HIV testing in a South African Emergency Department: A missed opportunity.

BACKGROUND: South Africa has the largest HIV epidemic in the world, with 19% of the global number of people living with HIV, 15% of new infections and 11% of AIDS-related deaths. Even though HIV testing is mandated in all hospital-based facilities in South Africa (SA), it is rarely implemented in the Emergency Department (ED). The ED provides episodic care to large volumes of undifferentiated who present with unplanned injury or illness. Thus, the ED may provide an opportunity to capture patients with undiagnosed HIV infection missed by clinic-based screening programs. METHODS AND FINDINGS: In this prospective exploratory study, we implemented the National South African HIV testing guidelines (counselor initiated non-targeted universal screening with rapid point of care testing) for 24-hours a day at Frere Hospital in the Eastern Cape from September 1st to November 30th, 2016. The purpose of our study was to quantify the burden of undiagnosed HIV infection in a South African ED setting. Furthermore, we sought to evaluate the effectiveness of the nationally recommended HIV testing strategy in the ED. All patients who presented for care in the ED during the study period, and who were clinically stable and fully conscious, were eligible to be approached by HIV counseling and testing (HCT) staff to receive a rapid point-of-care HIV test. A total of 2355 of the 9583 (24.6%) patients who presented to the ED for care during the study period were approached by the HCT staff, of whom 1714 (72.8%) accepted HIV testing. There was a high uptake of HIV testing (78.6%) among a predominantly male (58%) patient group who mostly presented with traumatic injuries (70.8%). Four hundred (21.6%) patients were HIV positive, including 115 (6.2%) with newly diagnosed HIV infection. The overall prevalence of HIV infection was twice as high in females (29.8%) compared to males (15.4%). Both sexes had a similar prevalence of newly diagnosed HIV infection (6.0% for all females and 6.4% for all males) in the ED. CONCLUSIONS: Overall there was high HIV testing acceptance by ED patients. A non-targeted testing approached revealed a high HIV prevalence with a significant burden of undiagnosed HIV infection in the ED. Unfortunately, a counselor-driven HIV testing approach fell short of meeting the testing needs in this setting, with over 75% of ED patients not approached by HCT staff.

A systematic review of emergency department based HIV testing and linkage to care initiatives in low resource settings.

INTRODUCTION: Only 45% of people currently living with HIV infection in sub-Saharan Africa are aware of their HIV status. Unmet testing needs may be addressed by utilizing the Emergency Department (ED) as an innovative testing venue in low and middle-income countries (LMICs). The purpose of this review is to examine the burden of HIV infection described in EDs in LMICs, with a focus on summarizing the implementation of various ED-based HIV testing strategies. METHODOLOGY AND RESULTS: We performed a systematic review of Pubmed, Embase, Scopus, Web of Science and the Cochrane Library on June 12, 2016. A three-concept search was employed with emergency medicine (e.g., Emergency department, emergency medical services), HIV/AIDS (e.g., human immunodeficiency virus, acquired immunodeficiency syndrome), and LMIC terms (e.g., developing country, under developed countries, specific country names). The search returned 2026 unique articles. Of these, thirteen met inclusion criteria and were included in the final review. There was a large variation in the reported prevalence of HIV infection in the ED population ranging from to 2.14% in India to 43.3% in Uganda. The proportion HIV positive patients with previously undiagnosed infection ranged from 90% to 65.22%. CONCLUSION: In the United States ED-based HIV testing strategies have been front and center at curbing the HIV epidemic. The limited number of ED-based studies we observed in this study may represent the paucity of HIV testing in this venue in LMICs. All of the studies in this review demonstrated a high prevalence of HIV infection in the ED and an extraordinarily high percentage of previously undiagnosed HIV infection. Although the numbers of published reports are few, these diverse studies imply that in HIV endemic low resource settings EDs carry a large burden of undiagnosed HIV infections and may offer a unique testing venue.