HIV Testing in Primary Care is not Enough. Multiyear analysis of HIV Testing among Patient Populations within the Emergency Department and Primary Care Settings in a Safety Net System

HIV Testing in Primary Care is not Enough. 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Multiyear analysis of HIV Testing among Patient Populations within the Emergency Department and Primary Care Settings in a Safety Net System Steven A Lewis, Claire Fritz, Ann Avery This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8071454/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background- HIV testing is a necessary component for ending the HIV epidemic, yet many individuals remain untested. We sought to evaluate the rate of ever tested for HIV among patients seeking care at the emergency department in a safety net healthcare system with an established large-volume, non-targeted HIV testing program in primary care. Methods- Patient encounters were reviewed for adults without HIV and with visits to primary care (PC) clinics and/or the emergency department (ED) during 2010 to 2018. Patient-level analyses assessed rates of ‘ever tested’ and rates of ‘tested on encounter’ during the study period for PC and ED only groups. Binary logistic regression models tested for significant associations for the two outcomes with visit setting, age group, sex at birth, and race as covariates. Results- Patients seen in PC were 4 times more likely to be ever tested for HIV compared to ED only patients (aOR: 4.40; 95% CI: 4.31–4.50). The highest rate of ever tested occurred among younger Black females who were seen in PC, while the lowest rate occurred among younger Non-Black males under 30 years of age who were seen in the ED only. Conclusions- Patients who received care only in the emergency department were unlikely to ever be tested for HIV. Strategies to increase single lifetime HIV testing in EDs are needed to reach priority populations not receiving PC. Figures Figure 1 Figure 2 Introduction The HIV epidemic remains a public health crisis in the United States despite the development of highly effective treatment regimens and improved prevention measures.( 1 ) In 2006, the CDC issued the recommendation that all adults 13–64 years of age be tested for HIV at least once in their lifetime,( 2 ) yet many individuals remain untested today. In fact, the National Institute of Health (NIH), estimates 15% of people with HIV in the U.S. are unaware of their infection, and 40% of new diagnoses are transmitted by those who are not aware of their diagnosis.( 3 ) As such, efforts to increase HIV testing are an essential component of ending the HIV epidemic. While there has been significant progress in ending the HIV epidemic, there remain economic and social factors driving health inequities in new diagnoses. Per the CDC HIV Surveillance Report, more than three fourths of new diagnoses were among men, more than half (53%) of new infections were in individuals aged 20–34 years old, new HIV cases were found to be concentrated in areas with the highest rate of poverty ( 4 ) and the rate of diagnosis in Black/African American individuals was seven times higher than their white counterparts.( 2 ) Despite CDC recommendations to offer routine opt-out testing in all healthcare settings including the emergency department, significant challenges in implementation of these recommendations remain ( 2 , 5 – 7 ). In 2010, we implemented an electronic medical record-based passive reminder for once-in-a-lifetime HIV testing for all individuals between 13 and 64 years of age. HIV testing was added to the Health Maintenance Topics, an area of the electronic health record that was already used by most primary care providers, visible to patients in the patient portal and printed on pre-visit paperwork. This intervention significantly increased HIV testing in primary care (PC) for both males and females across all racial and ethnic groups, which we have published previously.( 8 , 9 ) It also detected new infections, especially among males who had low rates of testing. Notably, in the first three years (2010–2012) after implementation, males were significantly more likely than females to be diagnosed with HIV when compared to the two year period prior to the intervention (2008–2009) (aOR 5.35 (1.25–27.58))( 10 ). Analysis of testing prior to the intervention underscored the need for system level approaches to large volume, non-targeted screening for HIV. During this same time, very little HIV testing was occurring in our system’s emergency department (ED). The CDC identified the ED as a key setting for routine HIV testing due to the prevalence of HIV reported among patients seeking emergency care.( 11 – 14 ) Additional cited benefits of HIV testing in the ED include access to diverse populations that better resembles the demographics of the national epidemic; the potential for earlier diagnosis and treatment; and access to vulnerable populations with barriers to healthcare.( 13 ) Despite the clear need to expand HIV testing initiatives to the emergency departments, notable challenges have prevented its implementation.( 15 – 21 ) Many individuals, especially in priority populations, do not make contact with primary care, which drives these disparities in testing and highlights the need for the ED to offer testing to reach these populations.( 7 ) This study aims to describe HIV testing among patients seen in primary care (PC) and/or the emergency department (ED) during 2010–2018 and compare the rates of ever tested by setting within a safety net healthcare system with an established large-volume, non-targeted HIV testing program in primary care. Methods Study Setting Our study setting is a public hospital system with an extensive network of community health centers and the sole level one trauma center in an End the HIV Epidemic priority jurisdiction in the Midwest. Over a million outpatient visits and over 100,000 ED visits are completed annually. This setting is the local safety net system and most individuals remain in the care system for all their medical needs. Data Collection Patient encounters were extracted from the electronic health record (EHR) for adults 18–64 years of age with visits to primary care (PC) clinics and/or the emergency department (ED) during 2010 to 2018 to determine if once in a lifetime HIV testing occurred. Primary care included internal medicine, family medicine and medicine/ pediatrics. Data on risk behavior or time from prior testing was not collected or included in analyses. Persons diagnosed with HIV prior to the study period were excluded. The unit of analysis was the patient, where patients were identified as having encounters with primary care (PC) and/or the emergency department (ED) during the study period. Measures HIV Test Setting Individuals were initially classified as “PC Only”, “ED Only”, or “Both PC and ED” patients. However, those with “PC Only” and “Both PC and ED” encounters were subsequently combined and reclassified as having “PC” encounters and patients with ED encounters exclusively remained classified as “ED Only”. Thus, two mutually exclusive test setting experiences were studied among patients: ( 1 ) PC encounter(s) (PC) and ( 2 ) only ED encounters (ED Only) during the study period. This consolidation was chosen given our desire to distinguish patients with some exposure to primary care during the study period from patients who only had exposure to the ED during the same period. Study Outcomes HIV testing consisted of HIV 1/HIV 2 antibody tests