Barriers and Mitigating Strategies to Routine HIV Screening in Emergency Departments: A National Qualitative Study

Abstract

Objectives:

The goal of this study was to explore current barriers and mitigating strategies to routine HIV screening in emergency departments (EDs) using a national sample of ED leadership, including both physician and non-physician providers.

Methods:

We employed an exploratory research design informed by the consolidated criteria for reporting qualitative research. Participants were recruited from a comprehensive database of U.S. EDs, targeting directors from diverse urban, suburban, and rural settings. Data were collected from semi-structured interviews conducted during May 2023 to July 2024. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis.

Results:

Twenty-one individuals participated in the study. Five key themes were identified: 1) The role of the ED within HIV screening; 2) Adequate resources and buy-in – from staff to administration - are crucial for successful screening programs; 3) Institutional and structural determinants shape ED HIV screening; 4) HIV stigma persists; and 5) Operationalization of ED HIV testing is crucial. Participants highlighted the strategic potential of EDs for HIV screening, the need for institutional support, and challenges posed by staffing, logistical issues, and stigma.

Conclusions:

This study provides an in-depth exploration of the barriers and mitigating strategies to HIV screening in U.S. EDs through the lens of directors around the country. Despite the capacity and strategic potential of EDs to contribute to HIV prevention, significant challenges persist, including staffing, logistical issues, and stigma. Institutional investment in staff support systems, integration of HIV screening into electronic medical records, and efforts to normalize HIV screening are essential to enhance the efficacy of screening programs.

INTRODUCTION

As our healthcare system is faced with declining access to primary care, emergency departments (EDs) are asked to provide a growing number of services [1]. This includes testing for transmissible infectious diseases like HIV to help bridge the gap in access to essential healthcare services. Despite this, EDs still have some of the lowest HIV testing rates compared to other healthcare settings; roughly only 1% of ED visits include an HIV test and HIV testing is one of the least commonly offered preventive health service in ED settings [2–4]. EDs are uniquely positioned to help end the HIV epidemic because they are the safety net for vulnerable and medically underserved populations, including those at highest risk for HIV (e.g., those uninsured or have barriers to other forms of care) [2,5–7]. These low HIV testing rates are also concerning given that roughly 1 in 8 Americans living with HIV are unaware of their status and the estimated time from infection to diagnosis is more than 3 years [5,8]. Timely detection of HIV improves health outcomes by leading to earlier initiation of antiretroviral therapy, viral suppression, reduced morbidity and mortality, and decreased transmission; therefore, minimizing delays is critical [9].

The prevalence of HIV among ED patients exceeds that of the general population, underscoring the strategic importance of this setting [10–17]. More routine HIV screening in ED settings can uncover previously undiagnosed infections, link persons living with HIV to care earlier, and reduce transmission rates [18,19]. As a result of insufficient response to prior national HIV testing guidelines, the Department of Health and Human Services and the Centers for Disease Control and Prevention (CDC) recently launched the 2019 Ending the HIV Epidemic in the U.S. (EHE) initiative, which represents renewed efforts geared towards ending the epidemic and calls for increased HIV testing in all healthcare settings, including the ED [7,8,20,21].

Identifying what role EDs can (and should) play in ending the HIV epidemic is important as many Americans - due to limited access to primary care - are turning to EDs for routine care needs beyond “acute” unscheduled care; more than one-quarter of U.S. adults report no usual source of care or report that the emergency room is their usual source of care [22]. Additionally, due to economic hardships, millions of Americans experienced job loss and income reduction, contributing to a rise in the number of uninsured Americans living in poverty - furthermore, with the reversal of the Medicaid Continuous Enrollment provision, millions of Americans lost Medicaid coverage [23]. With these changes, many Americans facing poverty, lack of insurance, and limited alternatives are turning to EDs for their basic healthcare needs [24–26]. This number is anticipated to continue growing with further deterioration in access to primary care and public health systems.

