DOI: 10.1111/hiv.12216 HIV Medicine (2015), 16, 326–328
© 2015 British HIV Association
SHORT COMMUNICATION
Routine HIV testing within the emergency department of a major trauma centre: a pilot study R Bath,1 K Ahmad2 and C Orkin3 Chest Medicine, St George’s NHS Trust, St George’s Hospital, London, UK, 2Emergency Department, Barts Health NHS Trust, London, UK and 3HIV Medicine, Barts Health, NHS Trust, London, UK 1
Objectives
UK guidelines recommend routine HIV testing for all medical admissions where the local prevalence exceeds 2 per 1000. We aimed to review uptake of HIV testing in the emergency department (ED) of one of the country’s major trauma centres in a 3-month pilot study (March−June 2013). Methods
ED attendees already having blood tests were routinely tested for HIV (based on the recommendation being made to all to test when having blood taken). Uptake was determined using the surrogate marker of ED attendees who had full blood counts (FBCs) as the denominator. Newly diagnosed patients were linked to care and contacts tested. Staff completed an anonymous online survey to determine acceptability at the end of the pilot study. Results
A total of 2828 patients were tested over 3 months. Nineteen HIV-positive individuals were identified. Eight were newly diagnosed, of whom two were thought to be seroconverting. The prevalence of new diagnoses was 8/2828 (0.28%); for comparison, the Public Health England (PHE) actual prevalence for Tower Hamlets is 6.25/1000 (0.625%). Uptake for HIV testing was 30%, a significant increase from 72 tests performed in the 2 months prior (P < 0.001). Ninety-five per cent of respondents to the staff survey agreed that routine HIV testing should be rolled out permanently in the ED. Conclusions
Despite an average uptake rate, there were 19 positive tests: eight in patients who were newly diagnosed, six in patients who had been lost to follow-up, and five in patients who were known to be positive and linked to care. The staff survey indicated recognition of the importance of HIV testing in the ED. These persuasive data achieved short-term Clinical Commissioning Group (CCG) funding for routine ED testing. Keywords: emergency department, HIV testing, late diagnosis, routine Accepted 15 October 2014
people living with HIV in the UK remained undiagnosed [5]. This is despite recommendations from the National Institute for Clinical Excellence (NICE) Public Health Committee and the UK’s National HIV Testing guidelines that all patients accessing secondary care or those having planned venepuncture should be tested for HIV if the diagnosed prevalence of HIV exceeds 2 per 1000 [1,6]. Low rates of HIV testing have been repeatedly demonstrated in hospital settings in the UK, even in those patients presenting with clinical indicators for HIV infection [5,7].
Introduction Early diagnosis of and treatment for HIV infection prolong life, reduce transmission, improve quality of life and have been demonstrated to be a cost-effective public health intervention [1–4]. However, in 2012 47% of new HIV diagnoses were late diagnoses, and 22% of the 98 400 Correspondence: Ms Rachel Bath, Chest Medicine, St George’s NHS Trust, St George’s Hospital, Blackshaw Road, London SW17 0QT, UK. Tel: 07791603071; fax: 02087251466; e-mail: [email protected]
326
HIV testing in an ED 327
The emergency department (ED) is a desirable target for HIV testing within hospitals as it serves a high-throughput population of diverse attendees. However, the focus on trauma and resuscitation as well as the 4-hour wait make it, understandably, logistically difficult to prioritize HIV testing initiatives. Our ED serves a population with a very high diagnosed prevalence of HIV (6 1000 population) [5]three times higher than the prevalence at which testing is routinely recommended. The busy ED is home to London’s air ambulance and has 400 000 attendances per year.
