Targeting Where the Burden is: Evaluating California's Emergency Department Screening Program Against Human Immunodeficiency Virus Epidemic Priorities

Abstract

Background: The federal Ending the Human Immunodeficiency Virus (HIV) Epidemic (EHE) initiative emphasizes targeted efforts in "priority" jurisdictions to reduce new infections through earlier diagnosis and treatment. In California, the Emergency Department Screening Program (EDSP) was recently implemented to expand HIV and sexually transmitted infection (STI) testing in emergency departments (EDs)-key access points for underserved populations.

Objective: To evaluate whether EDSP funding allocation aligns with EHE geographic and demographic priorities, and to identify opportunities to optimize ED-based HIV screening strategies.

Methods: We conducted an observational, retrospective analysis of California EDs using publicly available data; ED ZIP codes were used to stratify EDs by their funding status and priority county designation and to link them to corresponding county-level Centers for Disease Control and Prevention (CDC) data on population-adjusted estimates of HIV, syphilis, gonorrhea, and chlamydia.

Results: Of the 313 EDs analyzed, 27 (8.6%) received EDSP funding. Funded EDs were more often teaching hospitals and served higher proportions of patients who were homeless, Hispanic or Latino, Black or African American, or insured through Medi-Cal (all p < 0.01). Nearly all (90%) statewide ED visits occurred in nonfunded hospitals. Although median population-adjusted STI and HIV rates were similar by funding status, nonfunded EDs in priority counties had higher HIV prevalence than funded EDs in nonpriority counties (p < 0.001). Only a minority of the highest-burden EDs received EDSP funding.

Conclusion: While EDSP-funded EDs effectively reach populations at elevated risk for HIV, allocation did not consistently align with CDC-designated priority counties or areas of highest HIV burden. Future statewide funding strategies should prioritize high-burden jurisdictions while maintaining flexibility to support nonpriority areas with demonstrated need.

Keywords: California; HIV; financing; public health; testing.