (26) |
| Missing | 77 813 (4) | 731 (3) | 12 (3) | 376 (2) | 32 (3) | 150 (3) | 161 (2) | 77 082 (4) |
| Native Hawaiian or Pacific Islander | 5366 (0) | 54 (0) | 0 (0) | 31 (0) | 3 (0) | 7 (0) | 13 (0) | 5312 (0) |
| Other | 305 151 (14) | 2675 (10) | 41 (12) | 1429 (9) | 116 (01) | 200 (5) | 889 (13) | 302 476 (14) |
| 2 or more races | 39 119 (2) | 567 (2) | 3 (1) | 288 (2) | 25 (2) | 80 (2) | 171 (2) | 38 552 (2) |
| White | 1 106 625 (52) | 9334 (33) | 69 (20) | 4985 (33) | 497 (44) | 1445 (34) | 2338 (33) | 1 097 291 (52) |
| Ethnicity | ||||||||
| Hispanic or Latino | 616 834 (30) | 5383 (20) | 67 (20) | 2998 (20) | 252 (23) | 556 (13) | 1510 (22) | 611 451 (30) |
| Not Hispanic or Latino | 1 471 414 (70) | 22 199 (80) | 275 (80) | 11 958 (80) | 843 (77) | 3677 (87) | 5446 (78) | 1 449 215 (70) |
| Missing | 46 315 (0) | 470 (0) | 6 (0) | 253 (0) | 30 (0) | 57 (0) | 124 (0) | 45 845 (0) |
| Payer | ||||||||
| Private | 743 736 (35) | 5327 (19) | 30 (9) | 2560 (17) | 329 (29) | 768 (18) | 1640 (23) | 738 409 (35) |
| Public | 1 241 042 (58) | 18 798 (67) | 273 (79) | 10 509 (69) | 698 (62) | 2441 (57) | 4877 (69) | 1 222 244 (58) |
| Othera | 141 453 (7) | 3791 (14) | 43 (12) | 2052 (14) | 94 (8) | 1072 (25) | 530 (8) | 137 662 (7) |
| Missing | 8332 (0) | 136 (0) | 2 (0) | 88 (0) | 4 (0) | 9 (0) | 33 (0) | 8196 (0) |
| Childhood Opportunity Index | ||||||||
| Very low =1 | 614 666 (29) | 13 075 (47) | 215 (62) | 7362 (48) | 423 (38) | 1876 (44) | 3199 (45) | 601 591 (29) |
| Low = 2 | 393 092 (18) | 4860 (17) | 49 (14) | 2556 (17) | 181 (16) | 880 (21) | 1194 (17) | 388 232 (18) |
| Moderate = 3 | 363 917 (17) | 4172 (15) | 46 (13) | 2268 (15) | 197 (18) | 626 (15) | 1035 (15) | 359 745 (17) |
| High = 4 | 331 611 (16) | 2966 (11) | 22 (6) | 1566 (10) | 146 (13) | 419 (10) | 813 (11) | 328 645 (16) |
| Very high = 5 | 425 083 (20) | 2925 (10) | 14 (4) | 1422 (9) | 175 (16) | 486 (11) | 828 (12) | 422 158 (20) |
| Missing | 6194 (0) | 54 (0) | 2 (1) | 35 (0) | 3 (0) | 3 (0) | 11 (0) | 6140 (0) |
| Complex chronic condition = Yes | 118 513 (6) | 825 (3) | 6 (2) | 278 (2) | 106 (9) | 132 (3) | 303 (4) | 117 688 (6) |
| Geographic region of hospital | ||||||||
| Midwest | 627 603 (29) | 7432 (26) | 48 (14) | 3765 (25) | 219 (19) | 1997 (47) | 1403 (20) | 620 171 (29) |
| Northeast | 218 039 (10) | 3833 (14) | 53 (15) | 2052 (13) | 181 (16) | 119 (3) | 1428 (20) | 214 206 (10) |
| South | 813 708 (38) | 13 184 (47) | 213 (61) | 7590 (50) | 501 (45) | 1914 (45) | 2966 (42) | 800 524 (38) |
| West | 475 213 (22) | 3603 (13) | 34 (10) | 1802 (12) | 224 (20) | 260 (6) | 1283 (18) | 471 610 (22) |
Abbreviations: ICD-10, International Classification of Diseases, 10th Revision; N, total population size; n, subgroup of total population; STI, sexually transmitted infection.