Methods To complement the existing opt-out testing schemes in the medical admissions and intensive care units, ED staff and the HIV Testing Team collaborated to develop guidelines for implementation within the ED. Of the 350 daily ED attendees, 150 (43%) have bloods taken. Between March and July 2013, those over 16 years who had bloods taken were routinely tested for HIV unless they chose not to be. Information about the testing pilot study was communicated through banners and posters in the ED. Leaflets were available and the public were informed via local newspapers. These communications with the public made it clear that testing for HIV was routine when having any blood tests. Patient information was also available in Bengali and Russian (two very common local languages). Leaflets indicated that: ‘your blood will be tested for HIV unless you ask us not to’. We excluded those who disclosed their HIV-positive status, those who had been tested within the last 6 months, those without the capacity to consent and those who could not agree to testing (because of language issues). HIV tests were offered and performed by trained ED staff. Negative results were handled via a ‘no news is good news’ policy. Positive results were communicated to patients by an HIV testing facilitator using contact details provided or via a GP (if the patient was uncontactable). Contact tracing of untested partners and/or exposed children with linkage to appropriate HIV services was carried out. Uptake was determined by matching the number of HIV tests taken against the number of full blood counts (FBCs) taken over the same period – a surrogate marker for testing opportunities. We were not able to determine a refusal rate. Demographic data were extracted from the electronic patient record. Staff completed an anonymous online survey to determine acceptability at the end of the pilot study.
Results Between March and July 2013, 9297 ED attendees had an FBC taken, with 2828 of 9297 (30%) accepting an HIV test.
© 2015 British HIV Association
This constitutes a 12-fold increase in the HIV testing rate compared with 2 months prior to the study [72 tests (2.4%); no tests HIV positive; p < 0.001]. A total of 1527 patients (54%) were male, and the median age was 48 years. The numbers of patients tested for HIV within the different age categories were: 16–30 years, 877 (31%); 31–40 years, 650 (23%); 41–60 years, 764 (27%); and > 60 years, 537 (19%). Those receiving HIV tests were ethnically diverse (17 ethnicities). Most who were tested self-identified as British (33%), Bangladeshi (18%), African (3%), Pakistani (3%) and Caribbean (3%). Nineteen ED attendees had an HIV-positive blood test, equating to 1% of the population tested; for comparison, the known Public Health England (PHE) prevalence for Tower Hamlets is 0.6% [5]. Eight of the nineteen diagnoses were new diagnoses (8/2828; 0.28%). Two of these eight patients were found to be seroconverting based on viral load, avidity and HIV antibody results. All eight presented with clinical indicators for HIV infection (median CD4 count 256 cells/μL; interquartile range 42–348 cells/μL), such as tuberculosis, significant weight loss, unexplained diarrhoea and vomiting, and Guillain−Barre Syndrome. Of the 11 previously diagnosed patients, six had been lost to follow-up (LTFU) for ≥ 1 year and all had discontinued antiretroviral therapy (ART). The remaining five patients were engaged with HIV care but did not disclose their status in the ED setting. We were able to link 13 patients to HIV services (seven newly diagnosed and six LTFU) with eight eligible patients commencing ART. Contact tracing was successfully completed in 13 of 14 cases, including the HIV testing of an untested exposed infant and an untested child. In the staff survey, 100% of respondents had been trained and 95% agreed that routine HIV testing should be rolled out permanently in the ED. However, the uptake rate was very low, at 9.5%. Nineteen members of staff completed the survey, of whom 18 agreed with the statement that ‘opt out testing should be continued in the ED’. One hundred per cent of staff reported finding it easier to offer an HIV test as part of a routine policy rather than based on clinical suspicion.
