Manitoba: High rates of satisfaction with HIV testing in the Emergency Room
4 February 2014 - According to the Public Health Agency of Canada (PHAC), there are about 71,000 HIV-positive people in Canada, 25% of whom do not know their infection status . Such people, unaware that their immune systems are slowly being degraded by HIV, may only seek care once they become very ill.
A recent study from France focused on people who sought care relatively late in the course of HIV disease. Researchers in that study found that people with a "moderate degree of immunodeficiency" who have between 200 and 350 CD4+ cells are at an elevated risk of death compared to HIV-positive people who have more CD4+ cells. Thus, earlier HIV testing and swift referral to care and treatment with potent combination anti-HIV therapy (commonly called ART or HAART) would have likely resulted in better survival. Furthermore, early diagnosis and treatment of HIV is less costly than waiting until someone is very ill.
Some people may not choose to get tested for HIV for the following reasons:
- They perceive themselves to be at low risk for this infection.
- They worry about having a positive test result, in part because they may view HIV as a deadly disease rather than a chronic infection that can be managed with effective medicines.
- They are concerned about the confidentiality of their test results.
- They lead busy lives and find visiting a clinic or doctor inconvenient.
As people who are unaware of their infection status may only seek care when they are very ill, researchers have been increasingly calling for Emergency Rooms (ER) to offer HIV testing and counselling as part of normal ER assessments. Some hospitals in high-income countries are evaluating such testing and we now present a study done at one hospital in Canada.
In Manitoba
Researchers at the Health Sciences Hospital in Winnipeg conducted a study in 2010 and 2011 offering rapid HIV testing and counselling to adults who sought care in the ER. All initially "reactive" results with the rapid test (these may be considered a preliminary positive result) were later confirmed with more robust tests. Of the 501 adults who sought care during the study, there were seven cases (1.4%) of HIV that were uncovered. All seven cases were quickly linked to an HIV specialist. The vast majority of people (96%) who underwent rapid HIV testing and counselling reported satisfaction with the test. Furthermore, 93% of participants stated that such testing and counselling were appropriate for the ER.
Study details
Doctors and nurses in the ER told patients about the study; patients who expressed interest were interviewed by a research nurse associated with the study. The nurse explained details about the study and sought informed consent. People who agreed to participate received counselling both before and after the rapid HIV test. Patients were also interviewed about risk behaviours and other details.
The test used was INSTI, which is made by Biolytical Laboratories. It requires a couple of drops of blood from a finger prick. The test has a high sensitivity-it can detect HIV antibodies in at least 99.8% of cases, all within a couple of minutes. However, uncommonly, false-reactive tests can occur, so all reactive tests obtained with INSTI need to be confirmed with more specific and sensitive blood tests in a central laboratory.
People who disclosed that they were HIV positive were not enrolled into the study.
Results - Who was tested?
Most participants were younger than 40 years and nearly half (49%) were women. A majority (53%) of participants identified themselves as Aboriginal people and about 40% identified themselves as white.
Past testing
Nearly half (49%) of participants disclosed that they had previously been tested for HIV. In most cases such testing occurred more than a year before the present study. Women, people who injected street drugs and men who have sex with men (MSM) were likely to have had previous HIV tests. According to the researchers, participants who reported no HIV risk factors or who were married or in a monogamous relationship were "significantly less likely to have had a previous HIV test."
Nearly 40% of participants did not have a family doctor, but this did not have any statistical link to a lack of a previous HIV test.
Uncovering HIV
A total of seven people had a reactive test result with the rapid test. All reactive tests were confirmed positive with further testing. Here is a profile of those seven people who tested positive:
- average age - 43 years
- five men, two women
- four people identified themselves as Aboriginal
- six people had previously been tested for HIV; most such testing was done more than a year before they sought emergency care
- three people had more than 300 CD4+ cells/ml and sought help for conditions unrelated to HIV (details were not released)
- the remaining four people had less than 200 CD4+ cells/ml and signs/symptoms associated with a profoundly weakened immune system; they were all diagnosed with one of the following life-threatening infections:
- PCP (Pneumocystis pneumonia; caused by the fungus P. jirovecii )
- yeast infection of the mouth and throat (esophageal candidiasis; caused by Candida )
- fungal infection of the membrane surrounding the brain (Cryptococcal meningitis, caused by the fungus C. neoformans )
Fast track
- All four people with severe infections were hospitalized, treated and given ART.
- According to researchers, "within 24 hours of their reactive test results, all seven individuals were linked with an HIV specialist and a program team for ongoing care."
- Two of the three people without AIDS-related infections did not need to be admitted to the hospital. Their conditions were stabilized in the ER and they later received further care at an HIV clinic (within 10 days of their HIV diagnosis).