or confirmatory tests administered to patients during a primary care visit or an emergency department visit. Testing was determined to either be conducted on or before a visit encounter. If a patient was flagged as having a documented HIV test on file or received a test during the study period they were identified as “Ever Tested for HIV”. Similarly, if a patient received an HIV test on a visit encounter during the study period, they were identified as “Tested on Encounter”. (Patients with prior testing and testing on encounter were grouped as “Ever Tested for HIV” as well as “Tested on Encounter”). Outcome measures were derived from visit encounter data to capture these two outcomes where both “Ever Tested for HIV” and “Tested on Encounter” were operationalized as “Yes/No” dichotomous variables in analyses. Patient Characteristics Age at first encounter within the EHR was expressed as both a numeric variable and as a class variable to highlight differences in testing among young, middle-aged, and older persons (i.e., “< 30 years”, “30–49 years”, “50 + years”), and sex was based on sex at birth. Race was captured as a dichotomous class variable by collapsing categories of race to study disparities or variations in testing for Black/African American patients relative to other patients (i.e., “Black”, “Non-Black). The “Non-Black” category includes individuals who identify as “White”, “American Indian/Alaska Native”, “Asian”, “Native Hawaiian/Pacific Islander”, or “Multiracial”. Of note is that race information was unavailable for 10% of encounters. However, since we observed similar distributions on all study covariates and outcomes in both the original dataset and the dataset with missing race encounters excluded, we chose to conduct analyses using the latter dataset. Additional Covariate Visit count was calculated for each patient during the study period and used as a covariate in statistical modeling to control for variations in the number of visit encounters among patients. Statistical Analysis Descriptive statistics on patient characteristics and outcomes were generated across the entire sample and within each HIV test setting to highlight differences across and by test setting. Plots of the likelihood of “Ever Tested for HIV” and “Tested on Encounter” were generated by age, sex at birth, race, and test setting. These plots served to display interrelationships between these sets of factors for each HIV testing outcome. Binary logistic regression models were also used to formally test for statistically significant associations across the entire sample for the ‘Ever Tested’ outcome with test setting, age, sex at birth, and race as covariates and visit count. All statistical analyses were performed using Statistical Analysis System (SAS) v9.4 software, where statistical significance was determined using a cut-off of α = 0.05, and all figures were created using R software version 4.3.1. Results A total of 279,513 patients between ages 18 and 64 were seen in the ED and/or PC during 2010–2018 reflecting approximately 1.3 million PC encounters and 0.5 million ED encounters. Overall distributions of patient characteristics can be found in Table 1 . Of tests completed in the ED, 1.1 per 1,000 were new positives while only 0.2 per 1,000 in PC/ PC ED were new positives. Table 1 Patient Characteristics by Test Setting (2010–2018) Overall 279,513 (100.0%) Primary Care (PC)* 191,416 (68.5%) Emergency Department (ED) Only 88,097 (31.5%) Characteristic Total N (%) N (%) Age at 1st Encounter: Mean (SD) 38.3 (13.85) 39.8 (13.89) 35.0 (13.15) Age Group at 1st Encounter < 30 years 96,147 (34.4%) 57,151 (29.9%) 38,996 (44.3%) 30–49 years 107,733 (38.5%) 74,932 (39.1%) 32,801 (37.2%) 50 + years 75,633 (27.1%) 59,333 (31.0%) 16,300 (18.5%) Sex at Birth Female 147,023 (52.6%) 109,906 (57.4%) 37,117 (42.1%) Male 132,490 (47.4%) 81,510 (42.6%) 50,980 (57.9%) Race Black 120,248 (43.0%) 82,141 (42.9%) 38,107 (43.3%) Non-Black 159,265 (57.0%) 109,275 (57.1%) 49,990 (56.7%) Patient Cohort BF: < 30 years 25,704 (9.2%) 17,431 (9.1%) 8,273 (9.4%) BF: 30–49 years 23,375 (8.4%) 18,369 (9.6%) 5,006 (5.7%) BF: 50 + years 16,284 (5.8%) 13,850 (7.2%) 2,434 (2.8%) BM: < 30 years 19,435 (7.0%) 9,175 (4.8%) 10,260 (11.6%) BM: 30–49 years 21,845 (7.8%) 13,361 (7.0%) 8,484 (9.6%) BM: 50 + years 13,605 (4.9%) 9,955 (5.2%) 3,650 (4.1%) NF: < 30 years 27,654 (9.9%) 18,075 (9.4%) 9,579 (10.9%) NF: 30–49 years 31,185 (11.2%) 23,429 (12.2%) 7,756 (8.8%) NF: 50 + years 22,821 (8.2%) 18,752 (9.8%) 4,069 (4.6%) NM: < 30 years 23,354 (8.4%) 12,470 (6.5%) 10,884 (12.4%) NM: 30–49 years 31,328 (11.2%) 19,773 (10.3%) 11,555 (13.1%) NM: 50 + years 22,923 (8.2%) 16,776 (8.8%) 6,147 (7.0%) Test Positivity (New Diagnosis Only) 0.2% (158 / 64,398) 0.2% (136 / 62,213) 1% (22 / 2,185) Visit Count: Mean (SD) 6.4 (8.99) 8.4 (10.02) 2.2 (3.42) *PC includes patients seen only in PC and patients seen in both PC and ED; BM- Black male, BF- Black female, NM- Non-Black males, NF- Non-Black female Patient Characteristics by Test Setting There were notable differences between patient characteristics by setting. Most patients with PC encounters were female (57.4%), while the majority of patients exclusively seen in the ED were male (57.9%). “ED Only” patients were more likely to be younger (i.e., < 30 years old), whereas “PC” patients were more likely to be older (50 + years old). Males less than 50 years of age were also more commonly seen only in the ED. Ever Tested for HIV Overall, patients with a PC visit during the study period were shown to be 4 times more likely to be ever tested for HIV compared to patients who exclusively visited the ED (aOR: 4.40; 95% CI: 4.31–4.50) (Table 2 ). Comparing rates of ever tested by setting and patient characteristics, we found the highest rate of ever tested occurred among younger Black females who were seen in primary care, while the lowest rate occurred among younger Non-Black males who were exclusively seen in the ED (Fig. 1 ). Black patients consistently have higher rates of ever tested than Non-Black patients regardless of setting; and females under the age of 50 consistently have higher rates of ever tested than their male counterparts regardless of race or setting. Moreover, younger female patients in both groups have higher rates of ever tested than older female patients regardless of race. Figure 1 also depicts consistently higher rates of ever tested for patients seen in PC compared to “ED Only” patients. Table 2 Ever Tested for HIV (2010–2018) Adjusted Odds Ratio* Factor Estimate 95% CI Test Setting Primary Care (PC) 4.402 (4.306–4.500) Emergency Department (ED) Only ---- ----------- Sex at Birth Female 1.380 (1.356–1.404) Male ---- ----------- Race Black 2.052 (2.016–2.088) Non-Black ---- ----------- Age at 1st Encounter (unit = 10 Yrs) 0.855 (0.850–0.861) * Also adjusted for visit count Tested on Encounter The highest rate of testing on the encounter occurs among Black males seen in primary care with higher rates inversely related to age, while the lowest rates occur among patients of any race or gender seen exclusively in the ED, suggesting that setting affects testing trends (0.8% to 1.6%) (Fig. 2 ). Black patients consistently have higher rates of testing on the encounter than Non-Black patients regardless of setting; and male patients seen in primary care consistently have higher rates of testing on the encounter than their female counterparts regardless of age. Overall, low levels of testing on the encounter occur among patients seen exclusively in the ED