Staffing Crucial to HIV Testing in the ED

Of the more than 1 million HIV-positive patients in the United States, approximately 21% are undiagnosed, as more than 50,000 new infections occur annually. The emergency department is recognized as an important point of access to HIV testing for many patients.

In 2006, the Centers for Disease Control and Prevention recommended that HIV testing be incorporated into routine medical care, including emergency care and, in 2007, the American College of Emergency Physicians agreed, saying in a policy statement that HIV testing in the emergency department "should be available in an expeditious and efficient fashion similar to testing and results for other conditions."

Although HIV testing in EDs has become more common since the CDC and ACEP recommendations were made, controversies about and obstacles to such testing remain.

Perceptions of Testing

In a 2007 study of the perceived benefits and disadvantages of HIV testing in the ED, researchers did a structured evaluation of opinions gathered from 98 experts from 42 institutions who attended the 2007 conference of the National Emergency Department HIV Testing Consortium in Baltimore (Ann. Emerg. Med. 2011;58:S151-9).

The expert opinions were organized using a subjective analytic planning tool called SWOT (strengths, weaknesses, opportunities, threats) by the researchers, led by Aleksandar Kecojevic of Johns Hopkins University, Baltimore.

The identified strengths of HIV testing in the ED were the high volume of ED visits (110 million annually) and the high prevalence of HIV in the ED patient population (cited by 19.6% of the experts). Access to an underserved patient population was cited by 16.1%. Other strengths included the availability of testing around the clock (11.7%) and the chance for earlier diagnosis (8.1%).

A total of 23.2% of the experts identified the additional strain on ED staff and resources as the biggest weakness of the approach. Inadequate privacy for testing in the ED was mentioned by 13%.

The opportunity to reduce the stigma of HIV was cited by 26.8% of the experts and better surveillance of disease rates and transmission networks by 18.4%. The threat category included lack of funding and other resources (44%), and diversion of resources and staff from the emergency department’s primary mission of acute care (13.4%).

Increasing Rates of Testing

Despite the barriers to HIV testing in EDs, the rates have increased substantially since the testing recommendations were published.

A 1996 survey found that about 50% of academic EDs tested for HIV after suspected exposure. In 2006, a survey found that a similar 57% of academic EDs did some rapid HIV testing, but only 4% did so routinely. Only 3 years later, in 2009, a cross-sectional survey of medical providers by Dr. Richard E. Rothman and his colleagues found that 82% of EDs conducted HIV testing (Ann. Emerg. Med. 2011;58[suppl]:S3-9).

However, only 22% did so as part of a routine HIV testing program, and 18% did no testing at all, according to Dr. Rothman of Johns Hopkins University, Baltimore, and his coinvestigators.

The survey included 338 academic, nonacademic, and community hospitals from urban and rural areas across the country. Survey respondents included ED directors and chairs, HIV program directors, nurses, and ED social workers.

Of the 22% of EDs that reported routine HIV screening, 85% were in urban areas and 65% were in academic hospitals. Most of the 18% that did no testing were small community hospitals. Of large hospitals with more than 100,000 visits a year, 91% offered HIV testing and more than half had routine HIV testing programs. More than 80% of the screening programs had been in place for less than 3 years, and about a third had existed for less than a year.

"These results represent a recent increase in the availability of HIV testing in U.S. EDs and a steady increase in HIV screening," Dr. Rothman and his colleagues concluded.

Overall, EDs in academic hospitals implement HIV testing at a higher rate than do those in community hospitals, according to a 2007 cross-sectional survey by Dr. Jason S. Haukoos and his colleagues, which found significant differences in testing rates (Ann. Emerg. Med. 2011;58[suppl]:S10-16).

Their survey included ED administrators, emergency physicians, and other health care staff at 99 academic EDs and 150 community institutions. They found that 65% of academic EDs offered testing, compared with 50% of community hospitals; more academic institutions tested without charging patients (34% vs. 7%) and received funding for testing (15% vs. 2%), said Dr. Haukoos of Denver Health Medical Center and his colleagues.

Diagnostic testing was offered most widely (73% of academic EDs, 63% of community EDs). Nontargeted screening was performed at 16% of academic institutions, compared with only 5% of community EDs.

"There remain substantial differences related to HIV testing between academic and community institutions, and a substantial proportion of institutions still do not provide some form of HIV testing," the authors said.

