Introduction

Sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) infection remain closely related public health problems. The presence of an STI increases the risk of both acquiring and transmitting HIV, which makes its diagnosis a key opportunity for the early detection of this infection [1-3]. Accordingly, international bodies such as the World Health Organization and the European Centre for Disease Prevention and Control recommend the systematic performance of HIV serology in patients diagnosed with an STI [4,5]. In Spain, the incidence of STIs has risen significantly in recent years, particularly among young people, whereas a substantial proportion of new HIV diagnoses continues to be made late [6,7]. Early HIV detection and the comprehensive microbiological management of STIs are essential to improve individual prognosis and reduce transmission, and expanding screening strategies is a priority within public health plans [5,8,9].

Emergency departments (EDs) represent a key care setting for the detection of HIV infection, as they frequently attend to patients with STIs and to populations with poorer access to other healthcare resources or with risk practices such as chemsex [10-13]. In this context, optimising diagnostic processes in EDs constitutes a priority strategy to improve the management of infectious diseases and reduce missed opportunities for early intervention [14]. Several studies have shown that HIV screening in EDs is feasible and enables the identification of a relevant number of previously undiagnosed infections [15-17], on the basis of various indicator conditions managed in the emergency setting [18]. Nevertheless, the request for HIV serology remains suboptimal and heterogeneous [15-19], varying according to patient and clinical episode characteristics, including a sex-based screening bias [20]. In Spain, evidence on the practice of HIV screening in patients attended in the ED for an STI is still limited, although recent studies suggest considerable variability and ample room for improvement [21].

In our setting, opportunistic screening programmes for hidden infections have been implemented in EDs, confirming their feasibility and diagnostic yield, both for HIV and for other infections such as hepatitis C [22-25]. These experiences have also shown that the success of the strategy depends largely on organisational factors and on the involvement of professionals, such that interventions like specific training of nursing staff significantly increase test requests and the number of infections detected [26]. This suggests that screening practice in the ED is determined not only by patient characteristics but also by the organisation and care culture of each department.

In this regard, the Spanish Society of Emergency Medicine (SEMES) published in 2020 [27] and 2024 [28] two documents that defined, respectively, 6 and 9 situations in which HIV screening should be performed on a mandatory basis in EDs. In both documents, STIs were listed as one of those situations. Against this background, it is necessary to analyse the frequency, evolution and factors associated with HIV screening in patients diagnosed with an STI in EDs, with the aim of identifying areas for improvement and moving towards universal screening in this at-risk population.

Material and methods

Study design

A multicentre, observational, retrospective study was conducted that included all episodes of patients attended in the ED with a discharge diagnosis coded as an STI in the Minimum Basic Data Set (CMBD). The list of included conditions and their ICD-10-ES codes is shown in Table 1. All episodes recorded between January 2018 and December 2024 in 14 hospitals from 8 autonomous communities belonging to the INFURG-SEMES research network were included. The unit of analysis was the emergency episode, so that a given patient could contribute more than one episode if they attended for an STI on separate occasions during the study period. Episodes corresponding to patients with previously known HIV infection were excluded when this was recorded in the centre’s clinical history or in the records of its microbiology departments, as screening is not warranted in such cases.

Data were obtained automatically from the computerised records of the participating hospitals. The information was collected anonymously in an electronic database accessible only to the study investigators. Episodes with a diagnosis of STI in which HIV serology was requested, together with the result, were counted. The evolution of HIV screening throughout the study period was assessed. It was analysed whether there were differences in the request for HIV serology according to patient age, sex and nationality, prior HIV screening and year of inclusion, as well as for certain STI diagnoses. The STROBE recommendations for observational studies were followed. No a priori sample size was calculated, given that all available episodes meeting the inclusion criteria during the study period were included.

Dependent and independent variables

The dependent or outcome variable was the request for HIV serology during the patient’s care in the ED. For information purposes, the test result was recorded, but no distinction was made between positive results corresponding to patients with previously known infection and new diagnoses when there was no prior confirmation in the data records of the Clinical Microbiology department. The independent variables analysed were the patient’s year of inclusion, age and sex, nationality (Spanish or non-Spanish) and whether the patient had previously been screened for HIV. In addition, the main ICD-10 diagnoses coded in the ED were grouped according to clinical criteria to allow their evaluation with respect to their relationship with the outcome variable.