with no apparent differences observed by sex at birth. Discussion Among young and middle-aged patients, males were generally less likely than females to be ever tested for HIV. However, the opposite relationship between sex and ever tested for HIV was observed for older patients. Our findings highlight differences in the settings in which populations are most likely seen that contribute to disparities in ever being tested for HIV. Young males are more likely to be seen in the ED only and not in PC. We previously observed that males who attend PC had fewer visits per year than females ( 9 ) potentially making it more challenging to complete preventive health screenings. Strategies to increase testing for young men should consider venues frequented by the population; our findings support the inclusion of the ED as one of these venues. Despite low testing in the ED during the study period, its yield was high: 1% of tests were new positives while 0.2% of tests in PC/ PC ED were new positives. Numerous studies have shown that testing in the ED is likely to identify new positives and is cost effective ( 22 – 24 ). During the study period, patients with any visits in PC were more likely to be ever tested and tested on the encounter than individuals who were exclusively seen in the ED. It is a missed opportunity that persons seen exclusively in the ED were likely to remain untested despite interacting with the health care system. It is encouraging to observe that although men were less likely to be ever tested, they were more likely to be tested on encounter compared to females, suggesting that testing trends are matching the epidemiology of infection. This supports the ongoing need to connect patients to primary care and the benefit of a long standing HIV testing program. If we are to end the HIV epidemic, it is imperative to identify strategies to increase HIV testing, especially among populations most impacted by new infections. Our data supports the need to offer HIV testing in emergency care settings, as this continues to be the setting where some populations receive all their care. For example, we observed that of young Black men, less than 6% seen in the ED only had ever been tested. This is the group that has the highest rate of new HIV infections and is most in need of being tested and linked to care. It is encouraging to note that when young males make it to primary care, they are appropriately being tested. However, we also observed this group was the least likely to attend a primary care visit with less than 50% of all young Black men having a single visit in PC in the 9-year period. Novel approaches to improve linkage to primary care from the ED are needed as current efforts have had limited success. As mentioned earlier, we believe our findings highlight the need for HIV testing outside of primary care settings. Despite more than 10 years since CDC and professional societies recommended offering HIV testing in emergency settings, specifics on how to do this and support to incorporate testing has been missing.( 17 ) As a result, uptake has been slow and rates of testing in the ED remain low nationally.( 23 , 25 , 26 ) There is also lack of consensus on whether to apply a universal screening or a targeted screening approach in the ED.( 27 ) Nonetheless, there are successful models for both targeted and universal testing that deserve further consideration.( 28 – 30 ) It is important to note that even when ED providers are educated and support the need for HIV testing, many remained reluctant to offer testing because of ongoing barriers (lack of time and concern for follow up).( 15 ) The strengths of this study include that its datum encompasses a 9-year period, over a million patient encounters in two different practice settings and highlights findings that may be dismissed if only seen in a single year. The limitations include the retrospective nature of the study, the lack of data on if someone was offered a test and declined or if they reported testing outside of the healthcare system, and lack of data beyond demographics that might better triangulate populations more at risk. Our primary outcome was once in a lifetime testing and does not include repeat testing needs for higher risk behavior. Also, it is possible that patients seen in the ED received primary care (and possibly HIV testing) elsewhere; although, this is uncommon except among young women of childbearing age who may receive primary care from an obstetrician/ gynecologist including HIV testing as part of routine prenatal care. Conclusion HIV testing in PC settings is essential but not sufficient for all adults to be tested for HIV. Increasing testing in emergency departments will help to close the gap for once in a lifetime HIV testing for priority populations, especially young men. Abbreviations CDC Centers for Disease Control ED Emergency Department EHR Electronic Health Record HIV Human Immunodeficiency Virus NIH National Institute of Health OR Odds Ratio PC Primary Care Declarations Ethical Statement: All work was reviewed and approved by the MetroHealth Medical Center Institutional Review Board under IRB10-00366 in accordance with the Belmont Report and adhering to the Common Rule. The work was approved with a waiver of patient consent. Clinical trial number: not applicable Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Funding: Grant Support NIAID 5P30AI036219-28 (Avery), FOCUS program, Gilead Sciences (Avery, Fritz) Authors' contributions: AA conceived the study. CF and AA completed the primary data collection. 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Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 05 Dec, 2025 Editor invited by journal 11 Nov, 2025 Editor assigned by journal 11 Nov, 2025 Submission checks completed at journal 11 Nov, 2025 First submitted to journal 09 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":31355,"visible":true,"origin":"","legend":"\u003cp\u003eEver Tested for HIV (2010-2018) by Setting Race, Age, Sex at Birth\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8071454/v1/eb89abdb97e3f1b7be949db2.png"},{"id":97722108,"identity":"b4a7e1f8-4d73-4ee1-949d-12565972c0bc","added_by":"auto","created_at":"2025-12-08 15:39:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":634878,"visible":true,"origin":"","legend":"\u003cp\u003eHIV Tested on Encounter (2010-2018) by Setting, Race, Age, Sex at Birth\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8071454/v1/ad9a5423c27a992347d593bd.png"},{"id":97902563,"identity":"9e5f74fe-8dcb-416b-8c6c-3fb5159137cf","added_by":"auto","created_at":"2025-12-10 15:52:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1400399,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8071454/v1/08f1e1e4-10e1-4701-b7b0-7a3afd468954.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eHIV Testing in Primary Care is not Enough. Multiyear analysis of HIV Testing among Patient Populations within the Emergency Department and Primary Care Settings in a Safety Net System\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe HIV epidemic remains a public health crisis in the United States despite the development of highly effective treatment regimens and improved prevention measures.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) In 2006, the CDC issued the recommendation that all adults 13\u0026ndash;64 years of age be tested for HIV at least once in their lifetime,(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) yet many individuals remain untested today. In fact, the National Institute of Health (NIH), estimates 15% of people with HIV in the U.S. are unaware of their infection, and 40% of new diagnoses are transmitted by those who are not aware of their diagnosis.