Discussion The implementation of routine HIV testing significantly increased HIV testing rates within the ED during the pilot study. PHE figures indicate that 0.625% of those in Tower Hamlets are living with HIV. In our pilot study, despite excluding known positives from the target group, 1% of the population tested was found to be HIV positive; 0.28% were newly HIV positive. Tests were offered to and accepted by patients of all genders, ages and ethnicities
HIV Medicine (2015), 16, 326–328
328 R Bath et al.
alike. All of the ED attendees with new HIV diagnoses were from ‘at risk’ population groups and all presented with a clinical indicator for HIV infection and therefore should have been tested regardless. However, with only 72 HIV tests taken over the 2 months preceding the pilot study, it seems that this was not the case. Staff reported finding it easier to offer an HIV test as part of a routine policy rather than based on clinical suspicion. A quarter of the patients with new diagnoses were seroconverting and therefore at the highest risk of onward transmission of infection. By performing thorough contact tracing, the risks of onward transmission have been reduced in contacts of these very infectious individuals. With help from the HIV Testing Team, the highly motivated and committed ED staff were able to implement HIV testing within the busy ED setting. Linkage to care for HIV-positive individuals (new and LTFU) was achieved, with 93% (13 of 14) linked to care. On the basis of these results and the enthusiasm of the ED team, we managed to secure further funding through the local Clinical Commissioning Group (CCG) to continue testing until the end of the financial year 2013/14, with negotiations to extend for 2014/15 in Tower Hamlets. The study had some limitations. We were unable to ascertain a refusal rate of HIV tests offered, or to obtain patient feedback to establish acceptability to patients. However, patients of all ages, genders and ethnicities accepted testing. We matched the numbers of HIV tests against FBCs for those having bloods taken, and this may not have captured all patients having bloods taken, leading to a possible overestimate of the proportion tested for HIV. Uptake of the staff survey was low (19 of 100), and inadequate among emergency department assistants who championed the pilot study.
Conclusions Within a large trauma centre ED, it was possible to achieve an uptake of 30% in an HIV opt-out testing pilot study. In this short time, eight new HIV diagnoses were made. Onequarter of newly diagnosed patients were diagnosed during seroconversion, further indicating the importance of testing in the ED to reduce onward transmission. Patients diagnosed had mainly late diagnoses and all were from high-risk groups, suggesting further scope for truly uni-
© 2015 British HIV Association
versal HIV testing [7]. Loss to follow-up is a significant problem in the UK [8] and this pilot study enabled re-linkage to care for those patients. Although few completed the staff survey, 95% of those who completed it supported permanent routine HIV testing within the ED. The pilot study has raised awareness about HIV infection and its clinical indicators within the department and enabled us to obtain interim funding through the CCG to continue as well as justifying the ongoing negotiations to make this routine.
References 1 British HIV Association (BHIVA), British Association for Sexual Health and HIV (BASHH), British Infection Society (BIS). UK National Guidelines for HIV Testing 2008 [Guideline]. London, British HIV Association, 2008. 2 British HIV Association (BHIVA). BHIVA. [Online]. 2007. Available at http://www.bhiva.org/NationalAuditReports.aspx (accessed April 2014). 3 Health Protection Agency (HPA). HPA, Org. [Online]. 2011. Available at http://www.hpa.org.uk/timetotesthiv2011 (accessed April 2014). 4 Hartney T NACPFJ. HPA, Org. [Online]. 2012. Available at https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/326601/HIV_annual_report_2013.pdf (accessed April 2014). 5 Aghaizu A BANAGODV&c. HPA, Org. [Online]. London. 2013. Available at http://www.hpa.org.uk/Publications/ InfectiousDiseases/HIVAndSTIs/1311HIVintheUk2013report/ (accessed April 2014). 6 National Institute for Health and Care Excellence. NICE, Org. [Online]. 2011. Available at http://pathways.nice.org.uk/ pathways/hiv-testing-and-prevention#path=view%3A/ pathways/hiv-testing-and-prevention/increasing-the-uptake-of -hiv-testing.xml&content=view-index (accessed April 2014). 7 Elmahdi R GSMGGGFSCGWH. Low levels of HIV test coverage in clinical settings in the UK:a systematic review of adherence to 2008 guidelines. Sex Transm Infect 2014; 90: 119–124. 8 Rice BD DVCCTREJ. Loss to follow-up among adults attending human immunodeficiency virus services in England, Wales, and Northern Ireland. Sex Transm Dis 2011; 38: 685–690.