Staffing for Testing Programs

Having enough personnel with the right training is the key to implementing any HIV testing program in the ED. The Universal Screening for HIV Infection in the Emergency Room (USHER) trial compared HIV testing offered by supplemental HIV counselors to testing offered by ED providers. The objective of the trial was to determine whether testing rates were higher when offered by existing ED providers or by additional staff such as counselors and social workers (Ann. Emerg. Med. 2011;58[suppl]:S126-132).

"Routine, voluntary HIV testing was completed more than twice as frequently when personnel were dedicated specifically to this task," reported Dr. Rochelle P. Walensky of Massachusetts General Hospital, Boston, and her colleagues.

In this 2007-2008 randomized controlled trial, 2,446 ED patients were randomized to the counselor arm and 2,409 to the ED provider arm. A total of 80% of patients in the counselor arm were offered testing vs. 36% of those in the provider arm. In the provider arm, the offer rate declined with increasing age of the patient and declined over the course of the study (from 76% at 2 months to 25% at 17 months). "Testing attrition over time [in the provider arm] may be due to waning enthusiasm for the program in the face of patient acuity and other clinical duties," Dr. Walensky and her coauthors suggested.

A comparable proportion of patients accepted testing when it was offered (71% in the counselor arm and 75% in the provider arm), for an overall testing rate of 57% in the counselor arm and 27% in the provider arm.

"Although HIV counselor time certainly costs less than that of ED providers, the cost of additional trained personnel is not trivial." However, "without such resources, rapid HIV testing in this setting is most likely diagnostic and not truly routine," they concluded.

In another 2007-2008 study of six EDs that had HIV screening programs in place for at least 6 months, Gretchen Williams Torres and her coinvestigators found that "several sites had 1 or more staff individuals, generally an emergency physician or nurse, who took ownership of the screening program" (Ann. Emerg. Med. 2011;58[suppl]:S104-13).

Testing was done by supplemental staff at four hospitals and by existing ED staff at two. Costs were higher at the two EDs in which supplemental staff was used to implement the programs, at $10,200-$12,300, compared with $3,400-$8,600 when ED providers added it to their tasks, wrote Ms. Torres of the University of Chicago and her coauthors.

The six study institutions were a public hospital and a for-profit hospital in the South, two nonprofits in the Midwest, a public hospital in the West, and a public hospital in the Northeast. All were teaching hospitals, with a median of 37.5 ED beds. Two of the EDs did targeted screening of higher-risk patients, three screened some patients regardless of risk, and one screened all patients (universal screening).

Yet "none of the EDs were able to test more than 10% of the patients presenting for care," with a median of 4.7% of patients tested. EDs with targeted programs tested 2%-3% of their patients, those with nontargeted programs tested 5%-8%, and the hospital with universal screening tested 7% (while that institution offered screening to 97% of its patients, most declined the test).

In a report of a 2009 pilot program at an urban academic ED, the investigators found that the success of the program was dependent on "a core group of coordinators, involvement and support from administration, and broad buy-in from faculty and staff," including "ED technicians, nurses, and physician extenders and emergency physicians" (Ann. Emerg. Med. 2011;58[suppl]:S44-8).

The program required a commitment from staff to perform the tasks necessary "for patient recruitment, specimen collection and processing, result notification, posttest counseling, and data entry," said Dr. Bryn E. Mumma of the University of Pittsburgh and her colleagues.

"Finding someone with time to enroll patients and collect the OraSure specimen without compromising patient care or ED flow was the most significant barrier to universal screening in our pilot program," they said.

Providing HIV screening in the ED setting serves a hard-to-reach population, and much progress has been made in adding routine HIV testing to ED visits. However, the lack of available dedicated staff, inadequate funding, and other obstacles will continue to hamper future efforts.

Mr. Kecojevic had no disclosures. Dr. Rothman received funding from the Maryland Department of Health and Mental Hygiene. Dr. Haukoos received an award from the Agency for Healthcare Research and Quality, support from the CDC, and an unrestricted grant from Abbott Laboratories. Dr. Walensky received the Doris Duke Charitable Foundation Clinical Scientist Development Award, and her study had support from the National Institute of Mental Health. Ms. Torres’ study was funding by the CDC and the Health Research and Educational Trust of the American Hospital Association. The Allegheny County Health Department provided the OraSure tests and processing for Dr. Mumma’s study.