The CDC has long recommended routine, opt-out, HIV screening in all health care settings, including EDs [27]. Professional organizations such as the American College of Emergency Physicians have also issued policy statements supporting ED-based HIV screening as part of emergency medicine’s role in public health [28]. Given ongoing calls for EDs to play a more active role in ending the HIV epidemic combined with the growing crises of ED boarding and overcrowding, it is important to understand barriers and mitigating strategies to routine HIV testing in EDs. Although prior studies identified barriers such as cost, the impact of testing on overcrowding and boarding, and the role of social determinants of health (e.g., poverty, HIV stigma, and discrimination), these challenges remain relevant [29–31]. Since the launch of EHE, federal momentum has increased pressure on EDs to expand HIV testing; this raises questions about how these longstanding barriers are being experienced in the current policy environment. Therefore, the primary goal of this study was to use semi-structured interviews with a national sample of frontline HIV testing ED leadership and content experts to explore current barriers and mitigating strategies to routine HIV screening in EDs. We deliberately employed qualitative research methods across a diverse sample of EDs and health systems with the hope of gleaning more in-depth insights that are essential for uncovering nuanced barriers and context-specific strategies.

MATERIALS & METHODS

Study Design and Setting

Informed by the consolidated criteria for reporting qualitative research, we employed an exploratory qualitative research design to elicit the perspectives of healthcare leaders in the U.S. about current HIV testing practices within ED settings [32]. Our team consisted of emergency physicians (SW; CLB), public health researchers (ART; RNN), and an emergency medicine non-clinical faculty member (SSS-S) with expertise in qualitative research methodology.

Selection of Participants and Data Collection

We previously conducted a national study on preventive health services in EDs using a comprehensive database of all non-federal, non-specialty U.S. EDs as a sampling framework [33]. This database is considered the gold standard within the field to engage with ED leadership. In our previous study we identified a nationally representative sample of ED leaders who expressed interest in participating in follow-up studies. These included physicians and non-physicians (i.e., nurse managers, nurse directors and nurse practitioners) as some leadership roles in rural EDs were held by non-physician staff. For the current study, we started recruiting from this already established list, inviting ED leaders to participate in a semi-structured interview about routine HIV testing. Recruitment efforts purposively sampled ED leaders from urban, suburban, and rural EDs, reflecting diversity in practice environments. We also included participants with different HIV screening practices (i.e., those that do screen and those that do not screen for HIV) as well as those from both EHE priority jurisdictions—areas targeted in the Ending the HIV Epidemic initiative—and non-priority jurisdictions.

Email invitations were sent inviting ED leadership to participate in a 1-hour semi-structured interview. Purposive and snowball sampling were used to collect data from subsequent participants. Interviews were conducted by SSS-S (female), ART (female), and/or CLB (male) from May 2023 – July 2024. Inclusion criteria consisted of holding an ED leadership position with some degree of oversight for ED HIV screening practices (for complete demographics please see Table 1). As the study progressed, our inclusion criteria was expanded to include emergency physicians with domain expertise in health services research surrounding preventive health services and/or ED-based HIV screening as these participants helped refine our developing themes. This study was approved by the Stanford University Institutional Review Board.

Table 1:

Participant Characteristics

Characteristic	N	(%)
Gender
Male	8	(38)
Female	13	(62)
Median Age (IQR), in years	46 (39–50.5)
Median Length of Clinical Practice (IQR), in years	15.5 (12.5–21.5)
Priority Jurisdiction
In Priority Jurisdiction	8	(38)
US Census Region
West	8	(38)
Midwest	4	19)
Northeast	7	(33)
South	2	(10)
Practice Background
Physician	17	(81)
Non-Physician	4	(19)

Abbreviations: IQR (Interquartile Range), US (United States)

Priority Jurisdiction indicates whether a participant’s location falls within a geographic area disproportionately impacted by HIV and prioritized by the Centers for Disease Control and Prevention in the Ending the HIV Epidemic Initiative.