Statistical analysis

Discrete variables are expressed as absolute and relative values and were compared using the chi-square test. Continuous variables were expressed as median and interquartile range (IQR) and were compared using the non-parametric Mann-Whitney test. The association of the independent variables with the dependent variable (request for HIV serology in the ED) was investigated by unadjusted logistic regression and expressed as an odds’ ratio (OR) with its 95% confidence interval (95% CI). Multivariable models were then constructed including all independent variables, and adjusted ORs were calculated. Finally, the multivariable analysis was repeated after replacing the missing values of the variables included in the study with the mode (discrete variables) or the median (quantitative variables).

In addition to the logistic regression model, which assumes a linear relationship between the continuous variables (patient’s year of inclusion and age) and the outcome variable (HIV screening in the ED), this relationship was also assessed using non-linear models based on restricted cubic splines. For this purpose, three knots were placed at the 10th, 50th and 90th percentiles of the marginal distribution of the continuous variable, following Harrell’s recommendations [29]. The effect of each unit change (year of inclusion or year of age) on the probability of being screened for HIV was represented graphically by means of dose-response curves with their 95% CI. For the year of inclusion, the analysis was repeated including only those EDs that had reported data for every year of the study, in order to avoid the bias that could be introduced by the participation of centres present during only part of the period. Finally, it was assessed whether the relationship of each continuous variable with screening differed by sex, by incorporating into the model an interaction term between sex and the terms of the corresponding spline. Its significance was tested using the likelihood ratio test, comparing the models with and without that term. From this model, sex-specific dose-response curves were estimated, as well as the OR of screening in women relative to men, with its 95% CI, across the range of age and the study period. Values of p<0.05, or when the 95% CI of the OR excluded 1, were considered statistically significant. All statistical processing was performed using the SPSS Statistics V26 statistical package (IBM, Armonk, New York, USA) and Stata version 16.1 (Stata Corp, College Station, TX, USA).

Ethical considerations

The study followed local and international protocols and standards (Declaration of Helsinki) for the use of patient data, which were coded to ensure confidentiality. The Ethics Committee of the coordinating centre (Hospital Clínico San Carlos) approved the conduct of the study (25/118-E). As this was a retrospective study, the Ethics Committee waived the requirement for informed consent.

Results

Fourteen EDs from hospitals in 8 autonomous communities participated and, in total, retrieved data from 35,845 episodes that were coded in any of the ICD-10 categories previously defined as suggestive of an STI during the 2018-2024 period. The grouped diagnoses are presented in Table 2. More than half of the diagnoses corresponded to orchiepididymitis (24.9%), vulvovaginitis (16.4%) and non-specific urethritis (12.4%). The median patient age was 34 years (IQR 25-46), 60% were men, 74% were Spanish and 2% had previously been tested for HIV.

HIV serology was requested during ED care in 5,462 cases (15%), of which 253 (4.6%) were positive. These patients had significantly different characteristics from those in whom HIV serology was not requested: they were younger, more frequently men, of non-Spanish nationality and previously screened for HIV (Table 3). The screening rate, calculated as the percentage of patients tested within each diagnostic category, showed marked heterogeneity across diagnoses: it was highest in non-specific suspected STI (45.8%), risk exposure (40.1%) and urethritis (33.9%), with intermediate values in syphilis (22.9%) and gonorrhoea (20.8%), and considerably lower in vulvovaginitis (2.6%), orchiepididymitis (3.0%) and anal or perianal ulcer/lesion (5.2%) (Table 3).

Thirteen EDs provided the specific years of patient inclusion, and 8 included cases in every year of the study period. HIV screening increased significantly over time, from 5.3% in 2018 to 20.7% in 2024 (p<0.001). When the analysis was restricted to the EDs that had provided patients throughout the entire period, the results were similar, rising from a screening rate of 3.5% to 13.7% (p<0.001). The non-linear association of these relationships is presented in Figure 1. The annual increase differed by sex (p=0.002), such that women had a lower request rate throughout the whole period; however, a trend towards narrowing differences was observed in the more recent years of the study.