Of the more than 1 million HIV-positive patients in the United States, approximately 21% are undiagnosed, as more than 50,000 new infections occur annually. The emergency department is recognized as an important point of access to HIV testing for many patients.

In 2006, the Centers for Disease Control and Prevention recommended that HIV testing be incorporated into routine medical care, including emergency care and, in 2007, the American College of Emergency Physicians agreed, saying in a policy statement that HIV testing in the emergency department "should be available in an expeditious and efficient fashion similar to testing and results for other conditions."

Although HIV testing in EDs has become more common since the CDC and ACEP recommendations were made, controversies about and obstacles to such testing remain.

Perceptions of Testing

In a 2007 study of the perceived benefits and disadvantages of HIV testing in the ED, researchers did a structured evaluation of opinions gathered from 98 experts from 42 institutions who attended the 2007 conference of the National Emergency Department HIV Testing Consortium in Baltimore (Ann. Emerg. Med. 2011;58:S151-9).

The expert opinions were organized using a subjective analytic planning tool called SWOT (strengths, weaknesses, opportunities, threats) by the researchers, led by Aleksandar Kecojevic of Johns Hopkins University, Baltimore.

The identified strengths of HIV testing in the ED were the high volume of ED visits (110 million annually) and the high prevalence of HIV in the ED patient population (cited by 19.6% of the experts). Access to an underserved patient population was cited by 16.1%. Other strengths included the availability of testing around the clock (11.7%) and the chance for earlier diagnosis (8.1%).

A total of 23.2% of the experts identified the additional strain on ED staff and resources as the biggest weakness of the approach. Inadequate privacy for testing in the ED was mentioned by 13%.

The opportunity to reduce the stigma of HIV was cited by 26.8% of the experts and better surveillance of disease rates and transmission networks by 18.4%. The threat category included lack of funding and other resources (44%), and diversion of resources and staff from the emergency department’s primary mission of acute care (13.4%).

Increasing Rates of Testing

Despite the barriers to HIV testing in EDs, the rates have increased substantially since the testing recommendations were published.

A 1996 survey found that about 50% of academic EDs tested for HIV after suspected exposure. In 2006, a survey found that a similar 57% of academic EDs did some rapid HIV testing, but only 4% did so routinely. Only 3 years later, in 2009, a cross-sectional survey of medical providers by Dr. Richard E. Rothman and his colleagues found that 82% of EDs conducted HIV testing (Ann. Emerg. Med. 2011;58[suppl]:S3-9).

However, only 22% did so as part of a routine HIV testing program, and 18% did no testing at all, according to Dr. Rothman of Johns Hopkins University, Baltimore, and his coinvestigators.

The survey included 338 academic, nonacademic, and community hospitals from urban and rural areas across the country. Survey respondents included ED directors and chairs, HIV program directors, nurses, and ED social workers.

Of the 22% of EDs that reported routine HIV screening, 85% were in urban areas and 65% were in academic hospitals. Most of the 18% that did no testing were small community hospitals. Of large hospitals with more than 100,000 visits a year, 91% offered HIV testing and more than half had routine HIV testing programs. More than 80% of the screening programs had been in place for less than 3 years, and about a third had existed for less than a year.

"These results represent a recent increase in the availability of HIV testing in U.S. EDs and a steady increase in HIV screening," Dr. Rothman and his colleagues concluded.

Overall, EDs in academic hospitals implement HIV testing at a higher rate than do those in community hospitals, according to a 2007 cross-sectional survey by Dr. Jason S. Haukoos and his colleagues, which found significant differences in testing rates (Ann. Emerg. Med. 2011;58[suppl]:S10-16).

Their survey included ED administrators, emergency physicians, and other health care staff at 99 academic EDs and 150 community institutions. They found that 65% of academic EDs offered testing, compared with 50% of community hospitals; more academic institutions tested without charging patients (34% vs. 7%) and received funding for testing (15% vs. 2%), said Dr. Haukoos of Denver Health Medical Center and his colleagues.

Diagnostic testing was offered most widely (73% of academic EDs, 63% of community EDs). Nontargeted screening was performed at 16% of academic institutions, compared with only 5% of community EDs.

"There remain substantial differences related to HIV testing between academic and community institutions, and a substantial proportion of institutions still do not provide some form of HIV testing," the authors said.

