Emergency departments are a ‘hotspot’ for HIV test-and-treat in South Africa

Voluntary HIV testing and counselling carried out in South African emergency departments (EDs) can reach at-risk populations with knowledge of their status and HIV treatment services, finds a new paper. They also found poor rates of HIV treatment and care retention among people living with HIV in these settings.

It is already well known that, when compared to primary care settings, people who attend ED are generally young and more likely to be considered vulnerable (for example people affected by substance abuse, homelessness, mental health problems and victims of violent crime). In fact, these patients may be twice as likely to visit an ED over a primary care provider. A systematic review also found high levels of HIV prevalence in EDs across high- and low-resourced countries.

According to the paper, an estimated 86% of people living with HIV know their status, 61% are accessing antiretroviral treatment (ART) and only 47% are virally suppressed in South Africa. EDs provide a unique opportunity, already employed by high-income countries, to reach vulnerable populations with HIV testing and treatment. South African EDs may see anywhere between 150 and 300 patients per day.

This prospective cross-sectional observational study was conducted in the ED of three hospitals in the Eastern Cape Province between June 2017 and July 2018. All adult, non-critical patients were approached for point-of-care (POC) HIV testing following assessment. All patients already known to be HIV-positive, and those who were newly diagnosed, were asked to provide additional blood samples for lab testing. This sample tested for treatment cascade markers, including the presence of ART in the blood and viral load.

A total of 3,537 patients were approached across all three hospitals, of which 2,901 enrolled and had their HIV status determined. The acceptance of testing was consistent across the sites at around 66.5%. The age distribution was also consistent across the sites and most of the patients were under the age of 35.

The overall HIV prevalence of this ED group was 28% (n=811) of which 234 (28.9%) were newly diagnosed. HIV prevalence was significantly higher among women (n= 509, 35.3%) compared to males (n = 302, 20.7%). More specifically, HIV prevalence was highest in females aged 36–45 years (55.4%), and second highest in females aged 26–35 years (49.6%). Among men, HIV prevalence was highest in the 26-45 age group at 34.8%.

Younger populations were the least likely to know their status – and particularly those under 25. When compared to their female counterparts across all ages, men were twice as likely to be unaware of their status.

Of the patients who tested positive for HIV, including those who already knew their status, 617 (76.1%) consented to providing a blood sample, while ART testing could be performed in 585 patients.

ART was detected in the blood of 54% of the patients, and the only risk factor for the absence of ART was being male. Of the 615 samples, 609 patients had sufficient sample volume for viral load testing, of which 49% (299/609) were found to be virally suppressed. Again, male sex was identified as an independent risk factor for not being virally suppressed.

In 577 of patients living with HIV, the authors were able to define the complete HIV treatment cascade. The data revealed that 71.1% of ED patients were aware of their status, 54% were positive for ARTs, and 49% were virally suppressed.

Estimated HIV incidence among this population was 2.8 per 100 person-years (4.5 among females and 1.5 among males), which is much higher than national South African estimates, which report incidence of 0.79 per 100 person-years (0.93 among females and 0.69 among males).

The investigation highlights the important role of EDs in providing care to large numbers of people living with HIV who are at-risk of loss to follow-up along the care cascade. Moreover, they may be an important venue to capture young men who are often missed by current HIV testing and prevention programmes. Beyond simply playing a role in surveillance of the HIV epidemic, EDs should develop innovative HIV testing and linkage to care strategies that in particular meet the needs of young men who do not routinely access clinic-based health services.

“ED-based HIV care would need to address the known challenges of linkage and retention, such a location and access to care, in order to maximise impact,” note the authors in their conclusion. “Innovative solutions targeted to male patients, such as video-based programming, linkages to social networks and community-based support programs should be explored.”