Hospitals should follow their standard HIPAA compliance policies and procedures. HIPAA permits disclosures for public health activities. Syphilis, HIV and HCV are reportable to the local health officer under Title 17 CA Code of Regulations 2500 (by providers) and 2505 (by labs).

Continuity of care is vital to linkage. The HIPAA Privacy Rule allows providers to use or disclose protected health information for treatment and referral purposes. See 45 CFR 164.506 and the Health & Human Services HIPAA Home for Professionals for more information.

Likewise, each ED must make its own decision for what age to begin screening. Some EDs conduct opt-out testing among all patients 12 years of age and older. California law (Family Code 6926) allows minors 12 years of age and older to consent to preventive services for sexually transmitted infections (STIs) and diagnosis and treatment for reportable communicable diseases, including STIs. Other EDs choose to only test over the age of 18. We recommend selecting an age that will likely identify the most individuals infected in your community.

There is not a set recommended testing frequency and approaches may differ based on risk factors present in an ED’s patient population. Below is a summary of syphilis, HIV, and HCV screening considerations and recommendations for ED settings.

Considerations:

• Approaches to frequency may differ based on risk factors that are present in an ED’s patient population.
• Some EDs may choose to screen annually.
• Implementing EMR algorithms can simplify how to identify which patients should be screened and how frequently.
• EDs may also implement additional targeted screening for patients with symptoms or concerning lab findings.

Syphilis Screening Recommendations:

• US Preventive Services Task Force (USPSTF) issued a grade A recommendation for screening persons who are at increased risk for syphilis infection¹. 
• Optimal screening frequency for persons who are at increased risk for syphilis infection is not well established¹. 
  • Men who have sex with men (MSM) and/or persons living with HIV may benefit from screening at least annually or more frequently (e.g., every 3 to 6 months) if they continue to be at high risk¹. 
• Pregnant people should be tested at first prenatal visit^2,3,4  
  • Additional testing in the 3rd trimester and at delivery (except for those at low risk with a documented negative screen in the 3rd trimester)^3,4 
  • ACOG recommends screening all pregnant individuals serologically for syphilis at the first prenatal care visit, followed by universal rescreening during the third trimester and at birth, rather than use a risk-based approach to testing.⁵
  • **Of note, CDPH is currently in the process of updating its screening recommendations in pregnancy and these should be available soon.

HIV Screening Recommendations:

• USPSTF issued a grade A recommendation for:. 

• • • Screening adolescents and adults (15 to 65 years of age)¹.

• Repeat screening for persons known to be at increased risk (e.g., men who have sex with men (MSM), persons with a sex partner living with HIV, with ≥1 new partners, with unknown HIV status of sex partners; persons who inject drugs (PWID); transactional or commercial sex workers)¹.

• One time screening for pregnant people & third trimester screening in people with risk factors.

• There is insufficient evidence to determine appropriate or optimal time intervals or strategies for repeat HIV screening¹.
• CDC recommends considering screening MSM every 3-6 months depending on the patient’s risk factors, local HIV prevalence, and local policies².

At the beginning of the roll-out process: 

• Bring together all staff that may be impacted by the protocol (e.g., lab, nursing, ED clinicians, navigators, administration, IT, etc.) to communicate about the new project and the purpose of implementing opt-out testing in an ED setting. During this meeting, identify any key staff concerns and brainstorm a plan to address them early in the process.

After you have implemented routine opt-out testing: 

• Present at provider meetings on the opt-out testing, treatment, and linkage to care processes. 
• Send monthly emails (for approximately 3 months) and then quarterly emails to ED staff and providers with data updates/numbers of newly identified patients. For example, “Our testing rate increased by 20% over the last month; we identified XX syphilis, XX HIV, and XX HCV cases.” Consider including what percent were initiated on treatment in the ED and linked to care. 
• Attend ED rounds with providers to check-in, encourage testing, and share missed opportunities and success stories. Share examples of patients that tested positive and wouldn’t have received testing prior to the opt-out screening program, and the impact that had on their clinical care. 

As the project takes hold and becomes stabilized:

• Hardwire staff training into your processes and incorporate training materials into your onboarding process for new staff. Connect with ED resident leaders/coordinators so that trainees are aware of routine HIV/HCV/syphilis screening before they begin working in the ED.