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) As such, efforts to increase HIV testing are an essential component of ending the HIV epidemic.\u003c/p\u003e\u003cp\u003eWhile there has been significant progress in ending the HIV epidemic, there remain economic and social factors driving health inequities in new diagnoses. Per the CDC HIV Surveillance Report, more than three fourths of new diagnoses were among men, more than half (53%) of new infections were in individuals aged 20\u0026ndash;34 years old, new HIV cases were found to be concentrated in areas with the highest rate of poverty (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and the rate of diagnosis in Black/African American individuals was seven times higher than their white counterparts.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Despite CDC recommendations to offer routine opt-out testing in all healthcare settings including the emergency department, significant challenges in implementation of these recommendations remain (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn 2010, we implemented an electronic medical record-based passive reminder for once-in-a-lifetime HIV testing for all individuals between 13 and 64 years of age. HIV testing was added to the Health Maintenance Topics, an area of the electronic health record that was already used by most primary care providers, visible to patients in the patient portal and printed on pre-visit paperwork. This intervention significantly increased HIV testing in primary care (PC) for both males and females across all racial and ethnic groups, which we have published previously.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) It also detected new infections, especially among males who had low rates of testing. Notably, in the first three years (2010\u0026ndash;2012) after implementation, males were significantly more likely than females to be diagnosed with HIV when compared to the two year period prior to the intervention (2008\u0026ndash;2009) (aOR 5.35 (1.25\u0026ndash;27.58))(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Analysis of testing prior to the intervention underscored the need for system level approaches to large volume, non-targeted screening for HIV. During this same time, very little HIV testing was occurring in our system\u0026rsquo;s emergency department (ED).\u003c/p\u003e\u003cp\u003eThe CDC identified the ED as a key setting for routine HIV testing due to the prevalence of HIV reported among patients seeking emergency care.(\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) Additional cited benefits of HIV testing in the ED include access to diverse populations that better resembles the demographics of the national epidemic; the potential for earlier diagnosis and treatment; and access to vulnerable populations with barriers to healthcare.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Despite the clear need to expand HIV testing initiatives to the emergency departments, notable challenges have prevented its implementation.(\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) Many individuals, especially in priority populations, do not make contact with primary care, which drives these disparities in testing and highlights the need for the ED to offer testing to reach these populations.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThis study aims to describe HIV testing among patients seen in primary care (PC) and/or the emergency department (ED) during 2010\u0026ndash;2018 and compare the rates of ever tested by setting within a safety net healthcare system with an established large-volume, non-targeted HIV testing program in primary care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Setting\u003c/h2\u003e\u003cp\u003eOur study setting is a public hospital system with an extensive network of community health centers and the sole level one trauma center in an End the HIV Epidemic priority jurisdiction in the Midwest. Over a million outpatient visits and over 100,000 ED visits are completed annually. This setting is the local safety net system and most individuals remain in the care system for all their medical needs.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003ePatient encounters were extracted from the electronic health record (EHR) for adults 18\u0026ndash;64 years of age with visits to primary care (PC) clinics and/or the emergency department (ED) during 2010 to 2018 to determine if once in a lifetime HIV testing occurred. Primary care included internal medicine, family medicine and medicine/ pediatrics. Data on risk behavior or time from prior testing was not collected or included in analyses. Persons diagnosed with HIV prior to the study period were excluded.\u003c/p\u003e\u003cp\u003eThe unit of analysis was the patient, where patients were identified as having encounters with primary care (PC) and/or the emergency department (ED) during the study period.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eHIV Test Setting\u003c/h2\u003e\u003cp\u003eIndividuals were initially classified as \u0026ldquo;PC Only\u0026rdquo;, \u0026ldquo;ED Only\u0026rdquo;, or \u0026ldquo;Both PC and ED\u0026rdquo; patients. However, those with \u0026ldquo;PC Only\u0026rdquo; and \u0026ldquo;Both PC and ED\u0026rdquo; encounters were subsequently combined and reclassified as having \u0026ldquo;PC\u0026rdquo; encounters and patients with ED encounters exclusively remained classified as \u0026ldquo;ED Only\u0026rdquo;. Thus, two mutually exclusive test setting experiences were studied among patients: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) PC encounter(s) (PC) and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) only ED encounters (ED Only) during the study period. This consolidation was chosen given our desire to distinguish patients with some exposure to primary care during the study period from patients who only had exposure to the ED during the same period.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Outcomes\u003c/h3\u003e\n\u003cp\u003eHIV testing consisted of HIV 1/HIV 2 antibody tests or confirmatory tests administered to patients during a primary care visit or an emergency department visit. Testing was determined to either be conducted on or before a visit encounter. If a patient was flagged as having a documented HIV test on file or received a test during the study period they were identified as \u0026ldquo;Ever Tested for HIV\u0026rdquo;. Similarly, if a patient received an HIV test on a visit encounter during the study period, they were identified as \u0026ldquo;Tested on Encounter\u0026rdquo;. (Patients with prior testing and testing on encounter were grouped as \u0026ldquo;Ever Tested for HIV\u0026rdquo; as well as \u0026ldquo;Tested on Encounter\u0026rdquo;). Outcome measures were derived from visit encounter data to capture these two outcomes where both \u0026ldquo;Ever Tested for HIV\u0026rdquo; and \u0026ldquo;Tested on Encounter\u0026rdquo; were operationalized as \u0026ldquo;Yes/No\u0026rdquo; dichotomous variables in analyses.