Since 1993, the Centers for Disease Control recommendations for HIV testing were extended to include persons obtaining care in the emergency department (ED). Situated in Newark, New Jersey, the University Hospital (UH) ED serves a community with a greater than 2% HIV prevalence, and a recent study showed a UH ED HIV seroprevalence of 6.5%, of which 33% were unknown diagnoses. Electronic records for patients seen in the UH ED from October 1st, 2014, to February 28th, 2015, were obtained. Information was collected on demographics, ED diagnosis, triage time, and HIV testing. Random sampling of 500 patients was performed to identify those eligible for screening. Univariate and multivariate analysis was done to assess screening characteristics. Only 9% (8.8–9.3%) of patients eligible for screening were screened in the ED. Sixteen percent (15.7–16.6%) of those in the age group18–25 and 12% (11.6–12.3%) of those in the age group 26–35 were screened, whereas 8% (7.8–8.2%) of those in the age group 35–45 were screened. 19.6% (19–20.1%) of eligible patients in fast track were screened versus 1.7% (1.6–1.8%) in the main ED. Eighty-five percent of patients screened were triaged between 6 a.m. and 8 p.m. with 90% of all screening tests done by the HIV counseling, testing, and referral services. Due to the high prevalence of HIV, urban EDs play an integral public health role in the early identification and linkage to care of patients with HIV. By evaluating our current screening process, we identified opportunities to improve our screening process and reduce missed opportunities for diagnosis.