More care is moving into the nation’s EDs.

Emergency departments are an increasingly utilized front door to the American healthcare system. There are more than 5,500 of them. In 2023 they saw about 142 million visits, up from about 125 million in 2008.

The ED sees people other places miss

For many Americans, especially those without insurance or access to a regular doctor, the ED is where they get most, if not all, of their care. As visits to doctors’ offices for sudden illness have fallen, ED visits have grown.

These are often the people who most need an HIV test. In a study of more than 2,200 patients at four EDs, about 1 in 4 had never had an HIV test. Patients with recent HIV risk were no more likely to have been tested. And in a survey of young men who have sex with men and reported recent HIV risk, most said it was unlikely or impossible that they had HIV.

HIV testing has not kept up

As of 2022, an estimated 1 in 8 people living with HIV in the U.S. were unaware of their infection, and more than 1 in 5 people diagnosed in 2024 already had AIDS; these data reflect years of missed opportunities for diagnosis. EDs are well positioned to address this gap. However, only about 1 in 100 ED visits includes an HIV test, and only about 1 in 5 EDs offers any form of routine HIV screening, a proportion unchanged since 2008. Over the same period, EDs expanded most of the other preventive services we examined.

Screening can fit in a busy ED

Few ED directors believe preventive care does not belong in the ED; in a national survey, only 15% agreed. Instead, their concerns center on cost: more than half worried that offering preventive services would increase costs or lengths of stay. EDs whose directors were strongly worried about cost were far less likely to offer routine HIV screening. Yet about 1 in 3 EDs that do not screen report they could do so with their existing staff and funding.

Concerns about ED throughput likely stem from how most EDs test today; when an HIV test is ordered late in a visit, often to diagnose a problem, lengths of stay are longer. Routine screening at triage is different: in EDs taking part in a large national trial, it added only about 1.4 minutes to the average wait, although slightly more patients left before their care was complete. ED leaders also identify what helps; this includes prompts built into the electronic health record, a clinical champion, and a patient navigator.

Where should screening start?

Not all areas of the U.S. are affected by HIV at the same rates. Despite this, national screening recommendations have largely applied the same approach everywhere, regardless of local burden. That changed in 2019 with the launch of the Ending the HIV Epidemic (EHE) initiative, which focused federal resources on the “priority” jurisdictions hardest hit by HIV.

These jurisdictions include about 31% of U.S. EDs, which together see 39% of ED visits; this is still far too many EDs to start with. Further, HIV burden is largely measured and reported at the county level, so every ED in a county is assigned the same estimate, even though EDs within a county may serve very different patients. In California, for example, the 24 teaching hospital EDs in priority counties see 12% of the state’s ED visits and a higher share of patients from the groups most affected by HIV.

Better data are needed to estimate where HIV burden is highest. Without them, screening efforts will likely continue to miss many of those most at risk.

What the HIVer Project does

We work with EDs to build that missing picture: how many HIV tests each ED does and how many find HIV, shared as totals only. With it, health departments and funders can see where screening would help most.

We build it one state at a time, with the EDs, health departments and partners in each state. We started in California. Florida is next.