Staffing for Testing Programs

Having enough personnel with the right training is the key to implementing any HIV testing program in the ED. The Universal Screening for HIV Infection in the Emergency Room (USHER) trial compared HIV testing offered by supplemental HIV counselors to testing offered by ED providers. The objective of the trial was to determine whether testing rates were higher when offered by existing ED providers or by additional staff such as counselors and social workers (Ann. Emerg. Med. 2011;58[suppl]:S126-132).

"Routine, voluntary HIV testing was completed more than twice as frequently when personnel were dedicated specifically to this task," reported Dr. Rochelle P. Walensky of Massachusetts General Hospital, Boston, and her colleagues.

In this 2007-2008 randomized controlled trial, 2,446 ED patients were randomized to the counselor arm and 2,409 to the ED provider arm. A total of 80% of patients in the counselor arm were offered testing vs. 36% of those in the provider arm. In the provider arm, the offer rate declined with increasing age of the patient and declined over the course of the study (from 76% at 2 months to 25% at 17 months). "Testing attrition over time [in the provider arm] may be due to waning enthusiasm for the program in the face of patient acuity and other clinical duties," Dr. Walensky and her coauthors suggested.

A comparable proportion of patients accepted testing when it was offered (71% in the counselor arm and 75% in the provider arm), for an overall testing rate of 57% in the counselor arm and 27% in the provider arm.

"Although HIV counselor time certainly costs less than that of ED providers, the cost of additional trained personnel is not trivial." However, "without such resources, rapid HIV testing in this setting is most likely diagnostic and not truly routine," they concluded.

In another 2007-2008 study of six EDs that had HIV screening programs in place for at least 6 months, Gretchen Williams Torres and her coinvestigators found that "several sites had 1 or more staff individuals, generally an emergency physician or nurse, who took ownership of the screening program" (Ann. Emerg. Med. 2011;58[suppl]:S104-13).

Testing was done by supplemental staff at four hospitals and by existing ED staff at two. Costs were higher at the two EDs in which supplemental staff was used to implement the programs, at $10,200-$12,300, compared with $3,400-$8,600 when ED providers added it to their tasks, wrote Ms. Torres of the University of Chicago and her coauthors.

The six study institutions were a public hospital and a for-profit hospital in the South, two nonprofits in the Midwest, a public hospital in the West, and a public hospital in the Northeast. All were teaching hospitals, with a median of 37.5 ED beds. Two of the EDs did targeted screening of higher-risk patients, three screened some patients regardless of risk, and one screened all patients (universal screening).

Yet "none of the EDs were able to test more than 10% of the patients presenting for care," with a median of 4.7% of patients tested. EDs with targeted programs tested 2%-3% of their patients, those with nontargeted programs tested 5%-8%, and the hospital with universal screening tested 7% (while that institution offered screening to 97% of its patients, most declined the test).

In a report of a 2009 pilot program at an urban academic ED, the investigators found that the success of the program was dependent on "a core group of coordinators, involvement and support from administration, and broad buy-in from faculty and staff," including "ED technicians, nurses, and physician extenders and emergency physicians" (Ann. Emerg. Med. 2011;58[suppl]:S44-8).

The program required a commitment from staff to perform the tasks necessary "for patient recruitment, specimen collection and processing, result notification, posttest counseling, and data entry," said Dr. Bryn E. Mumma of the University of Pittsburgh and her colleagues.

"Finding someone with time to enroll patients and collect the OraSure specimen without compromising patient care or ED flow was the most significant barrier to universal screening in our pilot program," they said.

Providing HIV screening in the ED setting serves a hard-to-reach population, and much progress has been made in adding routine HIV testing to ED visits. However, the lack of available dedicated staff, inadequate funding, and other obstacles will continue to hamper future efforts.

Mr. Kecojevic had no disclosures. Dr. Rothman received funding from the Maryland Department of Health and Mental Hygiene. Dr. Haukoos received an award from the Agency for Healthcare Research and Quality, support from the CDC, and an unrestricted grant from Abbott Laboratories. Dr. Walensky received the Doris Duke Charitable Foundation Clinical Scientist Development Award, and her study had support from the National Institute of Mental Health. Ms. Torres’ study was funding by the CDC and the Health Research and Educational Trust of the American Hospital Association. The Allegheny County Health Department provided the OraSure tests and processing for Dr. Mumma’s study.