After obtaining verbal informed consent for the interviews, participants were oriented to the purpose of the study, asked a series of questions related to what HIV screening looked like in their ED, and prompted to comment on any challenges they encountered (See Appendix A for interview guide). The interviewer(s) followed a semi-structured approach so that there were opportunities to ask clarifying questions and probe as needed. After 15 interviews, to ensure representation and confirm that emerging themes were consistent across participants, we then specifically recruited participants who previously indicated that HIV screening should not occur in the ED to ensure we had achieved data sufficiency. This sampling of discrepant cases help ensures rigor in qualitative research methodology. All interviews were audio-recorded, transcribed verbatim, and de-identified prior to data analysis.

Data Analysis

While our semi-structured interview guide was informed by existing literature (deductive framing), data were analyzed using an inductive approach, following the 6-steps of thematic analysis [34]. Familiarization of the data began with SSS and CLB reviewing the transcripts with corresponding field notes to identify initial ideas and concepts. This led to the generation of an initial set of codes (SSS and CLB). At which point, an independent coder (ART) was brought in to independently familiarize herself with the data and generate her own initial codes. Then, ART and CLB met to review their initial codes and search for themes among these codes with any discrepancies resolved via consensus. These codes and themes were presented to the larger research team (i.e., SSS, SW, RNN, CLB) for review and refinement. After which, the entire dataset was re-coded by one member of the research team (ART). Once our themes were finalized, a final report describing the five themes was generated.

RESULTS

Twenty-one individuals participated in the study; one additional person agreed to be interviewed, but not audio recorded; their data were excluded from our analysis. Interviews ranged in length from 29 to 62 minutes, with an average time of 41 minutes. Of the participants, 17 were ED physicians, and 4 were non-physicians. Regarding practice setting, 20 were from urban settings, 2 from suburban, and 3 from rural areas, with some individuals selecting more than one setting to reflect their current work environments. Our study identified five themes: 1) The role of the ED within HIV screening; 2) Adequate resources and buy-in – from staff to administration - are crucial for successful screening programs; 3) Institutional and structural determinants shape ED HIV screening 4) HIV stigma persists, and 5) Operationalization of ED HIV testing is crucial. Participants highlighted the strategic potential of EDs for HIV screening, the need for institutional support, and the challenges posed by staffing, logistical issues, and stigma. These themes are discussed in further detail using participant quotes identified by P#.

The Role of the ED within HIV Screening

The ED was frequently viewed as a catchall for individuals without access to primary care and for those who receive support from social and public health initiatives. Although participants disagreed about using the ED for HIV screening, the majority believed HIV testing should occur in the ED: “the ED sees everyone. So, I’m not kind of in that camp of, you know, it’s not emergency medicine” (P14). Some EDs have more resources and opportunities to conduct HIV screening, yet the majority of participants described the need for increased screening:

“30% of our volume is a very low socio-economic area with a lot of [intravenous] drug abuse and I think that in that particular part of the population we can do a lot more screening, whether it’s education when they come in when we’re doing any like I said, STD, STI, education and testing” (P12).

Participants disagreed, however, as to whether targeted vs. non-targeted screening would be most effective for HIV testing. Nearly half of participants believed targeted screening is optimal in the ED to screen patients at high-risk for HIV. Populations identified as high-risk by participants included people who inject drugs (PWID), men who have sex with men, patients who engage in high-risk heterosexual behavior, and patients presenting with certain symptoms of sexually transmitted infections (STIs). One participant spoke about how these questions could be built into ‘standards of care’:

“I think that it should be part of the protocol’s standards of care for any STI complaint, any needle stick complaint, any IV drug abuse complaint. I think that we should be building that into our standards of care” (P12).

Contrastingly, some participants felt HIV screening should only occur universally for patients having blood drawn: “our goal is to try to screen as many eligible people who were already having blood drawn” (P9).

Targeted testing relied on “the patient’s desire to have it” (P13) or having risk factors (i.e. PWID, STIs). Non-targeted screening was seen by participants as “ideal” (P21) for capturing positive cases, yet at the same time “just not feasible” (P9). ED screening was seen as vital for finding “a lot of new diagnoses” (P1) and the majority of participants felt this was crucial in reducing HIV spread. The ED can identify patients early and refer them to treatment, which is especially important with vulnerable populations otherwise missed within the healthcare system.

