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HIV testing in South African ED reveals high burden of undiagnosed infections

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March 28, 2018

An HIV testing strategy implemented in an ED in South Africa identified 115 new infections in 3 months, according to findings recently published in PLoS One.

Bhakti Hansoti, PhD, MBChB, assistant professor of emergency medicine at Johns Hopkins University School of Medicine, and colleagues said their study demonstrates the potential of the testing strategy to detect cases that are missed by clinic-based screening programs. However, only a quarter of patients who presented to the ED during the study period were offered testing, highlighting the need to improve the intervention.

“We’re transitioning emergency care from a service focused only on stabilization and resuscitation to a health care venue that helps a difficult-to-reach population with preventative care and surveillance, such as HIV testing,” Hansoti said in a press release. “It’s time for a major paradigm shift for many hospitals and health systems as we define the role of emergency care in low-resource environments.”

The testing strategy was based on National South African HIV testing guidelines, which recommend counselor-initiated universal HIV screening with rapid point-of-care testing. Although these guidelines are mandated for all health care facilities in South Africa, the researchers noted that they are not routinely used in the ED.

The impact of the strategy was assessed at the Frere Hospital ED from Sept. 1 to Nov. 30, 2016. Lay counselors offered HIV counseling and testing (HCT) to clinically stable and fully conscious patients. Two HCT staff members were on duty 24-hours a day.

Of the 9,583 patients who visited the ED during the study period, 24.6% were offered testing. Acceptance was high, with 1,714 patients (72.8%) agreeing to be tested. Of these patients, 262 were positive for HIV.

The overall prevalence of HIV in the ED, which included patients who declined testing but reported being positive, was 21.6% (n = 400). The researchers said this estimate is much higher than the prevalence estimated for the local district (13.6%). Among all patients with HIV, 115 (6.2%) said they were previously unaware of their infection.

Women were more likely to have HIV than men (29.8% vs. 15.4%), and men were more likely to be unaware of their infection (RR = 1.75; 95% CI, 1.39-2.19). No other demographic or clinical risk factors were identified, supporting the use of nontargeted, universal testing, according to the researchers.

More than half of patients who were diagnosed with HIV in the past agreed to a repeat test when it was offered. Hansoti and colleagues said this finding indicates that ED-based screening may provide an opportunity to link patients to care or ART initiation. However, they concluded that more research is needed to develop an intervention that can overcome the potential financial burden of employing HCT staff, which costs approximately $40 per day, while increasing the percentage of patients who are offered testing.

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“A more integrated approach that places the impetus for testing on existing health care providers in the ED may be necessary to implement a sustainable and effective HIV testing program,” they wrote. – by Stephanie Viguers

Disclosures: The authors report no relevant financial disclosures.

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