All variables showed a significant association (direct or inverse) with the probability of screening in the ED in the unadjusted analysis. In the multivariable model, most of these associations were maintained, although some variables changed in magnitude or significance between the analysis without and with imputation of missing values (Table 4). In the model with imputation, a higher probability of being tested for HIV was identified in younger patients (adjusted OR per year of age 0.97, 95% CI 0.97-0.97), men (adjusted OR 3.83, 95% CI 3.35-4.37), those previously tested for HIV (adjusted OR 1.44, 95% CI 1.08-1.92) and those who had attended the ED in the more recent years of the study (adjusted OR per year elapsed 1.34, 95% CI 1.30-1.38). The non-linear association between age and HIV screening is presented in Figure 2, which shows a high and relatively stable probability of screening up to approximately 30 years of age, followed by a marked decline throughout middle age until becoming minimal in older patients. There were significant differences between men and women (interaction p<0.001), with a higher probability of screening in favour of men. This difference was greatest at younger ages and attenuated progressively with age, ceasing to be significant from approximately 70–75 years onwards. By diagnosis, some were associated with significantly higher probabilities of screening (risk exposure, suspected STI and urethritis), whereas others were associated with significantly lower probabilities (orchiepididymitis, vulvovaginitis, genital herpes, anal/perianal lesions, pelvic inflammatory disease, genital warts/condylomas and gonorrhoea).

Discussion

This multicentre study, which includes a cohort of 35,845 episodes diagnosed with an STI attended in Spanish EDs over seven years, provides robust evidence on the reality of HIV screening in a key care setting. The main finding is that, despite well-established national and international recommendations [4,5,27,28], the request for HIV serology in patients who attended for an STI was very low and reached only 15% of a population in whom screening is formally indicated. This confirms the persistence of a substantial missed diagnostic opportunity in emergency care [19].

Nonetheless, a progressive and statistically significant improvement was observed over the period, with a rise in the screening rate from a meagre 5.3% in 2018 to 20.7% in 2024. This trend suggests that the awareness strategies and educational interventions of recent years have begun to modify clinical practice in EDs. One example is the specific training of nursing staff in the “Urgències VIHgila” programme, which has been shown to increase test requests and the detection of infections [26]. Even so, the level reached in the last year remains far from the goal of universal screening set by the guidelines, reflecting still-low adherence to a clinically imperative indication.

Our data are consistent with previous Spanish evidence. A national survey reported that only one third of EDs stated that they requested HIV serology when an STI was suspected [30]. Our results, based on real-world practice, show that effective requesting is even lower. This gap between what is recommended and what is done is particularly relevant because HIV screening in the ED is feasible and efficient [22], also in economic terms [31], and because EDs are a privileged point of contact with populations poorly linked to the healthcare system [12,17].

The multivariable analysis identified clinically unjustifiable inequalities. The most marked was that of sex. Men had an almost fourfold higher probability of being tested than women (adjusted OR 3.83; 95% CI 3.35-4.37), a bias already described recently in our setting [20]. This gap translated into extremely low screening rates in female-predominant diagnoses, such as vulvovaginitis (2.6%) or pelvic inflammatory disease (6.5%), in clear contrast with male-predominant conditions such as urethritis (33.9%). The interaction analysis further showed that the difference between sexes is greater at younger ages. Although a certain temporal reduction of this negative bias against women has been observed, the differences at the end of the study remain extremely large and completely unacceptable. For its part, the probability of screening declined sharply with age from young ages onwards. Given that late HIV diagnosis is more frequent precisely in middle and older age, concentrating screening on the youngest perpetuates missed opportunities [19]. Since every patient with an STI has an equivalent indication for screening, selecting by sex or age constitutes a bias that must be eradicated from practice.

Regarding nationality, in the crude analysis patients of non-Spanish nationality had a higher probability of being screened, but this difference attenuated and ceased to be significant after adjustment and imputation, and should therefore be interpreted with caution, especially considering the high proportion of missing data for this variable (42%).