Defined as Children’s Health Insurance Program, free care, self-pay, or TRICARE per the Pediatric Health Information System database.
HIV Testing During Pediatric ED Encounters
Of the 2 134 563 included encounters, 1.3% (n = 28 052) included an HIV test, corresponding to a rate of 13.1 tests/1000 encounters. Of these, 75% (n = 20 972) were classified as targeted tests and 25% (n = 7080) were classified as screening tests. Encounters with HIV testing completed had a median patient age of 16 years (IQR, 15–17), 78% (n = 21 784) were female, 53% (n = 14 405) were Black or African American, 20% (n = 5383) were Hispanic or Latino, 67% (n = 18 798) were publicly insured, 47% (n = 13 075) had a COI score of 1 (very low), and 3% (n = 825) had a complex chronic condition.
Pediatric ED encounters with an ICD-10-CM code related to pregnancy (0.3%, n = 7688), STI or sexual health concerns (9%, n = 182 728), HIV symptoms and/or an associated HIV diagnosis (2%, n = 46 727), or a combination of these categories were identified. HIV testing was performed in 5% (n = 348), 8% (n = 15 209), 2% (n = 1125), and 8% (n = 4290) of these encounters, respectively. Among pediatric ED encounters with an HIV test, 94% (n = 24 653) also included testing for at least 1 other STI (Supplemental Table 3). HIV testing most frequently was done concomitantly with testing for chlamydia (85%, n = 23 887), gonorrhea (75%, n = 20 917), and syphilis (55%, n = 15 336).
The Southern United States accounted for 38% (n = 813 708) of all included pediatric ED encounters and 47% (n = 13 184) of those with HIV testing. HIV testing rates per 1000 pediatric ED encounters were as follows: Midwest (11.8), Northeast (17.6), South (16.2), and West (7.6).
HIV testing rates varied by diagnostic category over time (Figure 2). Testing done with multiple targeted indications present peaked in 2020, declined during the COVID-19 pandemic, and rose again in 2023 (P < .001). HIV screening rates, although low, increased significantly over time (P < .001).
FIGURE 2.
Pediatric emergency department HIV testing rates by encounter diagnosis group, 2019–2023.
Abbreviations: Assoc., Associated; Dx, Diagnosis; STDs, sexually transmitted diseases; Sym., Symptoms.
Factors Associated With HIV Testing in the Pediatric ED
Factors independently associated with HIV testing in the pediatric ED included female sex (adjusted odds ratio [aOR], 1.46; 95% CI, 1.42–1.51), Black or African American race (aOR, 1.71; 95% CI, 1.65–1.77), 2 or more races (aOR, 1.52; 95% CI, 1.38–1.66), public insurance (aOR, 1.69; 95% CI, 1.63–1.75), other insurance (aOR, 2.60; 95% CI, 2.48–2.73), and living in very low COI neighborhoods (aOR, 1.67; 95% CI, 1.59–1.75; Table 2).
TABLE 2.
Univariate and Multivariable Logistic Regressions of Patient- and Hospital-Level Factors Associated with HIV Testing in Pediatric Emergency Departments
| Characteristic | Odds Ratio (95% CI) | Adjusted Odds Ratio (95% CI) |
|---|---|---|
| Age, years | 1.42 (1.40–1.43)a | 1.27 (1.26–1.28)a |
| Sex | ||
| Female | 2.80 (2.72–2.88)a | 1.46 (1.42–1.51)a |
| Male | Referentb | Referentb |
| Race | ||
| American Indian or Alaskan Native | 1.15 (1.03–1.29)a | 0.99 (0.76–1.28) |
| Asian | 0.67 (0.62–0.73)a | 0.73 (0.64–0.83)a |
| Black or African American | 2.47 (2.40–2.54)a | 1.71 (1.65–1.77)a |
| Native Hawaiian or Pacific Islander | 1.12 (1.00–1.26) | 1.05 (0.82–1.35) |
| Other | 1.23 (1.18–1.29)a | 1.01 (0.96–1.06) |
| 2 or more races | 1.63 (1.51–1.76)a | 1.52 (1.38–1.66)a |
| White | Referentb | Referentb |
| Ethnicity | ||
| Hispanic or Latino | 0.80 (0.77–0.82)a | 0.84 (0.80–0.87)a |
| Not Hispanic or Latino | Referentb | Referentb |