Adequate Resources and Buy-in – From Staff to Administration - are Crucial for Successful Screening Programs

Having personnel that believe in the program, identifying people willing to screen and follow up with patients, and situating this work squarely in public health are vital to ensure buy-in. One participant spoke about why this was important in their setting, “people just buy into the idea that we are responsible for all aspects of these patients’ health because they don’t get healthcare at other locations” (P17).

Utilizing health navigators was also described as helpful because “public health navigators or case managers or somebody to give a warm handoff to, that is easy” (P17) and these individuals could ease the burden of follow up and connecting patients with positive treatment. Relatedly, time required to complete work associated with HIV screening was seen as a significant barrier – reflecting not only a time pressure but also a broader paradigm that screening is not yet fully integrated into ED clinical care. Some participants attributed this to inadequate staffing as many EDs are functioning over capacity. One participant highlighted that screening requires follow-up:

“So you’re testing everyone for COVID, and then who’s calling the patients to tell them? [...] I would have had to employ a person full time just to do callbacks on all the testing that we were doing” (P5).

Institutional and Structural Determinants Shape ED HIV Screening

Within hospitals, participants thought automated screening processes integrated into the electronic medical record (EMR) systems would support HIV screening. As this one participant describes:

“I think EMR support is really important […] finding some kind of EMR, way of leveraging your EMR to help you with the screening, to help you figure out who needs to be screened, or help you get it easily ordered” (P1).

Although EMRs might be different for each health system, it highlights the importance of having an existing data infrastructure. Some participants described how competing priorities contributed to HIV screening being ignored or backgrounded. Providing care for the presenting concern was often prioritized over any additional screening; this created tension between addressing the presenting concern and managing resources for prevention of additional illnesses:

“They’re focused on making sure the patient’s okay, hooking them up to the monitor, making sure all the lights are off, making sure that they’re clean and decontaminated from all their own feces, getting them [...] You know, they’re dealing with so much bullshit that it’s like screening is the last priority, and then you have providers, and providers are also pretty stretched thin, and I don’t know if screening is the best use of providers, to be honest” (P20).

Incorporating screening and communicating the initiatives are challenging in the ED, especially with the evolving need to balance providing quality patient care and compliance with public health initiatives:

“There’s a lot coming at docs, and part of my job is to try to kind of remind people of, “Hey, we have this new resource in our ED. Don’t forget about them, they’re doing this,” or “Remember this thing that we educated you on. Don’t forget. Try to still use it” (P14).

Overcrowding and boarding – exacerbated by limited capacity - were identified as barriers to successful ED HIV screening. Participants also noted competing priorities from other ED- and hospital-level initiatives. Given these, for some participants, HIV screening seemed only possible when supported by individual champions or external grant funding:

“an individual provider who is passionate about a project and grant funding that makes systems possible. And I don’t think that is sustainable or the way to improve population health” (P18).

Participants also discussed financial barriers related to HIV testing, both well-established challenges and newer issues emerging within hospital systems. These were related to the cost of testing, for both the patient and hospital:

“We need to consider covering the cost of those tests, and that becomes a challenge, that we’ve had to deal with […]. After a few years of things going, our lab started billing the privately insured, for their test, and that’s helped offset some or most of the cost for self-pay, so that’s probably a zero-sum game for the lab, but they’re willing to do it kind of thing” (P19).

HIV Stigma Persists

The perceptions of societal stigma of living with HIV, as described by ED leadership, remains a significant barrier. Participants frequently noted that negative perceptions – particularly assumptions surrounding sexual orientation or behaviors – impact receptivity to testing. For some providers in smaller communities, it also directly impacted privacy, noting that patients might worry about others overhearing results, being “singled out,” or having private information shared in crowded spaces. For others, stigma existed for certain racial and ethnic groups. One participant described observing the impact of stigma,

“I mean on the patient end it’s definitely the stigma. Like I said, we work, we live in a very, diverse neighborhood, predominantly Hispanic, Bengali, different types of Southeast Asian. Those populations I’ve had a lot of push, like even just from the patient them self being, like, ‘No, no, no, like, I don’t have HIV.’ Then they just don’t want to test” (P3).