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003ePatient Characteristics\u003c/h2\u003e\u003cp\u003eAge at first encounter within the EHR was expressed as both a numeric variable and as a class variable to highlight differences in testing among young, middle-aged, and older persons (i.e., \u0026ldquo;\u0026lt; 30 years\u0026rdquo;, \u0026ldquo;30\u0026ndash;49 years\u0026rdquo;, \u0026ldquo;50\u0026thinsp;+\u0026thinsp;years\u0026rdquo;), and sex was based on sex at birth. Race was captured as a dichotomous class variable by collapsing categories of race to study disparities or variations in testing for Black/African American patients relative to other patients (i.e., \u0026ldquo;Black\u0026rdquo;, \u0026ldquo;Non-Black). The \u0026ldquo;Non-Black\u0026rdquo; category includes individuals who identify as \u0026ldquo;White\u0026rdquo;, \u0026ldquo;American Indian/Alaska Native\u0026rdquo;, \u0026ldquo;Asian\u0026rdquo;, \u0026ldquo;Native Hawaiian/Pacific Islander\u0026rdquo;, or \u0026ldquo;Multiracial\u0026rdquo;. Of note is that race information was unavailable for 10% of encounters. However, since we observed similar distributions on all study covariates and outcomes in both the original dataset and the dataset with missing race encounters excluded, we chose to conduct analyses using the latter dataset.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAdditional Covariate\u003c/h3\u003e\n\u003cp\u003eVisit count was calculated for each patient during the study period and used as a covariate in statistical modeling to control for variations in the number of visit encounters among patients.\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics on patient characteristics and outcomes were generated across the entire sample and within each HIV test setting to highlight differences across and by test setting. Plots of the likelihood of \u0026ldquo;Ever Tested for HIV\u0026rdquo; and \u0026ldquo;Tested on Encounter\u0026rdquo; were generated by age, sex at birth, race, and test setting. These plots served to display interrelationships between these sets of factors for each HIV testing outcome.\u003c/p\u003e\u003cp\u003eBinary logistic regression models were also used to formally test for statistically significant associations across the entire sample for the \u0026lsquo;Ever Tested\u0026rsquo; outcome with test setting, age, sex at birth, and race as covariates and visit count. All statistical analyses were performed using Statistical Analysis System (SAS) v9.4 software, where statistical significance was determined using a cut-off of α\u0026thinsp;=\u0026thinsp;0.05, and all figures were created using R software version 4.3.1.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 279,513 patients between ages 18 and 64 were seen in the ED and/or PC during 2010\u0026ndash;2018 reflecting approximately 1.3\u0026nbsp;million PC encounters and 0.5\u0026nbsp;million ED encounters. Overall distributions of patient characteristics can be found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of tests completed in the ED, 1.1 per 1,000 were new positives while only 0.2 per 1,000 in PC/ PC ED were new positives.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient Characteristics by Test Setting (2010\u0026ndash;2018)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOverall\u003c/p\u003e\u003cp\u003e279,513 (100.0%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary Care (PC)*\u003c/p\u003e\u003cp\u003e191,416 (68.5%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEmergency Department (ED) Only\u003c/p\u003e\u003cp\u003e88,097 (31.5%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge at 1st Encounter: Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.3 (13.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39.8 (13.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35.0 (13.15)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAge Group at 1st Encounter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;30 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96,147 (34.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57,151 (29.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38,996 (44.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u0026ndash;49 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e107,733 (38.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74,932 (39.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32,801 (37.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75,633 (27.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59,333 (31.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16,300 (18.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSex at Birth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e147,023 (52.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e109,906 (57.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37,117 (42.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e132,490 (47.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81,510 (42.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50,980 (57.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eRace\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e120,248 (43.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82,141 (42.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38,107 (43.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-Black\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e159,265 (57.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e109,275 (57.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49,990 (56.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePatient Cohort\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBF: \u0026lt; 30 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25,704 (9.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17,431 (9.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8,273 (9.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBF: 30\u0026ndash;49 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23,375 (8.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18,369 (9.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5,006 (5.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBF: 50\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16,284 (5.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13,850 (7.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2,434 (2.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBM: \u0026lt; 30 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19,435 (7.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9,175 (4.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10,260 (11.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBM: 30\u0026ndash;49 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21,845 (7.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13,361 (7.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8,484 (9.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBM: 50\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13,605 (4.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9,955 (5.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3,650 (4.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNF: \u0026lt; 30 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27,654 (9.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18,075 (9.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9,579 (10.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNF: 30\u0026ndash;49 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31,185 (11.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23,429 (12.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7,756 (8.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNF: 50\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22,821 (8.