Of the more than 1 million HIV-positive patients in the United States, approximately 21% are undiagnosed, as more than 50,000 new infections occur annually. The emergency department is recognized as an important point of access to HIV testing for many patients.

In 2006, the Centers for Disease Control and Prevention recommended that HIV testing be incorporated into routine medical care, including emergency care and, in 2007, the American College of Emergency Physicians agreed, saying in a policy statement that HIV testing in the emergency department "should be available in an expeditious and efficient fashion similar to testing and results for other conditions."

Although HIV testing in EDs has become more common since the CDC and ACEP recommendations were made, controversies about and obstacles to such testing remain.

Perceptions of Testing

In a 2007 study of the perceived benefits and disadvantages of HIV testing in the ED, researchers did a structured evaluation of opinions gathered from 98 experts from 42 institutions who attended the 2007 conference of the National Emergency Department HIV Testing Consortium in Baltimore (Ann. Emerg. Med. 2011;58:S151-9).

The expert opinions were organized using a subjective analytic planning tool called SWOT (strengths, weaknesses, opportunities, threats) by the researchers, led by Aleksandar Kecojevic of Johns Hopkins University, Baltimore.

The identified strengths of HIV testing in the ED were the high volume of ED visits (110 million annually) and the high prevalence of HIV in the ED patient population (cited by 19.6% of the experts). Access to an underserved patient population was cited by 16.1%. Other strengths included the availability of testing around the clock (11.7%) and the chance for earlier diagnosis (8.1%).

A total of 23.2% of the experts identified the additional strain on ED staff and resources as the biggest weakness of the approach. Inadequate privacy for testing in the ED was mentioned by 13%.

The opportunity to reduce the stigma of HIV was cited by 26.8% of the experts and better surveillance of disease rates and transmission networks by 18.4%. The threat category included lack of funding and other resources (44%), and diversion of resources and staff from the emergency department’s primary mission of acute care (13.4%).

Increasing Rates of Testing

Despite the barriers to HIV testing in EDs, the rates have increased substantially since the testing recommendations were published.

A 1996 survey found that about 50% of academic EDs tested for HIV after suspected exposure. In 2006, a survey found that a similar 57% of academic EDs did some rapid HIV testing, but only 4% did so routinely. Only 3 years later, in 2009, a cross-sectional survey of medical providers by Dr. Richard E. Rothman and his colleagues found that 82% of EDs conducted HIV testing (Ann. Emerg. Med. 2011;58[suppl]:S3-9).

However, only 22% did so as part of a routine HIV testing program, and 18% did no testing at all, according to Dr. Rothman of Johns Hopkins University, Baltimore, and his coinvestigators.

The survey included 338 academic, nonacademic, and community hospitals from urban and rural areas across the country. Survey respondents included ED directors and chairs, HIV program directors, nurses, and ED social workers.

Of the 22% of EDs that reported routine HIV screening, 85% were in urban areas and 65% were in academic hospitals. Most of the 18% that did no testing were small community hospitals. Of large hospitals with more than 100,000 visits a year, 91% offered HIV testing and more than half had routine HIV testing programs. More than 80% of the screening programs had been in place for less than 3 years, and about a third had existed for less than a year.

"These results represent a recent increase in the availability of HIV testing in U.S. EDs and a steady increase in HIV screening," Dr. Rothman and his colleagues concluded.

Overall, EDs in academic hospitals implement HIV testing at a higher rate than do those in community hospitals, according to a 2007 cross-sectional survey by Dr. Jason S. Haukoos and his colleagues, which found significant differences in testing rates (Ann. Emerg. Med. 2011;58[suppl]:S10-16).

Their survey included ED administrators, emergency physicians, and other health care staff at 99 academic EDs and 150 community institutions. They found that 65% of academic EDs offered testing, compared with 50% of community hospitals; more academic institutions tested without charging patients (34% vs. 7%) and received funding for testing (15% vs. 2%), said Dr. Haukoos of Denver Health Medical Center and his colleagues.

Diagnostic testing was offered most widely (73% of academic EDs, 63% of community EDs). Nontargeted screening was performed at 16% of academic institutions, compared with only 5% of community EDs.

"There remain substantial differences related to HIV testing between academic and community institutions, and a substantial proportion of institutions still do not provide some form of HIV testing," the authors said.