Participants also described that staff often feel “intimidated, unnecessarily” (P8) to talk to patients about HIV testing and may struggle due to “unfamiliarity with patient preferences” (P8), which may also contribute to discomfort. Some providers felt that the ED is a challenging venue to have conversations about sensitive topics like HIV. However, some participants noted that awareness of and knowledge about HIV – among both patients and medical providers - have improved through screening in the ED. Talking about HIV is one approach to decreasing stigma by “taking away the taboo of it” (P2).

Operationalization of ED HIV Testing is Crucial

Participants expressed how operationalizing ED HIV testing is crucial, especially in relation to how tests are requested. Although providers or patients could initiate testing, providers tended to initiate testing because patients presented with certain symptoms or were part of a certain group (e.g., PWID). One participant spoke about their heuristic for targeting screening:

“I don’t order an HIV test on every patient. I order it selectively based on [if] you’re presenting with these symptoms or you tell me something in the history of high risk behavior. So I mean, I don’t order a CBC on every patient, so I use it as part of my diagnostic armamentarium” (P15).

In some testing programs explicit patient consent was required, which some participants found challenging, especially compared to EDs that implemented opt out consent approaches (i.e., where patients are informed of testing and have the opportunity to decline). Sometimes the required consent was part of the general consent to treat: “I don’t ask the patient if they want a troponin. I’m just like, okay, you’re here and we’re gonna help you” (P8). Having a general opt out approach instead of a formal written or verbal consent process can also lead to success as this participant described,

“the language matters, and we’ve tried to change the language to one of ‘hey we screen everybody for testing, hope that’s okay with you’ so that it becomes much more of an opt out. That I think it’s highly effective when phrased in a manner like that” (P16).

Patients often requested tests after potential exposures (e.g., cases of rape or accidental needle sticks), “[…] but that’s pretty much the only time we do it at the request of [the] patient” (P11).

Offering HIV screening in the ED also provided opportunities to educate patients and the greater community about HIV. One participant explained the benefits of doing so, “it might inspire some educational conversations about what HIV is and how to protect oneself from HIV, how one gets it, all those sort of things” (P8).

Most participants described using blood-based HIV screening with approximately half of participants mentioning that they use some form of rapid testing in their department. The definition of “rapid” varied widely: for some it meant results within 2–3 hours, for others it implied results within 30–45 minutes; non-rapid test results were typically available within 24–48 hours, often requiring external lab processing. This delay was cited by participants as a barrier compared to rapid tests, which facilitated more immediate follow-up. There were also several differences in how patients were informed of their results, utilizing both internal and external resources; internally, it was often a healthcare provider (e.g., ordering physician, nurses, or a specifically identified callback provider). Healthcare navigator support was identified by some participants and one described how these folks were integrated into their system,

“Usually it’s the provider who’s counseling them about a positive result, what the implications of that might mean and the process of getting a confirmatory, and next steps. So that probably, 99 times out of 100, it’s managed by the provider. If it happens to be Monday through Friday at 10:00 AM, the linkage coordinator might be available to help with that counseling” (P19).

Externally, local public health departments were used by some participants to inform patients of their results. One participant described their role in this equation as being “just the conduit to get the sample and then everything from the sample onward goes to public health” (P15).

Some participants reported that their sites informed patients of results after their ED visit, while others were able to provide results before the patient left the hospital. A smaller group of participants described referring patients immediately to the infectious disease department after a positive test result with minimal insight about what happened next: “We have an infectious disease doctor here, who specifically deals with newly diagnosed HIV patients from our hospital. So, all of them get referred to her” (P4).