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18,752 (9.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4,069 (4.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNM: \u0026lt; 30 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23,354 (8.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12,470 (6.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10,884 (12.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNM: 30\u0026ndash;49 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31,328 (11.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19,773 (10.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11,555 (13.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNM: 50\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22,923 (8.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16,776 (8.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6,147 (7.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTest Positivity (New Diagnosis Only)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.2% (158 / 64,398)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2% (136 / 62,213)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1% (22 / 2,185)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eVisit Count: Mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.4 (8.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.4 (10.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.2 (3.42)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*PC includes patients seen only in PC and patients seen in both PC and ED; BM- Black male, BF- Black female, NM- Non-Black males, NF- Non-Black female\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003ePatient Characteristics by Test Setting\u003c/h2\u003e\u003cp\u003eThere were notable differences between patient characteristics by setting. Most patients with PC encounters were female (57.4%), while the majority of patients exclusively seen in the ED were male (57.9%). \u0026ldquo;ED Only\u0026rdquo; patients were more likely to be younger (i.e., \u0026lt; 30 years old), whereas \u0026ldquo;PC\u0026rdquo; patients were more likely to be older (50\u0026thinsp;+\u0026thinsp;years old). Males less than 50 years of age were also more commonly seen only in the ED.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eEver Tested for HIV\u003c/h2\u003e\u003cp\u003eOverall, patients with a PC visit during the study period were shown to be 4 times more likely to be ever tested for HIV compared to patients who exclusively visited the ED (aOR: 4.40; 95% CI: 4.31\u0026ndash;4.50) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Comparing rates of ever tested by setting and patient characteristics, we found the highest rate of ever tested occurred among younger Black females who were seen in primary care, while the lowest rate occurred among younger Non-Black males who were exclusively seen in the ED (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Black patients consistently have higher rates of ever tested than Non-Black patients regardless of setting; and females under the age of 50 consistently have higher rates of ever tested than their male counterparts regardless of race or setting. Moreover, younger female patients in both groups have higher rates of ever tested than older female patients regardless of race. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e also depicts consistently higher rates of ever tested for patients seen in PC compared to \u0026ldquo;ED Only\u0026rdquo; patients.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEver Tested for HIV (2010\u0026ndash;2018)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eAdjusted Odds Ratio*\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEstimate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTest Setting\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrimary Care (PC)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.402\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(4.306\u0026ndash;4.500)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEmergency Department (ED) Only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e----\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-----------\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003eSex at Birth\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.380\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(1.356\u0026ndash;1.404)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e----\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-----------\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(2.016\u0026ndash;2.088)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNon-Black\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e----\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-----------\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAge at 1st Encounter (unit\u0026thinsp;=\u0026thinsp;10 Yrs)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.855\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e(0.850\u0026ndash;0.861)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e*\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e\u003cem\u003eAlso adjusted for visit count\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eTested on Encounter\u003c/h2\u003e\u003cp\u003eThe highest rate of testing on the encounter occurs among Black males seen in primary care with higher rates inversely related to age, while the lowest rates occur among patients of any race or gender seen exclusively in the ED, suggesting that setting affects testing trends (0.8% to 1.6%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBlack patients consistently have higher rates of testing on the encounter than Non-Black patients regardless of setting; and male patients seen in primary care consistently have higher rates of testing on the encounter than their female counterparts regardless of age. Overall, low levels of testing on the encounter occur among patients seen exclusively in the ED with no apparent differences observed by sex at birth.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAmong young and middle-aged patients, males were generally less likely than females to be ever tested for HIV. However, the opposite relationship between sex and ever tested for HIV was observed for older patients. Our findings highlight differences in the settings in which populations are most likely seen that contribute to disparities in ever being tested for HIV. Young males are more likely to be seen in the ED only and not in PC. We previously observed that males who attend PC had fewer visits per year than females (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) potentially making it more challenging to complete preventive health screenings. Strategies to increase testing for young men should consider venues frequented by the population; our findings support the inclusion of the ED as one of these venues.\u003c/p\u003e\u003cp\u003eDespite low testing in the ED during the study period, its yield was high: 1% of tests were new positives while 0.2% of tests in PC/ PC ED were new positives. Numerous studies have shown that testing in the ED is likely to identify new positives and is cost effective (\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDuring the study period, patients with any visits in PC were more likely to be ever tested and tested on the encounter than individuals who were exclusively seen in the ED. It is a missed opportunity that persons seen exclusively in the ED were likely to remain untested despite interacting with the health care system. It is encouraging to observe that although men were less likely to be ever tested, they were more likely to be tested on encounter compared to females, suggesting that testing trends are matching the epidemiology of infection. This supports the ongoing need to connect patients to primary care and the benefit of a long standing HIV testing program.