| Payer | ||
| Private | Referentb | Referentb |
| Public | 2.24 (2.17–2.30)a | 1.69 (1.63–1.75)a |
| Other | 3.45 (3.30–3.59)a | 2.60 (2.48–2.73)a |
| Childhood Opportunity Index | ||
| Very low =1 | 3.07 (2.96–3.19)a | 1.67 (1.59–1.75)a |
| Low = 2 | 1.98 (1.90–2.07)a | 1.38 (1.31–1.45)a |
| Moderate = 3 | 1.71 (1.64–1.79)a | 1.29 (1.22–1.36)a |
| High = 4 | 1.42 (1.35–1.49)a | 1.17 (1.11–1.24)a |
| Very high = 5 | Referentb | Referentb |
| Complex chronic condition = Yes | 0.50 (0.47–0.53)a | 0.53 (0.49–0.57)a |
| Encounter ICD-10 grouping | ||
| (a) Pregnancy | 12.36 (11.29–13.54)a | 6.02 (5.37–6.75)a |
| (b) Sexual health and/or STI/STDs | 24.93 (24.23–25.64)a | 21.68 (21.04–22.35)a |
| (c) HIV symptom and/or associated HIV diagnosis | 6.79 (6.42–7.19)a | 6.77 (6.34–7.23)a |
| Combination of a, b, or c | 25.56 (24.48–26.68)a | 18.69 (17.82–19.61)a |
| Other (presumed HIV screens) | Referentb | Referentb |
| Geographic region of hospital | ||
| Midwest | Referentb | Referentb |
| Northeast | 0.73 (0.29–1.85) | 0.84 (0.44–1.57) |
| South | 1.58 (0.80–3.12) | 1.53 (0.10–2.39) |
| West | 0.81 (0.37–1.74) | 1.08 (0.58–2.02) |
Abbreviation: ICD-10, International Classification of Diseases, 10th Revision;
STI, sexually transmitted infection; STDs, sexually transmitted diseases.
P < .001.
Referent groups were selected a priori based on hypothesized low likelihood of HIV testing.
When compared to encounters with HIV screening tests, encounters with targeted HIV tests had associations with the following ICD-10-CM groups: (a) pregnancy (aOR, 6.02; 95% CI, 5.37–6.75), (b) sexual health or STI/STDs (aOR, 21.68; 95% CI, 21.04–22.35), (c) HIV symptoms and/or an associated HIV diagnosis (aOR, 6.77; 95% CI, 6.34–7.23), or a combination of these ICD-10-CM code groups (aOR, 18.69; 95% CI, 17.82–19.61).
Hispanic or Latino patients (aOR, 0.84; 95% CI, 0.80–0.87), Asian patients (aOR, 0.73; 95% CI, 0.64–0.83), and those with complex chronic conditions (aOR, 0.53; 95% CI, 0.49–0.57) were less likely to have HIV testing during pediatric ED encounters. In adjusted analyses, HIV testing did not vary by geographic region.
DISCUSSION
HIV testing in pediatric EDs was exceptionally low, representing a missed opportunity to identify adolescents who may have HIV. Among encounters with ICD-10-CM codes related to pregnancy, sexual health, STIs or disease, HIV symptoms, or associated HIV diagnoses, only 1% included HIV testing, despite these encounters accounting for 13% of pediatric ED visits. Our temporal analysis was congruent with other published studies that demonstrated a reduction in HIV testing and screening during the COVID-19 pandemic.30–32 Only 0.3% of all analyzed adolescent pediatric ED encounters had an HIV screen completed or an HIV screening rate of 3.3 tests per 1000 pediatric ED encounters. Although rare, the increase in HIV screening rates over time may represent growing awareness and recognition of CDC recommendations, technological advances, or public health campaigns and initiatives.33,34
These rates are lower than those reported in prior single-center studies with established HIV testing and screening programs, which ranged from 2% to 37%.14–17 Our study extends previous findings by reporting multicenter HIV testing rates within pediatric EDs. Our lower rates likely reflect the lack of established HIV testing and screening practices within pediatric EDs as well as the many competing interests within this practice setting. Future studies are indicated to assess whether implementing recommended opt-out HIV screening programs in pediatric EDs can improve time to HIV diagnosis for adolescents.