HIV Medicine (2015), 16, 326–328
Copyright of HIV Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
© 2015 British HIV Association
SHORT COMMUNICATION
Routine HIV testing within the emergency department of a major trauma centre: a pilot study R Bath,1 K Ahmad2 and C Orkin3 Chest Medicine, St George’s NHS Trust, St George’s Hospital, London, UK, 2Emergency Department, Barts Health NHS Trust, London, UK and 3HIV Medicine, Barts Health, NHS Trust, London, UK 1
Objectives
UK guidelines recommend routine HIV testing for all medical admissions where the local prevalence exceeds 2 per 1000. We aimed to review uptake of HIV testing in the emergency department (ED) of one of the country’s major trauma centres in a 3-month pilot study (March−June 2013). Methods
ED attendees already having blood tests were routinely tested for HIV (based on the recommendation being made to all to test when having blood taken). Uptake was determined using the surrogate marker of ED attendees who had full blood counts (FBCs) as the denominator. Newly diagnosed patients were linked to care and contacts tested. Staff completed an anonymous online survey to determine acceptability at the end of the pilot study. Results
A total of 2828 patients were tested over 3 months. Nineteen HIV-positive individuals were identified. Eight were newly diagnosed, of whom two were thought to be seroconverting. The prevalence of new diagnoses was 8/2828 (0.28%); for comparison, the Public Health England (PHE) actual prevalence for Tower Hamlets is 6.25/1000 (0.625%). Uptake for HIV testing was 30%, a significant increase from 72 tests performed in the 2 months prior (P < 0.001). Ninety-five per cent of respondents to the staff survey agreed that routine HIV testing should be rolled out permanently in the ED. Conclusions
Despite an average uptake rate, there were 19 positive tests: eight in patients who were newly diagnosed, six in patients who had been lost to follow-up, and five in patients who were known to be positive and linked to care. The staff survey indicated recognition of the importance of HIV testing in the ED. These persuasive data achieved short-term Clinical Commissioning Group (CCG) funding for routine ED testing. Keywords: emergency department, HIV testing, late diagnosis, routine Accepted 15 October 2014
people living with HIV in the UK remained undiagnosed [5]. This is despite recommendations from the National Institute for Clinical Excellence (NICE) Public Health Committee and the UK’s National HIV Testing guidelines that all patients accessing secondary care or those having planned venepuncture should be tested for HIV if the diagnosed prevalence of HIV exceeds 2 per 1000 [1,6]. Low rates of HIV testing have been repeatedly demonstrated in hospital settings in the UK, even in those patients presenting with clinical indicators for HIV infection [5,7].
Introduction Early diagnosis of and treatment for HIV infection prolong life, reduce transmission, improve quality of life and have been demonstrated to be a cost-effective public health intervention [1–4]. However, in 2012 47% of new HIV diagnoses were late diagnoses, and 22% of the 98 400 Correspondence: Ms Rachel Bath, Chest Medicine, St George’s NHS Trust, St George’s Hospital, Blackshaw Road, London SW17 0QT, UK. Tel: 07791603071; fax: 02087251466; e-mail: [email protected]
326
HIV testing in an ED 327
The emergency department (ED) is a desirable target for HIV testing within hospitals as it serves a high-throughput population of diverse attendees. However, the focus on trauma and resuscitation as well as the 4-hour wait make it, understandably, logistically difficult to prioritize HIV testing initiatives. Our ED serves a population with a very high diagnosed prevalence of HIV (6 1000 population) [5]three times higher than the prevalence at which testing is routinely recommended. The busy ED is home to London’s air ambulance and has 400 000 attendances per year.