- The third person without an AIDS-related infection has been in contact with an HIV outpatient clinic via telephone but has not yet visited the clinic.
Satisfaction
According to the researchers, "96% of participants were satisfied with the test and confident [about its accuracy]." Furthermore, 96% of participants agreed that they would be willing to have rapid HIV testing in a hospital's ER should they be offered the opportunity again in the future. Slightly less, 93% believed that rapid HIV testing belonged in the ER. People who tested positive for HIV had similar levels of satisfaction.
Focus on risk or not?
The present study was not targeted at specific HIV risk groups. The Manitoba researchers suggested that their non-targeted approach to HIV screening might have encouraged more people to agree to such testing. Moreover, the researchers suggested that three of the people who tested positive were seeking care for non-HIV-related issues and may not otherwise have been tested if targeted HIV risk screening was applied. A larger, more complex and expensive study conducted in Denver, Colorado, also dealt with HIV testing in the ER. The Denver researchers found that non-targeted HIV testing uncovered more HIV infections than targeted screening.
Some patient perspectives - San Francisco
In San Francisco, researchers interviewed participants who had been newly diagnosed in the ER. They found that patients in the ER, unlike those who specifically seek HIV testing, "may be completely unprepared for an HIV diagnosis." Such people may be less informed about HIV and the profound health-improving effects of modern treatment, and so, according to researchers, "lack psychological strategies for handling [some of the distressing feelings that can occur after receiving a positive HIV test result]."
Just being in an ER can be stressful and an unexpected HIV diagnosis can certainly add to that. Patients in the ER are sometimes alone without emotional support or, according to researchers, sometimes they are "with family members or friends to whom they do not wish to immediately disclose." The researchers caution doctors and other hospital staff to be aware of this latter possibility.
The San Francisco researchers reported that being in the hospital and having access to thoughtful, caring and sensitive staff provided newly diagnosed patients with emotional support and education about the many benefits of modern ART and the likelihood of surviving for several decades after initiating therapy. This education helped to build trust with the medical-healthcare system and, according to researchers, "[instilled a sense of hope about the future, as their response to an HIV diagnosis remained characterized by fear of death, even 30 years into the epidemic.]"
Back to Winnipeg
It is likely that a combination of supportive counselling and thoughtful and sensitive staff involved with HIV testing in the Winnipeg study resulted in the high levels of satisfaction reported. Furthermore, the staff involved in educating and linking patients to HIV care and treatment likely played an important role in helping to patients to be psychologically ready for accepting their diagnosis and treatment.
For the future
The Winnipeg and San Francisco studies and their results are important for HIV testing and treatment programs to consider, as such programs are likely to become increasingly vital in uncovering previously unrecognized HIV infections.
-Sean R. Hosein
Resources
Just diagnosed with HIV - first things you need to know about living with HIV
A rapid approach to community-based HIV testing - Prevention in Focus
Routine HIV Testing in Acute Care - Programming Connection
HIV home-based testing: Potential benefits and ongoing concerns - Prevention in Focus
REFERENCES:
- Deblonde J, De Koker P, Hamers FF, et al. Barriers to HIV testing in Europe: a systematic review. European Journal of Public Health. 2010 Aug;20(4):422-32.
- Montlahuc C, Guiguet M, Abgrall S, et al. Impact of late presentation on the risk of death among HIV-infected people in France (2003-2009). Journal of Acquired Immune Deficiency Syndromes. 2013 Oct 1;64(2):197-203.
- de Wit JB, Adam PC. To test or not to test: psychosocial barriers to HIV testing in high-income countries. HIV Medicine . 2008 Jul;9 Suppl 2:20-2.
- Haukoos JS, Campbell JD, Conroy AA, et al. Programmatic cost evaluation of nontargeted opt-out rapid HIV screening in the Emergency Department. PLoS One . 2013 Dec 31;8(12):e81565.
- Christopoulos KA, Massey AD, Lopez AM, et al. Patient perspectives on the experience of being newly diagnosed with HIV in the emergency department/urgent care clinic of a public hospital. PLoS One. 2013 Aug 26;8(8):e74199.
- Becker ML, Thompson LH, Pindera C, et al. Feasibility and success of HIV point-of-care testing in an emergency department in an urban Canadian setting. Canadian Journal of Infectious Diseases & Medical Microbiology. 2013 Spring;24(1):27-31.
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From Canadian AIDS Treatment Information Exchange (CATIE). For more information visit CATIE's Information Network at http://www.catie.ca
Source: CATIE: CANADIAN AIDS TREATMENT INFORMATION EXCHANGE
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