Our findings indicate that HIV testing in pediatric EDs was most often conducted in a targeted manner and accompanied by at least 1 other STI test. Prior studies have reported low rates of concurrent HIV testing among individuals diagnosed with other STIs and have highlighted the need for more integrated approaches to STI and HIV testing, particularly among high-risk populations.35–37 In many pediatric ED encounters, blood and urine testing may not be clinically indicated. Thus, a systems-level barrier to implementation of universal opt-out HIV testing may be variability in noninvasive HIV test availability.38 Limited access to noninvasive HIV testing options, such as rapid oral buccal swabs, may constrain feasibility even when ED providers are willing to offer screening tests. Further consideration of the availability of noninvasive testing methodologies is needed to support earlier HIV diagnosis.
Our study adds to the body of literature that suggests HIV testing is more frequently conducted among adolescents who are older, are female, have public insurance, and are from lower socioeconomic status.39,40 Additionally, we observed that Black or African American adolescents were more likely to be tested for HIV compared with white adolescents and that non-Hispanic adolescents were more likely to be tested compared with Hispanic or Latino adolescents. Although our study did not directly measure or evaluate provider intent or bias, these disparities in HIV testing practices may reflect implicit biases among clinicians who may associate the need for HIV testing with certain populations. This bias may inadvertently benefit some groups given factors such as poverty and low median household income that contribute to HIV transmission,1 but it may be detrimental to others such as Hispanic and Latino adolescents, who despite having an HIV prevalence rate 4 times that of white individuals,1 were 28% less likely to be tested for HIV in pediatric EDs compared with non-Hispanic or Latino adolescents.
Disparities in adolescent HIV testing are likely multifactorial.41 Within subpopulations identified in our study with lower rates of HIV testing in pediatric EDs, contributing factors may include limited English proficiency, cultural stigma, and stigma related to sexual identity and practices. One study found that no interpreter was used in 46% of ED encounters involving patients with limited English proficiency,42 potentially hindering effective communication. Language barriers have been linked to lower HIV testing rates and reduced awareness of HIV status in populations with limited English proficiency.43
Adolescent males were less likely to receive HIV testing in pediatric EDs. This is particularly important for adolescent men who have sex with men, who have a significantly lower awareness of their HIV status compared with other age groups. This may be due to fear of judgement by providers and family, lack of access to confidential testing, limited knowledge, and perceived vulnerability.1,44 Future studies are indicated to explore whether implementation of universal opt-out HIV testing in pediatric EDs can mitigate the impact of language barriers and cultural stigma adolescents face from minoritized populations.
When HIV testing was completed for an adolescent in the pediatric ED, it was most likely due to the encounter being related to STI care, sexual health concerns, or pregnancy. Even when HIV testing was indicated, our study found that only a minority of encounters with the identified ICD-10-CM codes included HIV testing. The CDC recommends HIV testing for all persons seeking STI evaluation and should occur at the time of STI evaluation, regardless of whether the patient reports specific behavioral risks for HIV.45 In the absence of universal opt-out screening, targeted HIV testing should be offered to adolescents, especially those who are (or may be) pregnant or seeking care for STI testing or evaluation, as STI diagnosis is a known marker for greater HIV acquisition risk.45 Future studies may use our testing rates as a benchmark to improve targeted HIV practices within pediatric EDs.
Our study demonstrated that HIV testing in pediatric EDs had no significant regional variability, despite differences in HIV prevalence across US regions. Although the Southern US region accounts for nearly half (49%) of new HIV infections and has the highest HIV prevalence,1 we found similar HIV testing rates in pediatric EDs across all regions. Increasing universal opt-out HIV testing in pediatric EDs, particularly in high-burden regions, should be strongly considered.
Low rates of HIV testing among adolescents in pediatric EDs, along with disparities suggestive of targeted rather than universal testing practices, highlight the need for multilevel interventions. To align with CDC testing recommendations and promote equitable health care delivery, health care providers and administrators, public health agencies, and policymakers should consider integrating noninvasive HIV testing methods,38,46 including HIV screening consent within general consent-to-treat documentation,10,47,48 embedding HIV testing prompts into electronic medical record workflows for eligible adolescents,15,46,49 and allocating resources to train ED providers and staff on the importance of HIV testing in acute care settings.50,51 Our findings are relevant to general EDs, where a substantial proportion of adolescent care occurs.52,53 General EDs may face additional barriers to testing adolescents for HIV, including variable adolescent-specific confidential history taking training, broader clinical demands, and limited pediatric-focused resources, which may make implementation of universal HIV screening even more impactful.54–56 Efforts must also focus on building strong linkage-to-care pathways for adolescents who test positive.