Methods To complement the existing opt-out testing schemes in the medical admissions and intensive care units, ED staff and the HIV Testing Team collaborated to develop guidelines for implementation within the ED. Of the 350 daily ED attendees, 150 (43%) have bloods taken. Between March and July 2013, those over 16 years who had bloods taken were routinely tested for HIV unless they chose not to be. Information about the testing pilot study was communicated through banners and posters in the ED. Leaflets were available and the public were informed via local newspapers. These communications with the public made it clear that testing for HIV was routine when having any blood tests. Patient information was also available in Bengali and Russian (two very common local languages). Leaflets indicated that: ‘your blood will be tested for HIV unless you ask us not to’. We excluded those who disclosed their HIV-positive status, those who had been tested within the last 6 months, those without the capacity to consent and those who could not agree to testing (because of language issues). HIV tests were offered and performed by trained ED staff. Negative results were handled via a ‘no news is good news’ policy. Positive results were communicated to patients by an HIV testing facilitator using contact details provided or via a GP (if the patient was uncontactable). Contact tracing of untested partners and/or exposed children with linkage to appropriate HIV services was carried out. Uptake was determined by matching the number of HIV tests taken against the number of full blood counts (FBCs) taken over the same period – a surrogate marker for testing opportunities. We were not able to determine a refusal rate. Demographic data were extracted from the electronic patient record. Staff completed an anonymous online survey to determine acceptability at the end of the pilot study.
Results Between March and July 2013, 9297 ED attendees had an FBC taken, with 2828 of 9297 (30%) accepting an HIV test.
© 2015 British HIV Association
This constitutes a 12-fold increase in the HIV testing rate compared with 2 months prior to the study [72 tests (2.4%); no tests HIV positive; p < 0.001]. A total of 1527 patients (54%) were male, and the median age was 48 years. The numbers of patients tested for HIV within the different age categories were: 16–30 years, 877 (31%); 31–40 years, 650 (23%); 41–60 years, 764 (27%); and > 60 years, 537 (19%). Those receiving HIV tests were ethnically diverse (17 ethnicities). Most who were tested self-identified as British (33%), Bangladeshi (18%), African (3%), Pakistani (3%) and Caribbean (3%). Nineteen ED attendees had an HIV-positive blood test, equating to 1% of the population tested; for comparison, the known Public Health England (PHE) prevalence for Tower Hamlets is 0.6% [5]. Eight of the nineteen diagnoses were new diagnoses (8/2828; 0.28%). Two of these eight patients were found to be seroconverting based on viral load, avidity and HIV antibody results. All eight presented with clinical indicators for HIV infection (median CD4 count 256 cells/μL; interquartile range 42–348 cells/μL), such as tuberculosis, significant weight loss, unexplained diarrhoea and vomiting, and Guillain−Barre Syndrome. Of the 11 previously diagnosed patients, six had been lost to follow-up (LTFU) for ≥ 1 year and all had discontinued antiretroviral therapy (ART). The remaining five patients were engaged with HIV care but did not disclose their status in the ED setting. We were able to link 13 patients to HIV services (seven newly diagnosed and six LTFU) with eight eligible patients commencing ART. Contact tracing was successfully completed in 13 of 14 cases, including the HIV testing of an untested exposed infant and an untested child. In the staff survey, 100% of respondents had been trained and 95% agreed that routine HIV testing should be rolled out permanently in the ED. However, the uptake rate was very low, at 9.5%. Nineteen members of staff completed the survey, of whom 18 agreed with the statement that ‘opt out testing should be continued in the ED’. One hundred per cent of staff reported finding it easier to offer an HIV test as part of a routine policy rather than based on clinical suspicion.
Discussion The implementation of routine HIV testing significantly increased HIV testing rates within the ED during the pilot study. PHE figures indicate that 0.625% of those in Tower Hamlets are living with HIV. In our pilot study, despite excluding known positives from the target group, 1% of the population tested was found to be HIV positive; 0.28% were newly HIV positive. Tests were offered to and accepted by patients of all genders, ages and ethnicities
