Screening for HIV, Hepatitis C, and Syphilis in Emergency Departments

Implementation Guide | Screening for HIV, Hepatitis C, and Syphilis in Emergency Departments

Setting the Stage

Syphilis & congenital syphilis (CS) cases have been increasing in California (CA) over the last decade. This is especially concerning as CS can cause severe illness including premature birth, low birth weight, meningitis, blindness, deafness, anemia, bone abnormalities, hepatosplenomegaly, jaundice, & skin rashes. HIV can also be transmitted from a pregnant person to their fetus &, often, birthing parents of infants with perinatal HIV are co-infected with or have a recent history of syphilis, highlighting the need for an integrated approach to these preventable infections.¹ In addition, CA has a significant burden of chronic hepatitis C virus (HCV) & HIV, & many people remain unaware of their infection or have not been treated.

Emergency departments (EDs) are critical access points for some of the most underserved communities & are uniquely positioned to identify people with undiagnosed HIV, HCV, & syphilis infections who otherwise may remain undiagnosed. Among those experiencing barriers accessing routine primary care, EDs often serve as the sole point of contact with the healthcare system. EDs offer an opportunity to identify & treat patients at highest risk for HIV, HCV, & syphilis infection. ^2,3,4,5

The CA Department of Public Health (CDPH) issued a health alert, which includes a recommendation for ED providers to confirm syphilis status of all pregnant patients prior to discharge.⁴ In addition, the implementation of opt-out HIV, HCV, & syphilis testing is supported by CA health department recommendations.^2,4,5,6,7

Key Information from this Implementation Guide

Please select from the below categories to learn more about benefits, lessons learned, potential funding resources, resources, and references.

Benefits of Screening in EDs

Screening for HIV, HCV, & syphilis in EDs has been shown to detect unidentified & untreated infections. Evaluation studies on various screening models have been published by EDs across the country. CDPH has also interviewed four CA EDs that have implemented opt-out HIV, HCV, & syphilis screening programs. Based on literature & experience, ED screening programs can:

Published Literature

Increase diagnoses of syphilis^8,9,10 & asymptomatic sexually transmitted infections¹⁰

Avert cases of CS^10,12

Reach populations that otherwise may be missed through traditional screening recommendations^8,11

CA Emergency Departments

Increase access to testing

Reduce healthcare costs due to increased & earlier treatment of STIs

Reduce transmission due to early detection & treatment

Increase screening & treatment of individuals who are undiagnosed

Lessons Learned from EDs

EDs in CA that have implemented routine, opt-out HIV, HCV, & syphilis screening programs have noted several keys to the successful implementation of this initiative. It may be important to consider the following emerging best practices during implementation:

Garner buy-in from staff

Have a champion within both the ED & the public health department to generate excitement & buy-in.
Have conversations with other EDs that are already implementing screening programs.
Include key decision makers impacted by the screening protocol (e.g., ED providers, nursing, front desk staff, IT, lab, finance, administration) from the outset & get their buy-in.
Educate staff on new screening & treatment protocols including opt-out screening, empiric treatment in the ED, linkage to care, & automated ordering. Consider ways that your local health department could support this process (e.g., trainings/in-services, virtual learning opportunities).

Identify protocols and workflows

Consider implementing HIV, HCV, & syphilis at the same time to streamline implementation.
Automate the test ordering process via EMR algorithms to identify individuals for testing, limit impacts to existing workflows, & reduce opportunities for human error, if possible.
Separate, written consent is not required for HIV testing. Opt-out testing – in which the patient if notified that testing will be performed unless they decline – is recommended by the CDC as best clinical care, regardless of reported risk behaviors.
Identify opportunities to reduce laboratory turnaround time (e.g., reflex testing for confirmatory tests, processing tests in-house) so that initial results can be obtained, & the patient can be treated prior to discharge.
Utilize HIV, HCV, and syphilis testing & Treatment algorithms to facilitate empiric treatment in the ED to reduce lost to follow up & failure to initiate treatment.

Consider who will follow-up on positives and linkage to care

Prior to roll-out, determine standard operating procedures (.doc) (SOPs) for (1) patients who test positive including identification of who at the hospital & the health department will ensure treatment & seamless linkage to care, and (2) notifying patients who have negative confirmatory tests to discontinue treatment.
When possible, expand linkage to care services during the times of the day when you see the most patients (e.g., outside of business hours)

Potential Funding Sources

To support HIV, HCV, & syphilis screening, emergency departments (EDs) may be able to leverage one or more existing local, state, and/or federally funded initiatives below:

County General Funds

Some counties may have discretionary funds available for priority public health initiatives. For more information, contact your local board of supervisors, city council, or your local health department.