\u003c/p\u003e\u003cp\u003eIf we are to end the HIV epidemic, it is imperative to identify strategies to increase HIV testing, especially among populations most impacted by new infections. Our data supports the need to offer HIV testing in emergency care settings, as this continues to be the setting where some populations receive all their care. For example, we observed that of young Black men, less than 6% seen in the ED only had ever been tested. This is the group that has the highest rate of new HIV infections and is most in need of being tested and linked to care. It is encouraging to note that when young males make it to primary care, they are appropriately being tested. However, we also observed this group was the least likely to attend a primary care visit with less than 50% of all young Black men having a single visit in PC in the 9-year period. Novel approaches to improve linkage to primary care from the ED are needed as current efforts have had limited success. As mentioned earlier, we believe our findings highlight the need for HIV testing outside of primary care settings.\u003c/p\u003e\u003cp\u003eDespite more than 10 years since CDC and professional societies recommended offering HIV testing in emergency settings, specifics on how to do this and support to incorporate testing has been missing.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) As a result, uptake has been slow and rates of testing in the ED remain low nationally.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) There is also lack of consensus on whether to apply a universal screening or a targeted screening approach in the ED.(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) Nonetheless, there are successful models for both targeted and universal testing that deserve further consideration.(\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) It is important to note that even when ED providers are educated and support the need for HIV testing, many remained reluctant to offer testing because of ongoing barriers (lack of time and concern for follow up).(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe strengths of this study include that its datum encompasses a 9-year period, over a million patient encounters in two different practice settings and highlights findings that may be dismissed if only seen in a single year. The limitations include the retrospective nature of the study, the lack of data on if someone was offered a test and declined or if they reported testing outside of the healthcare system, and lack of data beyond demographics that might better triangulate populations more at risk. Our primary outcome was once in a lifetime testing and does not include repeat testing needs for higher risk behavior. Also, it is possible that patients seen in the ED received primary care (and possibly HIV testing) elsewhere; although, this is uncommon except among young women of childbearing age who may receive primary care from an obstetrician/ gynecologist including HIV testing as part of routine prenatal care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHIV testing in PC settings is essential but not sufficient for all adults to be tested for HIV. Increasing testing in emergency departments will help to close the gap for once in a lifetime HIV testing for priority populations, especially young men.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCDC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCenters for Disease Control\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eED\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEmergency Department\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEHR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eElectronic Health Record\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHuman Immunodeficiency Virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNIH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNational Institute of Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOdds Ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePrimary Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical Statement: All work was reviewed and approved by the MetroHealth Medical Center Institutional Review Board under IRB10-00366 in accordance with the Belmont Report and adhering to the Common Rule. The work was approved with a waiver of patient consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding: Grant Support NIAID 5P30AI036219-28 (Avery), FOCUS program, Gilead Sciences (Avery, Fritz)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: AA conceived the study. CF and AA completed the primary data collection. SAL completed statistical analyses. All authors contributed to the writing of the manuscript and all authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending the HIV Epidemic: A Plan for the United States. JAMA. 2019;321(9):844\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBranson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR\u0026ndash;14):1\u0026ndash;17. quiz CE1-4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHIV Testing | NIH [Internet]. [cited 2025 Jan 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-testing\u003c/span\u003e\u003cspan address=\"https://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-testing\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCDC. HIV Surveillance Supplemental Report: Estimated HIV Incidence and Prevalence in the United States; 2018\u0026ndash;2022 [Internet]. 2024 May. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://stacks.cdc.gov/view/cdc/156513\u003c/span\u003e\u003cspan address=\"https://stacks.cdc.gov/view/cdc/156513\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHam DC, Lecher S, Gvetadze R, Huang YLA, Peters P, Hoover KW. HIV Testing at Visits to Physicians\u0026rsquo; Offices in the U.S., 2009\u0026ndash;2012. Am J Prev Med. 2017;53(5):634\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHam DC, Huang YL, Gvetadze R, Peters PJ, Hoover KW. Health Care Use and HIV Testing of Males Aged 15\u0026ndash;39 Years in Physicians\u0026rsquo; Offices - United States, 2009\u0026ndash;2012. MMWR Morb Mortal Wkly Rep. 2016;65(24):619\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoover KW, Huang YLA, Tanner ML, Zhu W, Gathua NW, Pitasi MA, et al. HIV Testing Trends at Visits to Physician Offices, Community Health Centers, and Emergency Departments - United States, 2009\u0026ndash;2017. MMWR Morb Mortal Wkly Rep. 2020;69(25):776\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAvery AK, Del Toro M, Caron A. Increases in HIV screening in primary care clinics through an electronic reminder: an interrupted time series. BMJ Qual Saf. 2014;23(3):250\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAvery AK, Toro MD, Einstadter D. Decreasing Missed Opportunities for HIV Testing in Primary Care through Enhanced Utilization of the Electronic Medical Record. J AIDS Clin Res. 2012;Suppl 4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTillison AS, Avery AK. Evaluation of the Impact of Routine HIV Screening in Primary Care. J Int Assoc Provid AIDS Care. 2017;16(1):18\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlpert PL, Shuter J, DeShaw MG, Webber MP, Klein RS. Factors Associated With Unrecognized HIV-1 Infection in an Inner-City Emergency Department. Ann Emerg Med. 1996;28(2):159\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaker JL, Kelen GD, Sivertson KT, Quinn TC. Unsuspected human immunodeficiency virus in critically ill emergency patients. JAMA. 1987;257(19):2609\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBatey DS, Hogan VL, Cantor R, Hamlin CM, Ross-Davis K, Nevin C, et al. Short communication routine HIV testing in the emergency department: assessment of patient perceptions. AIDS Res Hum Retroviruses. 