Limitations
Our study findings are subject to limitations. This was a multicenter study that used administrative codes in PHIS that are subject to inaccuracies in coding or documentation. The methods used to collect race and ethnicity may have varied, potentially affecting data consistency. Due to the retrospective nature of our study, assumptions were made regarding the intent of testing and whether it was targeted or screening based on each encounter’s assigned ICD-10-CM codes. We considered the possibility of classification bias for intent of testing. Therefore, each ICD-10-CM code designation was reviewed by the study group and classified based on both pediatric emergency medicine and adolescent medicine expertise (eg, an encounter with an STI-referable symptom with an HIV test was classified as a targeted test). We could not assess whether prior HIV tests were reviewed during ED encounters, whether HIV screening protocols were in place at each institution, or whether an HIV test was completed in an opt-out or opt-in fashion. Clinical transaction codes used to identify HIV testing did not specify the method of test collection (eg, serum collection, buccal swab), which has been shown to influence an adolescent’s decision to consent to an HIV test.38 Results of HIV tests are not available in the database to analyze seropositivity rates. However, the focus of this study was to elucidate HIV testing practices, not HIV testing results.
The PHIS database does not contain provider- or staff-level characteristics. Therefore, we could not examine the potential impact of implicit bias on HIV testing practices. Future studies could explore how provider-patient discordance in sex, race, ethnicity, or language may contribute to disparities in HIV testing. Finally, because this study contained data from pediatric EDs within children’s hospitals, our findings may not generalize to general EDs that care for children.
CONCLUSIONS
Almost 2 decades after the CDC recommended universal opt-out testing for individuals aged 13 years and older in all health care settings, adolescent HIV testing rates in pediatric EDs remain exceedingly low. Adolescents are more likely than other age groups to rely on acute care settings to meet health care needs, making pediatric EDs critical points of intervention. Successful implementation of HIV screening programs in pediatric EDs can play a pivotal role in the early identification and timely treatment of HIV in adolescents. Continued reliance on targeted testing practices may perpetuate disparities, as these approaches may be subject to implicit biases of providers, language barriers, cultural stigma surrounding sexuality, and assumptions about HIV risk based on socioeconomic or geographic factors. Future studies are needed to evaluate whether universal opt-out testing can mitigate disparities and promote more equitable HIV testing and screening practices in pediatric EDs.
Supplementary Material
WHAT’S KNOWN ON THIS SUBJECT:
Adolescents account for one-fifth of new HIV infections in the United States, the majority have delayed diagnoses due to unique challenges. Despite Centers for Disease Control and Prevention recommendations, HIV testing in pediatric emergency departments is inconsistent and infrequent, representing missed opportunities in this practice setting.
WHAT THIS STUDY ADDS:
This study provides the first national multicenter analysis of HIV testing in US pediatric emergency departments. It provides benchmark data to guide implementation of Centers for Disease Control and Prevention–recommended HIV screening in acute care settings to enhance HIV detection and improve adolescent health outcomes.
ACKNOWLEDGMENTS
We would like to thank Sidoine Manono Fotso espe Kamgang and Nikolay Braykov from the Children’s Healthcare of Atlanta advanced analytics and outcomes team and Scott Gillespie, MS, MSPH, from the Emory Pediatric Biostatistics Core for their assistance obtaining and analyzing data from PHIS. We would like to thank the following individuals for their feedback as members of the pediatric emergency medicine fellowship scholarly oversight committee: Dr Sherita Holmes, Dr Kim Norris, Dr Mark Griffiths, Dr Claudia Morris, Dr Sofia Chaudhary, Dr Srikant Iyer, Dr Wendy Little, Dr Brittany Murray, Dr Carmen Sulton, and Dr Hal Simon.
The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
FUNDING:
Dr Rees was supported by the National Institutes of Health (K23HL173694). The Emory Biomedical Informatics Core is supported by Clinical and Translational Science Award Grant UL1TR002378. This work was also supported by the Emory University Pediatric Biostatistics Core (RRID:SCR_025834). (Continued)
Footnotes
CONFLICT OF INTEREST DISCLOSURES: The authors have no conflicts of interest to disclose.
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