Most participants felt that screening for HIV in the ED was cost effective, often framing costs considerations from the perspective of the hospital, patient, or insurer. Costs to the hospital included staff time, materials, lab time, and unreimbursed expenses – such as costs not fully covered by the insurer. Costs to the patient were out of pocket expenses such as deductibles and self-pay charges. As one participant stated, “prevention is really the key, really with all aspects of health, but particularly HIV testing” (P6). Screening as a preventive tool was viewed as cost effective towards ensuring positive outcomes for both the patient and the healthcare system.

DISCUSSION

This study provides an in-depth qualitative exploration of barriers and offers mitigating strategies to enhance HIV screening in the U.S., using the perspective of ED leaders and experts in preventive health services. Currently, most EDs across the U.S. offer a growing number of preventive health services – yet HIV screening remains a notable exception [33,35]. Despite many EDs having the capacity to screen, HIV screening remains one of the least commonly offered preventive health services [35]. By interviewing a diverse group of participants, including physician and non-physician leaders with different training backgrounds, we were able to capture a broader range of perspectives and experiences related to HIV screening in EDs. Importantly, we still know very little about how HIV screening is implemented—or not—at individual sites, with not all EDs currently conducting HIV screening: this directly limits the pool of potential participants for studies like ours.

Our findings are situated within recent data demonstrating that although only a small proportion of ED leaders oppose offering preventive health services like HIV screening, many still express concerns that such services would lead to longer lengths of stay, increase costs to their EDs, and result in a diversion of staff time from providing acute care [33,35,36]. This raises important questions regarding the scope of services that should appropriately fall within the responsibilities of the ED. Given that the core mission of EDs is to provide rapid unscheduled care for acute and emergent conditions, expanding preventive care initiatives—such as routine HIV screening—must be carefully considered due to limited resources (e.g., staffing, space, funding), operational strain (e.g., ongoing demands of high ED volumes and overcrowding), and competing clinical priorities (e.g., the need to triage time-sensitive emergencies over preventive services) [30,31]. Within this context, cost emerged as a subtheme across multiple discussions: participants frequently described financial barriers at both the hospital- and patient-levels, noting that even when screening was perceived as cost-effective (in the long term), unreimbursed expenses, staff time, and patient out-of-pocket costs created persistent challenges to implementation. This underscores the tension between recognizing the economic value of screening and contending with the day-to-day financial realities of already overburdened ED systems.

While many emergency physicians support the public health value of HIV screening, there remains an ongoing debate about whether EDs should assume primary responsibility for its implementation as ideally, routine HIV screening would occur in the primary care setting [30, 31]. However, EDs are often tasked with filling gaps in the healthcare system. While ED-based HIV screening offers clear public health benefits, its integration into already overburdened systems underscores the need for thoughtful resource allocation, system-level support, and institutional commitment to ensure both feasibility and sustainability of these services. Nonetheless, our findings – and disagreements noted between participants regarding the most appropriate screening strategy (i.e., targeted or non-targeted) – suggests that many support more routine HIV testing when done purposefully and carefully. This aligns with recent national data from our group showing that while most U.S. EDs do not currently offer routine HIV screening, few directors oppose such services outright; instead, barriers are primarily related to cost and time [30,33].

Participants also reaffirm the strategic potential of EDs as underutilized access points for HIV screening, given their role as safety nets for underserved populations. Many ED utilizers may not seek or have access to primary care; EDs care for vulnerable populations and present a unique opportunity for national HIV-related efforts [4,6,7]. Our data highlight that while many EDs have capacity to contribute to HIV prevention, significant barriers persist. Our participants voiced concerns around staffing, the need for adequate training and buy-in from both clinical and non-clinical staff, and logistical issues related to follow-up care. Beyond the structural and logistical aspects of screening, participants also emphasized that having champions – including committed staff and health navigators – could make a meaningful difference in overcoming these barriers. This reinforces the importance of institutional investment in staff support systems to enhance the efficacy of screening programs. In addition, structured training interventions can reduce provider stigma and promote non-judgmental communication around HIV testing [37].