Closing the gap between evidence and practice requires moving from manual screening, dependent on the clinician’s memory and disposition in a high-pressure care environment, towards structured support strategies. Indeed, the main difficulties perceived by professionals in implementing screening are organisational rather than attitudinal [32]. In line with the “Leave Your Mark” programme and its 2024 update [28], this includes electronic alerts in the clinical history when an STI is coded, preconfigured laboratory panels that systematically incorporate HIV and viral hepatitis, and the active involvement of nursing staff [26]. Selective requesting based on the clinician’s subjective criteria perpetuates the observed heterogeneity and diagnostic inefficiency. The results of our study confirm this need.

The systematisation of screening through automated alerts and preconfigured laboratory panels must be reconciled with the information and consent requirements specific to the HIV test. Automation should not lead to an impersonal or inadvertent request [33]. Targeted or opt-out models are compatible with these safeguards provided they ensure clear information, the possibility of refusal, and defined circuits for communicating results and linkage to care. Reconciling the efficiency of automation with these requirements is essential so that the expansion of screening is both effective and respectful of patients’ rights.

Finally, the positivity recorded among tested patients was high (4.6%). However, and despite excluding patients with a previously known HIV diagnosis, it is not possible to ascertain what proportion of cases truly correspond to new diagnoses. Even so, this prevalence lies well above the threshold usually considered cost-effective for screening, which reinforces the strategic role of EDs in HIV detection and in the control of its community transmission [22,30].

Limitations

Our study has limitations that must be considered when interpreting the results. First, its retrospective nature, based on the computerised registry and on the ICD-10-ES coding of the CMBD, may have led to an under-registration bias in the identification of STIs or in the actual reasons for the visit. Second, there was a high volume of missing data in relevant independent variables, such as nationality (42.0%) or a history of prior HIV screening (57.1%), a limitation inherent to the automated databases of EDs that made it necessary to resort to statistical imputation to ensure the robustness of the multivariable analysis. Third, the unit of analysis was the episode, so that a given patient could contribute more than one. Finally, the laboratory database used did not allow precise discrimination between newly diagnosed positive results and already known cases that re-attended the ED, so diagnostic yield was not analysed. In addition, the participation of centres from the INFURG-SEMES network may limit the generalisability of the results to Spanish EDs as a whole.

Conclusion

There is low and heterogeneous HIV screening among patients diagnosed with an STI in Spanish EDs, conditioned by demographic and clinical biases that mistakenly prioritise younger patients, men and certain syndromic profiles. Although the progressive increase in the screening rate over the years confirms the usefulness of educational campaigns and the positive impact of the “Leave Your Mark” programme, the current testing rate falls considerably short of the universal ideal. It is imperative to integrate HIV serology automatically into emergency care pathways through electronic decision-support tools and multidisciplinary involvement, transforming opportunistic screening into a homogeneous and mandatory quality standard for all EDs of the National Health System.

Funding

This work was carried out within the framework of the collaboration agreement between the Ministry of Health and the Spanish Society of Emergency Medicine (SEMES) for the development of activities related to the management of sexually transmitted infections (BOE-A-2025-14078).

Author contributions

Conceptualisation: OJSB, JGC; Formal analysis: OM; Methodology: FBS; Data collection: FBS, OJSB, PTE, MTSM, JLA, CNB, JJGR, VAR, JGC; Investigation: FBS, OJSB, EMA, PTE, MTSM, JLA, CNB, JJGR, VAR, JGC; Drafting – initial draft: OM, OJSB, JGC; Drafting, checking, and editing: OM, JHM, OJSB, JGC; Supervision: JHM, JGC; Project management: JGC. All authors have read and approved the final version of this manuscript.

Conflicts of interest

The authors declare that there is no commercial or financial conflict of interest for this research.

Ethical declarations

The study was approved by the Hospital Clínico San Carlos Ethics Committee on May 13, 2026, under approval code No. 25/118-E , and complies with national and international ethical standards applicable to research involving human beings.

AI statement

The authors declare that no artificial intelligence tools (such as ChatGPT, Copilot, Gemini, or others) have been used in the writing, analysis, or review of this article.

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