Increasing HIV Early Diagnosis by Implementing an Automated Screening Strategy in Emergency Departments

Inês Vaz-Pinto; Ana Gorgulho; Catarina Esteves; Mafalda Guimarães; Vanda Castro; Alba Carrodeguas; Diogo Medina


HIV Medicine. 2022;23(11):1153-1162. 

In This Article

Abstract and Introduction


Introduction: Late HIV diagnosis is associated with increased morbidity, mortality and risk of onward transmission. Increasing HIV early diagnosis is still a priority. In this observational study with historical control, we determined the impact of an opportunistic HIV screening strategy in the reduction of late diagnosis and missed opportunities for earlier diagnosis.

Methods: The screening programme was implemented in the emergency department (ED) of the Hospital de Cascais between September 2018 and September 2021. Eligible patients were aged 18–64 years, with no known HIV diagnosis or antibody testing performed in the previous year, and who required blood work for any reason. Out of the 252 153 emergency visits to the ED, we identified 43 153 (17.1%) patients eligible for HIV testing. Among the total population eligible for the screening, 38 357 (88.9%) patients were ultimately tested for HIV. Impact of the ED screening was determined by analysing late diagnosis in the ED and missed opportunities at different healthcare settings 3 years before and 3 years after the start of the ED screening.

Results: After 3 years of automated HIV ED testing, we found 69 newly diagnosed HIV cases (54% male, 39% Portuguese nationals, mean age 40.5 years). When comparing the characteristics of HIV diagnoses made in the ED, we observed a significant reduction in the number of people with late HIV diagnosis before and after implementation of the screening programme (78.4% vs. 39.1%, respectively; p = 0.0291). The mean number of missed opportunities for diagnosis also fell (2.6 vs. 1.5 annual encounters with the healthcare system per patient, p = 0.0997).

Conclusions: People living with HIV in Cascais and their providers miss several opportunities for earlier diagnosis. Opportunistic screening strategies in settings previously deemed to be unconventional, such as EDs, are feasible and effective in mitigating missed opportunities for timely HIV diagnosis.


Despite multiple efforts to reduce the HIV epidemic over recent decades and the important therapeutic advances achieved over this time, HIV infection is still a public health challenge causing a large number of deaths worldwide.[1] Global efforts aim at tackling HIV/AIDS disease by stopping its transmission.[2] However, late diagnosis of HIV infection (CD4 T-cell count ≤ 350 cells/μL at diagnosis),[3] thought to increase the likelihood of transmission, is still a major local, national and European problem.[1]

Late HIV diagnosis is problematic for affected individuals, who experience increased morbidity and mortality, and because of missed opportunities by public health systems to interrupt transmission.[4] Official numbers from the Portuguese General Directorate for Health indicate that 2800 people living with HIV are unaware of their infection, with one in two receiving their diagnosis at a late stage.[5] A similar 50% rate of late diagnosis was reported in a large hospital in Lisbon by Miranda et al.,[6] reporting higher rates in those of male gender, patients with heterosexual transmission, immigrants originating from sub-Saharan Africa and patients aged between 31 and 55 years old. The results of Miranda et al. were also consistent with previous reports in other countries.[7–9] Considering the negative impact of late HIV detection in the prognosis of the patient, reaching and testing those at risk of infection remain a major challenge.

National and international guidelines alike recommend enhancing HIV screening and linkage to care (LTC) practices.[10–12] In its evidence-based guidance on integrated HIV testing, the European Centre for Disease Prevention and Control urges countries to increase testing coverage and uptake towards achieving the United Nations' epidemic control goals for 2030.[11] However, to date, HIV screening has typically followed traditional models, requiring dedicated staff and resources that are separate from routine clinical practice.[13] Instead of integrating screening into the regular provision of care for all eligible patients, conventional approaches often rely on a case-by-case decision, which may reinforce the deterring stigma associated with testing for these infections.[14] Besides, screening and testing awareness campaigns have had no impact in lowering late diagnosis numbers, and insufficient HIV testing in different healthcare settings seems to be generalized.[15]

According to the Portuguese General Directorate for Health recommendations, people aged 18–64 should be offered HIV testing at least once in their lifetime, and more often depending on risk behaviour.[10] Despite these recommendations, implementation of HIV screening and LTC in formal healthcare organizations in Portugal is low and heterogeneous. Healthcare professionals and the health system itself have been identified as one of the major barriers to HIV testing, allegedly because of lack of time, lack of training, uneasiness discussing sexual health with patients or even fear of being perceived as discriminatory by patients.[16]

To overcome this perceived barrier, we implemented a completely automated HIV screening programme in a general emergency department (ED) that is independent from physician request, thereby removing the 'human factor' from testing decisions. The aim of our study was to evaluate the impact of this opportunistic screening programme, specifically in terms of decreasing late HIV diagnosis and reducing missed opportunities for earlier diagnosis.