Department of Health Care Services

DHCS oversees Medi-Cal along with state-funded mental health and substance use disorder services. Their listserv often includes funding announcements as well as information on implementation of Cal-AIM (described in more detail below). Find out more about how to join the DHCS listserv on the DHCS website.

Industry

Some private companies, such as medication manufacturers and pharmacies, have given limited-term funding to help EDs establish the infrastructure to implement routine opt-out testing for syphilis, HIV, and HCV.

Medi-Cal Managed Care Plans

Medi-Cal Managed Care Plans (MCPs) are responsible for implementing California Advancing and Innovating Medi-Cal (CalAIM), including through contracts with local organizations. MCPs often have flexibility to pilot different collaborative models to achieve desired improvements in patient outcomes. Given the complexity of Cal-AIM, approaching local MCPs may be a useful strategy to identify which components could be leveraged to support ED and MCPs’ mutual goals. Potential initiatives within Cal-AIM and/or Medi-Cal for exploration include, but are not limited to:

Community health worker (CHW) benefit: Enables qualified CHWs to bill for eligible services.
Enhanced care management and community supports: Provides care coordination and support, such as housing navigation, for eligible Medi-Cal members with complex needs. Covered community supports vary by county (PDF).
Incentive payment plan: MCPs receive incentive payments to establish local Cal-AIM infrastructure.
Providing access and transforming health (PATH): Provides funding and technical assistance to build capacity to offer Cal-AIM services.
Population health management: Promotes data-sharing, care transitions, and strategies to reduce disparities and ED use.

Local Public Health Departments (LHDs)

Some LHDs may have syphilis, HIV, and/or HCV funding available from the California Department of Public Health (CDPH), including to support routine opt-out testing in emergency departments. This could include direct funding or in-kind support, such as embedding disease investigation specialists in the ED.

Note: LHDs may have limitations in their ability to support testing in their local EDs, including state rules limiting local partnerships to non-profit entities or funding being earmarked for other priority activities. Nevertheless, EDs should reach out to their LHDs to explore potential opportunities for collaboration. For EDs who need assistance identifying a contact at your LHD, please contact [email protected].

Opioid Settlement Funds

California has entered into multiple settlement agreements with companies that may have contributed in some way to the prescription opioid epidemic. Many of these opioid settlement funds have been allocated for use by city and county governments for a range of allowable activities outlined in Exhibit E (PDF) of the National Opioid Settlement Agreements. Allowable activities include, but are not limited to:

Expanding access to testing and treatment for infectious diseases such as HIV and Hepatitis C resulting from intravenous opioid use.
Providing training in harm reduction strategies to health care providers, students, peer recovery coaches, recovery outreach specialists, or other professionals that provide care to persons who use opioids or persons with [opioid use disorder] and any cooccurring [substance use disorder/mental health] conditions.
Provide comprehensive syringe services programs with more wrap-around services, including linkage to opioid use disorder treatment, access to sterile syringes and linkage to care and treatment of infectious diseases.

Responsibility for managing the use of opioid settlement funds varies by city and county. Potential contacts may include the local behavioral health director, local health officer, sheriff’s department, or opioid safety coalition. For more information, visit the DHCS Opioid Settlement Funds website.

Sierra Health Foundation

Sierra Health Foundation often manages federally funded substance use disorder initiatives for DHCS. They frequently release funding announcements for local and community applicants. To learn more about current projects and to join their mailing list, visit the Sierra Health Foundation website.

Resources

Example ED Standard Operating Procedure for HIV, HCV, & Syphilis Screening (Word)
Emergency Department Test-to-Treat Algorithms [HIV, HCV, Syphilis] (Bridge)

Walk through of test-to-treat case studies, May 2024 Community of Practice (COP) recording