An important theme that participants discussed was the critical role that hospital infrastructure and systems play in facilitating (or hindering) screening efforts. The integration of HIV screening into EMRs and automated processes was cited as best practice for seamless implementation; prior work has demonstrated that EMR-based best practice alerts and automated prompts can substantially increase HIV screening uptake in EDs [10,12,38]. However, this was often at odds with competing hospital priorities, operational demands, and capacity constraints. Beyond testing itself, participants emphasized that linkage to care is a critical determinant of program success: without reliable pathways for confirmatory testing, referral, and care engagement, the benefits of ED-based screening are substantially diminished. Strengthening these linkage mechanisms—through dedicated navigators, care coordinators, or robust partnerships with outpatient HIV clinics—was viewed as essential to achieving the public health impact of ED screening. This is in the context of navigator programs having been shown to improve linkage to care and retention following ED-based HIV testing [39].

The study also foregrounds the persistent stigma surrounding HIV, which continues to be a barrier at both patient and provider levels [40]. As highlighted by participants, and through the work of others, HIV stigma continues to influence patient willingness to be tested and impacts provider comfort in initiating conversations about HIV, especially in communities with cultural or social sensitivities around sexual health. Some participants noted that increased awareness and education through routine testing could help destigmatize HIV, highlighting the dual benefit of screening as both a diagnostic and educational tool.

Finally, our study provides valuable insights into the complex and multifaceted landscape associated with routine HIV screening in EDs through multiple diverse perspectives. It follows two major events: the COVID-19 pandemic—which resulted in missed HIV diagnoses and a rise in late diagnoses—and the launch of CDC’s EHE [8]. Progress toward EHE goals has been uneven, and several performance indicators remain off track. These challenges are compounded by recent – broad - policy shifts under the current administration that will likely further disrupt HIV-related public health efforts nationwide.

Limitations

As with any qualitative study, our findings are contextual and represent the perspectives of the national sample of participants we interviewed. Additional studies conducted in local environments may yield further context-specific insights about various health systems and/or population settings. Although there exists potential for selection bias in any research study, we attempted to mitigate this by sampling a diverse set of participants across a variety of factors (e.g., provider role in healthcare system, hospital in an EHE priority jurisdiction, type of HIV screening strategy used, and proportion of patients with risk factors). Additionally, both this study and the parent study were developed with input from qualitative and quantitative experts and followed rigorous data collection and analytic plans, routine team meetings, and use of a validated framework. Given prior work demonstrating that only a small subset of EDs conduct HIV screening nationally, our approach was pragmatic and represents one of the first efforts to capture a broad national sample of ED leaders.

As is typical in qualitative research, sample size is determined by achieving theoretical sufficiency rather than statistical power. While our sample (n= 21) was carefully selected to capture a broad range of perspectives, the findings are inherently tied to the unique experiences of those interviewed. This sample size is consistent with other published qualitative studies in HIV and emergency care and was sufficient in providing a rich and robust conceptualization of the barriers to HIV screening in the ED [41–47]. The findings should be interpreted as contextual rather than statistically generalizable, and further research is needed to assess the transferability of these results to other EDs, health systems, and geographic locations. Additionally, this work is limited to the perspectives of ED leadership who largely support ED-based HIV screening. Future research may consider incorporating a broader range of perspectives by including a greater diversity of hospital staff and patients. Finally, while we identified barriers and facilitators, we did not directly assess the effectiveness of specific implementation strategies—such as EMR-based best practice alerts, navigator programs, or provider training in stigma-free communication—which have been described in the broader literature. These areas are the focus of current efforts by our group.

Conclusion

This study highlights ED leadership’s perspectives on barriers and mitigating strategies to HIV screening within the ED. Moving forward, stakeholders and funding agencies should focus on these identified barriers through policies and interventions that bolster staffing, standardize and integrate procedures that support automated screening as well as provide funding and institutional support to ED settings. Efforts to normalize and standardize HIV screening as part of quality ED care is essential in overcoming stigma and positioning EDs as key players in the national effort to end the HIV epidemic.