2012;28(4):352\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoggin MA, Davidson AJ, Cantril SV, O\u0026rsquo;Keefe LK, Douglas JM. The extent of undiagnosed HIV infection among emergency department patients: Results of a blinded seroprevalence survey and a pilot HIV testing program. J Emerg Med. 2000;19(1):13\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArbelaez C, Wright EA, Losina E, Millen JC, Kimmel S, Dooley M, et al. Emergency provider attitudes and barriers to universal HIV testing in the emergency department. J Emerg Med. 2012;42(1):7\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe Rossi N, Dattner N, Cavassini M, Peters S, Hugli O, Darling KEA. Patient and doctor perspectives on HIV screening in the emergency department: A prospective cross-sectional study. PLoS ONE. 2017;12(7):e0180389.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEscudero DJ, Bahamon M, Panakos P, Hercz D, Seage GR, Merchant RC. How to best conduct universal HIV screening in emergency departments is far from settled. J Am Coll Emerg Physicians Open. 2021;2(1):e12352.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNiforatos JD, Nowacki AS, Avery A, Gripshover BM, Yax JA. Clinical knowledge of human immunodeficiency virus and sexually transmitted infections among emergency medicine providers. Int J STD AIDS. 2019;30(13):1290\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTan R, Hugli O, Cavassini M, Darling K. Non-targeted HIV testing in the emergency department: not just how but where. Expert Rev Anti Infect Ther. 2018;16(12):893\u0026ndash;905.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTorres M. Rapid HIV screening in the emergency department. Emerg Med Clin North Am. 2010;28(2):369\u0026ndash;80. Table of Contents.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIbitoye M, Bennett AS, Bugaghis M, Chernick LS, Des Jarlais DC, Aronson ID. Provider Perspectives on Barriers to Routine HIV Testing of Adolescent and Young Adult Patients in Emergency Department Settings. Behav Med. 2023;49(2):204\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMwachofi A, Fadul NA, Dortche C, Collins C. Cost-effectiveness of HIV screening in emergency departments: a systematic review. AIDS Care. 2021;33(10):1243\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaukoos JS, Hopkins E, Hull A, Dean C, Donahoe K, Ruzas CM et al. HIV testing in emergency departments in the United States: a national survey. Ann Emerg Med. 2011;58(1 Suppl 1):S10-16.e1-8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRothman RE, Ketlogetswe KS, Dolan T, Wyer PC, Kelen GD. Preventive care in the emergency department: should emergency departments conduct routine HIV screening? a systematic review. Acad Emerg Med. 2003;10(3):278\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eClay CE, Ling AY, Bennett CL. HIV Testing at Visits to US Emergency Departments, 2018. J Acquir Immune Defic Syndr. 2022;90(3):256\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eClay CE, Hoover KW, Le Guen Y, Bennett CL. Estimates of HIV testing at visits to United States emergency departments. AIDS. 2024;38(2):255\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaukoos JS, Lyons MS, Rothman RE. The Evolving Landscape of HIV Screening in the Emergency Department. Ann Emerg Med. 2018;72(1):54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTan R, Hugli O, Cavassini M, Darling K. Non-targeted HIV testing in the emergency department: not just how but where. Expert Rev Anti Infect Ther. 2018;16(12):893\u0026ndash;905.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLyons MS, Lindsell CJ, Ruffner AH, Wayne DB, Hart KW, Sperling MI et al. Randomized Comparison of Universal and Targeted HIV Screening in the Emergency Department. Journal of acquired immune deficiency syndromes (1999). 2013;64(3):315.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeblanc J, Hejblum G, Costagliola D, Durand-Zaleski I, Lert F, de Truchis P, et al. Targeted HIV Screening in Eight Emergency Departments: The DICI-VIH Cluster-Randomized Two-Period Crossover Trial. Ann Emerg Med. 2018;72(1):41\u0026ndash;e539.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8071454/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8071454/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground- HIV testing is a necessary component for ending the HIV epidemic, yet many individuals remain untested. We sought to evaluate the rate of ever tested for HIV among patients seeking care at the emergency department in a safety net healthcare system with an established large-volume, non-targeted HIV testing program in primary care.\u003c/p\u003e\u003cp\u003eMethods- Patient encounters were reviewed for adults without HIV and with visits to primary care (PC) clinics and/or the emergency department (ED) during 2010 to 2018. Patient-level analyses assessed rates of \u0026lsquo;ever tested\u0026rsquo; and rates of \u0026lsquo;tested on encounter\u0026rsquo; during the study period for PC and ED only groups. Binary logistic regression models tested for significant associations for the two outcomes with visit setting, age group, sex at birth, and race as covariates.\u003c/p\u003e\u003cp\u003eResults- Patients seen in PC were 4 times more likely to be ever tested for HIV compared to ED only patients (aOR: 4.40; 95% CI: 4.31\u0026ndash;4.50). The highest rate of ever tested occurred among younger Black females who were seen in PC, while the lowest rate occurred among younger Non-Black males under 30 years of age who were seen in the ED only.\u003c/p\u003e\u003cp\u003eConclusions- Patients who received care only in the emergency department were unlikely to ever be tested for HIV. Strategies to increase single lifetime HIV testing in EDs are needed to reach priority populations not receiving PC.\u003c/p\u003e","manuscriptTitle":"HIV Testing in Primary Care is not Enough. Multiyear analysis of HIV Testing among Patient Populations within the Emergency Department and Primary Care Settings in a Safety Net System","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 15:38:48","doi":"10.21203/rs.3.rs-8071454/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-12-05T14:48:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-11T15:12:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-11T08:39:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-11T08:37:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-11-09T23:17:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"50be1151-c574-42ab-9b0e-2a5cc7bff093","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T15:38:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 15:38:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8071454","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8071454","identity":"rs-8071454","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}