Impact of Removing Question Offering HIV Testing from Primary Triage on the Number of HIV Tests Offered and Ordered in a Safety-Net Emergency Department: A Retrospective Interrupted Time Series Open Access

Abstract

Background

Offering HIV tests to patients as part of the triage process during emergency department (ED) visits can lower barriers to testing, including stigma and lack of primary care access. This is especially relevant for the Grady Memorial Hospital Emergency Department, a safety-net hospital for Atlanta, Georgia; Atlanta is a city with one of the highest incidences of HIV in the United States. For the prior ten years, the Grady ED offered HIV testing during triage. However, due to concerns about the length of the triage process, leadership removed the question offering an HIV test from primary triage in July of 2023.

 

Objective

To study the impact of removing from primary triage the question offering HIV testing on the number HIV tests offered and ordered in the Grady Emergency Department. 

 

Methods

Data from the electronic medical records were extracted for one year before and one year after the removal of the HIV question from triage. Descriptive statistics were calculated and graphed. Simple and multivariate linear regression were conducted to assess the number of HIV tests offered and ordered before and after the removal of the HIV question.

 

Results

There were 260,608 visits to the Emergency Care Center: 200,630 (77%) to the main ED, 27,770 (11%) to the Walk-In Center, and 32,208 visits of unknown location (12%). The Walk-In Center offered HIV tests to greater than 90% of patients with no significant change after the removal of the HIV question from triage; therefore, data from the Walk-In Center were removed from further analyses. Conversely, in the ED, there was a statistically significant drop in people being offered an HIV test, from 54% being offered before the change to 7% being offered after it (p < 0.0001). Similarly, the percentage of people who had an HIV test ordered in the ED dropped from 9.9% to 7.9% (p < 0.0001). The percentage of HIV tests ordered later in the visit for those who did not accept HIV testing (i.e. answered anything other than “accept” when offered an HIV test or were not offered an HIV test in triage) went up after the removal of the HIV question from primary triage, which ameliorated the overall drop in HIV tests ordered.

 

Conclusion 

Removal of the HIV question from ED primary triage resulted in large reductions in HIV tests offered and ordered in the ED. Bringing back the HIV question to primary triage would likely help to increase HIV tests offered and ordered to prior levels. Even when the HIV question was included in triage, only half of ED patients were being offered an HIV test. Future work should explore barriers to offering and ordering HIV testing in triage. 

Table of Contents

CHAPTER 1: INTRODUCTION..................................................................................................... 1

1.      Introduction and rationale.................................................................................................... 1

2.      Problem statement............................................................................................................... 1

3.      Theoretical framework........................................................................................................ 1

4.      Purpose statement............................................................................................................... 2

5.      Research question............................................................................................................... 2

6.      Significance........................................................................................................................ 2

7.      Definition of terms.............................................................................................................. 2

 

CHAPTER 2: REVIEW OF THE LITERATURE.............................................................................. 4

1.      HIV burden......................................................................................................................... 4

2.      Social determinants of health............................................................................................... 5

3.      Race and ethnicity............................................................................................................... 7

4.      HIV screening and opt-out testing in the emergency department............................................. 9

5.      Grady Health System ........................................................................................................ 10

6.      FOCUS Program at Grady Memorial Hospital..................................................................... 11

7.      Time pressures in the emergency department....................................................................... 11

8.      Summary of current problem and study relevance............................................................... 12

 

CHAPTER 3: METHODOLOGY.................................................................................................. 12

1.      Population and sample....................................................................................................... 12

2.      Research design................................................................................................................ 12

3.      Data source and instrument................................................................................................ 12

4.      Procedures........................................................................................................................ 12

5.      Data analysis.................................................................................................................... 12

 

CHAPTER 4: RESULTS............................................................................................................... 14

1.      HIV tests offered in the emergency department .................................................................. 14

2.      HIV tests ordered in the emergency department................................................................... 20

3.      Summary of results........................................................................................................... 23

 

CHAPTER 5: DISCUSSION......................................................................................................... 23

1.      Discussion........................................................................................................................ 23

2.      Limitations....................................................................................................................... 25

3.      Implications...................................................................................................................... 25

4.      Recommendations............................................................................................................. 26

5.      Conclusion....................................................................................................................... 26

 

TABLES

1.      Proportions of patients triaged in the Grady Emergency Care Center who were offered an HIV test, Atlanta, July 2022 – June 2024.............................................................................................................. 16

2.      Simple and multivariate linear regressions of HIV tests ordered by removal of HIV question from primary triage, Grady Emergency Department, Atlanta, July 2022 – June 2024.................................. 19

3.      Simple and multivariate linear regressions of HIV tests ordered by removal of HIV question from primary triage........................................................................................................................................ 22

 

FIGURES

A.    Prevalence and new diagnoses rates of HIV in the Atlanta Metropolitan Area, GA, 2025......... 5

B.     HIV prevalence in counties around Atlanta, GA, 2025........................................................... 5

C.     percentage of new HIV cases by race and ethnicity, Atlanta, GA, 2025................................... 8

D.    Black race and social vulnerability by census tract, Atlanta, GA, 2025.................................... 8

E.     Status neutral HIV prevention and care strategy from CDC.................................................. 10

1.      Proportion of patients offered an HIV test in triage by month, Grady Emergency Department, Atlanta, July 2022 – June 2024...................................................................................................................... 18

2.      Rate of acceptance of HIV testing in HIV testing in triage, Grady Emergency Department, Atlanta, July 2022 – June 2024......................................................................................................................... 20

3.      HIV tests ordered by answer to HIV triage question, Grady Emergency Department, Atlanta, July 2022 – June 2024................................................................................................................................. 21

4.      Percentage of visits with an HIV Test ordered by month and acceptance of HIV test in triage, Grady Emergency Department, Atlanta, July 2022 – June 2024........................................................................ 22

 

REFERENCES............................................................................................................................. 27

About this Master's Thesis

Rights statement

• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Executive Masters of Public Health - MPH
Subfield / Discipline	Prevention Science
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	Emergency medicine Hypertension
Committee Chair / Thesis Advisor	Patrick Sullivan, Emory University
Committee Members	Anna Yaffe, Emory University

Last modified

Primary PDF

Thumbnail	Title	Date Uploaded	Actions
	Impact of Removing Question Offering HIV Testing from Primary Triage on the Number of HIV Tests Offered and Ordered in a Safety-Net Emergency Department: A Retrospective Interrupted Time Series ()	2025-07-24 15:21:11 -0400	Press to Select an action Download

Supplemental Files

Thumbnail	Title	Date Uploaded	Actions