Staffing for Testing Programs

Having enough personnel with the right training is the key to implementing any HIV testing program in the ED. The Universal Screening for HIV Infection in the Emergency Room (USHER) trial compared HIV testing offered by supplemental HIV counselors to testing offered by ED providers. The objective of the trial was to determine whether testing rates were higher when offered by existing ED providers or by additional staff such as counselors and social workers (Ann. Emerg. Med. 2011;58[suppl]:S126-132).

"Routine, voluntary HIV testing was completed more than twice as frequently when personnel were dedicated specifically to this task," reported Dr. Rochelle P. Walensky of Massachusetts General Hospital, Boston, and her colleagues.

In this 2007-2008 randomized controlled trial, 2,446 ED patients were randomized to the counselor arm and 2,409 to the ED provider arm. A total of 80% of patients in the counselor arm were offered testing vs. 36% of those in the provider arm. In the provider arm, the offer rate declined with increasing age of the patient and declined over the course of the study (from 76% at 2 months to 25% at 17 months). "Testing attrition over time [in the provider arm] may be due to waning enthusiasm for the program in the face of patient acuity and other clinical duties," Dr. Walensky and her coauthors suggested.

A comparable proportion of patients accepted testing when it was offered (71% in the counselor arm and 75% in the provider arm), for an overall testing rate of 57% in the counselor arm and 27% in the provider arm.

"Although HIV counselor time certainly costs less than that of ED providers, the cost of additional trained personnel is not trivial." However, "without such resources, rapid HIV testing in this setting is most likely diagnostic and not truly routine," they concluded.

In another 2007-2008 study of six EDs that had HIV screening programs in place for at least 6 months, Gretchen Williams Torres and her coinvestigators found that "several sites had 1 or more staff individuals, generally an emergency physician or nurse, who took ownership of the screening program" (Ann. Emerg. Med. 2011;58[suppl]:S104-13).

Testing was done by supplemental staff at four hospitals and by existing ED staff at two. Costs were higher at the two EDs in which supplemental staff was used to implement the programs, at $10,200-$12,300, compared with $3,400-$8,600 when ED providers added it to their tasks, wrote Ms. Torres of the University of Chicago and her coauthors.

The six study institutions were a public hospital and a for-profit hospital in the South, two nonprofits in the Midwest, a public hospital in the West, and a public hospital in the Northeast. All were teaching hospitals, with a median of 37.5 ED beds. Two of the EDs did targeted screening of higher-risk patients, three screened some patients regardless of risk, and one screened all patients (universal screening).

Yet "none of the EDs were able to test more than 10% of the patients presenting for care," with a median of 4.7% of patients tested. EDs with targeted programs tested 2%-3% of their patients, those with nontargeted programs tested 5%-8%, and the hospital with universal screening tested 7% (while that institution offered screening to 97% of its patients, most declined the test).

In a report of a 2009 pilot program at an urban academic ED, the investigators found that the success of the program was dependent on "a core group of coordinators, involvement and support from administration, and broad buy-in from faculty and staff," including "ED technicians, nurses, and physician extenders and emergency physicians" (Ann. Emerg. Med. 2011;58[suppl]:S44-8).

The program required a commitment from staff to perform the tasks necessary "for patient recruitment, specimen collection and processing, result notification, posttest counseling, and data entry," said Dr. Bryn E. Mumma of the University of Pittsburgh and her colleagues.

"Finding someone with time to enroll patients and collect the OraSure specimen without compromising patient care or ED flow was the most significant barrier to universal screening in our pilot program," they said.

Providing HIV screening in the ED setting serves a hard-to-reach population, and much progress has been made in adding routine HIV testing to ED visits. However, the lack of available dedicated staff, inadequate funding, and other obstacles will continue to hamper future efforts.

Mr. Kecojevic had no disclosures. Dr. Rothman received funding from the Maryland Department of Health and Mental Hygiene. Dr. Haukoos received an award from the Agency for Healthcare Research and Quality, support from the CDC, and an unrestricted grant from Abbott Laboratories. Dr. Walensky received the Doris Duke Charitable Foundation Clinical Scientist Development Award, and her study had support from the National Institute of Mental Health. Ms. Torres’ study was funding by the CDC and the Health Research and Educational Trust of the American Hospital Association. The Allegheny County Health Department provided the OraSure tests and processing for Dr. Mumma’s study.