Dear Colleague Letter: Opt-Out ED Screening for HIV, HCV, and Syphilis (PDF) (CDPH)
ED Syphilis/HIV/HCV Screening Program: Implementation Webinar Recordings(under ‘Awardee TA Webinars’ section; Bridge)
ED Syphilis/HIV/HCV Screening Program: Resources (Bridge)
Syphilis Train the Trainer Case-Based Educational Tool: Clinicians or LHDs can receive syphilis education and provide training to other ED staff on the varied manifestations, diagnosis, and management of syphilis. For a copy of this presentation, contact [email protected].
Health Update: California Department of Public Health Updates Syphilis Screening Recommendations (CDPH)
Hepatitis C Community Navigation Model and Toolkit (NASTAD)
Congenital Syphilis Update for CA ED Clinicians (CA Prevention Training Center)
CDPH STD, HCV, and CDC HIV Clinical Guidelines
Medi-Cal Explained: 2024 Medi-Cal Managed Care Plans by County (PDF) (CHCF)
Braiding Medicaid Funds to Support Person Centered Care: Lessons from Medi-Cal - Center for Health Care Strategies (CHCS)
Medi-Cal Explained: New Medi-Cal Services at a Glance (2020–2023) (PDF) (CHCF)

References

1 Dear Colleague Letter: Call to Expand HIV and Syphilis Testing for Pregnant Women (PDF); California Department of Public Health. November 2021.

2 HIV Testing in Emergency Departments: Findings and Recommendations Assembly Bill No. 2439 (PDF); California Department of Public Health. November 2019.

3 Trends in the Utilization of Emergency Department Services, 2009- 2018 (PDF); U.S. Department of Health and Human Services. March 2021.

4 Health Alert: California Department of Public Health Updates Syphilis Screening Recommendations, October 2024.

5 Dear Colleague Letter: Opt-Out Emergency Department HIV, HCV, and Syphilis Screening (PDF); California Department of Public Health. March 2022.

6 Summary of Laws and Regulations Related to Sexually Transmitted Disease Prevention and Control in California (PDF); California Department of Public Health. May 2018.

7 Prenatal Syphilis Testing: Senate Bill 306 Fact Sheet (PDF); California Department of Public Health.

8 Stanford KA, Hazra A, Schneider J. Routine Opt-out Syphilis Screening in the Emergency Department: A Public Health Imperative. Academic Emergency Medicine. 2020;27(5):437-438. doi:10.1111/acem.13897

9 Chechi T, Sage AC, Tran N, Waldman S, May LS. 433. Implementation of an Emergency Department Syphilis Screening Program. Open Forum Infect Dis. 2019;6(Supplement_2):S216-S216. doi:10.1093/ofid/ofz360.506

10 Stanford K, Ridgway J, Schneider J. P740 Improving syphilis diagnosis and treatment in an urban population through routine emergency department screening. Sex Transm Infect. 2019;95(Suppl 1):A319-A320. doi:10.1136/sextrans-2019-sti.800

11 Stanford KA, Hazra A, Friedman E, Devlin S, Winkler N, Ridgway JP, Schneider J. Opt-out, routine emergency department syphilis screening as a novel intervention in at-risk populations. Sex Transm Dis. 2020 Oct 1. doi: 10.1097/OLQ.0000000000001311. Epub ahead of print. PMID: 33009277.

12 Larios Venegas A, Melbourne HM, Castillo IA, et al. Enhancing the Routine Screening Infrastructure to Address a Syphilis Epidemic in Miami-Dade County. Sexually Transmitted Diseases. 2020;47(5S):S61. doi:10.1097/OLQ.0000000000001133

Emergency-Departments

Sexually transmitted diseases control branch

Implementation Guide | Screening for HIV, Hepatitis C, and Syphilis in Emergency Departments

Setting the Stage

Key Information from this Implementation Guide

Benefits of Screening in EDs

Published Literature

CA Emergency Departments

Lessons Learned from EDs

Garner buy-in from staff

Identify protocols and workflows

Consider who will follow-up on positives and linkage to care

Potential Funding Sources

County General Funds

Department of Health Care Services

Industry

Medi-Cal Managed Care Plans

Local Public Health Departments (LHDs)

Opioid Settlement Funds

Sierra Health Foundation

Resources

References

What’s New

Administrative

Diseases and Conditions

Family Health

Health and Safety

Health Facilities

Personal Health and Prevention

Licensing, Certification and Other Credentials

Person Interested In

Sexually transmitted diseases control branch

Implementation Guide | Screening for HIV, Hepatitis C, and Syphilis in Emergency Departments

Setting the Stage

Key Information from this Implementation Guide

Benefits of Screening in EDs

Published Literature

CA Emergency Departments

Lessons Learned from EDs

Garner buy-in from staff

Identify protocols and workflows

Consider who will follow-up on positives and linkage to care

Potential Funding Sources

County General Funds

Department of Health Care Services

Industry

Medi-Cal Managed Care Plans

Local Public Health Departments (LHDs)

Opioid Settlement Funds

Sierra Health Foundation

Resources

References