HIV Medicine (2015), 16, 326–328
328 R Bath et al.
alike. All of the ED attendees with new HIV diagnoses were from ‘at risk’ population groups and all presented with a clinical indicator for HIV infection and therefore should have been tested regardless. However, with only 72 HIV tests taken over the 2 months preceding the pilot study, it seems that this was not the case. Staff reported finding it easier to offer an HIV test as part of a routine policy rather than based on clinical suspicion. A quarter of the patients with new diagnoses were seroconverting and therefore at the highest risk of onward transmission of infection. By performing thorough contact tracing, the risks of onward transmission have been reduced in contacts of these very infectious individuals. With help from the HIV Testing Team, the highly motivated and committed ED staff were able to implement HIV testing within the busy ED setting. Linkage to care for HIV-positive individuals (new and LTFU) was achieved, with 93% (13 of 14) linked to care. On the basis of these results and the enthusiasm of the ED team, we managed to secure further funding through the local Clinical Commissioning Group (CCG) to continue testing until the end of the financial year 2013/14, with negotiations to extend for 2014/15 in Tower Hamlets. The study had some limitations. We were unable to ascertain a refusal rate of HIV tests offered, or to obtain patient feedback to establish acceptability to patients. However, patients of all ages, genders and ethnicities accepted testing. We matched the numbers of HIV tests against FBCs for those having bloods taken, and this may not have captured all patients having bloods taken, leading to a possible overestimate of the proportion tested for HIV. Uptake of the staff survey was low (19 of 100), and inadequate among emergency department assistants who championed the pilot study.
Conclusions Within a large trauma centre ED, it was possible to achieve an uptake of 30% in an HIV opt-out testing pilot study. In this short time, eight new HIV diagnoses were made. Onequarter of newly diagnosed patients were diagnosed during seroconversion, further indicating the importance of testing in the ED to reduce onward transmission. Patients diagnosed had mainly late diagnoses and all were from high-risk groups, suggesting further scope for truly uni-
© 2015 British HIV Association
versal HIV testing [7]. Loss to follow-up is a significant problem in the UK [8] and this pilot study enabled re-linkage to care for those patients. Although few completed the staff survey, 95% of those who completed it supported permanent routine HIV testing within the ED. The pilot study has raised awareness about HIV infection and its clinical indicators within the department and enabled us to obtain interim funding through the CCG to continue as well as justifying the ongoing negotiations to make this routine.
References 1 British HIV Association (BHIVA), British Association for Sexual Health and HIV (BASHH), British Infection Society (BIS). UK National Guidelines for HIV Testing 2008 [Guideline]. London, British HIV Association, 2008. 2 British HIV Association (BHIVA). BHIVA. [Online]. 2007. Available at http://www.bhiva.org/NationalAuditReports.aspx (accessed April 2014). 3 Health Protection Agency (HPA). HPA, Org. [Online]. 2011. Available at http://www.hpa.org.uk/timetotesthiv2011 (accessed April 2014). 4 Hartney T NACPFJ. HPA, Org. [Online]. 2012. Available at https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/326601/HIV_annual_report_2013.pdf (accessed April 2014). 5 Aghaizu A BANAGODV&c. HPA, Org. [Online]. London. 2013. Available at http://www.hpa.org.uk/Publications/ InfectiousDiseases/HIVAndSTIs/1311HIVintheUk2013report/ (accessed April 2014). 6 National Institute for Health and Care Excellence. NICE, Org. [Online]. 2011. Available at http://pathways.nice.org.uk/ pathways/hiv-testing-and-prevention#path=view%3A/ pathways/hiv-testing-and-prevention/increasing-the-uptake-of -hiv-testing.xml&content=view-index (accessed April 2014). 7 Elmahdi R GSMGGGFSCGWH. Low levels of HIV test coverage in clinical settings in the UK:a systematic review of adherence to 2008 guidelines. Sex Transm Infect 2014; 90: 119–124. 8 Rice BD DVCCTREJ. Loss to follow-up among adults attending human immunodeficiency virus services in England, Wales, and Northern Ireland. Sex Transm Dis 2011; 38: 685–690.
HIV Medicine (2015), 16, 326–328
Copyright of HIV Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
