title: Routine HIV testing in the emergency department: tough lessons in sustainability.
abstract: OBJECTIVE
  Routine HIV testing in nonspecialist settings has been shown to be acceptable to patients and staff in pilot studies. The question of how to embed routine HIV testing, and make it sustainable, remains to be answered.
  
  
  METHODS
  We established a service of routine HIV testing in an emergency department (ED) in London, delivered by ED staff as part of routine clinical care. All patients aged 16 to 65 years were offered an HIV test (latterly the upper age limit was removed). Meetings were held weekly and two outcome measures examined: test offer rate (coverage) and test uptake. Sustainability methodology (process mapping; plan-do-study-act (PDSA) cycles) was applied to maximize these outcome measures.
  
  
  RESULTS
  Over 30 months, 44,582 eligible patients attended the ED. The mean proportion offered an HIV test was 14%, varying from 6% to 54% per month over the testing period. The mean proportion accepting a test was 63% (range 33-100%). A total of 4327 HIV tests have been performed. Thirteen patients have been diagnosed with HIV infection (0.30%). PDSA cycles having the most positive and sustained effects on the outcome measures include the expansion to offer blood-based HIV tests in addition to the original oral fluid tests, and the engagement of ED nursing staff in the programme.
  
  
  CONCLUSIONS
  HIV testing can be delivered in the ED, but constant innovation and attention have been required to maintain it over 30 months. Patient uptake remains high, suggesting acceptability, but time will be required before true embedding in routine clinical practice is achieved.
authors.affiliation: Directorate of HIV/GU Medicine, Chelsea and Westminster Hospital NHS Foundation Trust.
authors.forename: M
authors.initials: M
authors.lastname: Rayment
authors.forename: C
authors.initials: C
authors.lastname: Rae
authors.forename: F
authors.initials: F
authors.lastname: Ghooloo
authors.forename: E
authors.initials: E
authors.lastname: Doku
authors.forename: J
authors.initials: J
authors.lastname: Hardie
authors.forename: S
authors.initials: S
authors.lastname: Finlay
authors.forename: S
authors.initials: S
authors.lastname: Gidwani
authors.forename: M
authors.initials: M
authors.lastname: Atkins
authors.forename: P
authors.initials: P
authors.lastname: Roberts
authors.forename: A K
authors.initials: AK
authors.lastname: Sullivan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D057210:Delayed Diagnosis / Q000517:prevention & control; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis*; D006801:Humans; D008131:London / Q000453:epidemiology; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008875:Middle Aged; D015397:Program Evaluation / Q000706:statistics & numerical data*; D006113:United Kingdom; D055815:Young Adult
keywords: Emergency Department; HIV testing; acceptability; feasibility; non-specialist settings; sustainability methodology