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Targeting the HIV Epidemic in South Africa: The Need for Testing and Linkage to Care in Emergency Departments.

ABSTRACT: Background:The Eastern Cape province of South Africa has one of the highest burdens of HIV in the world. Emergency Departments (EDs) can serve as optimal clinical sites for the identification of new HIV infections and entry into care. We sought to determine the current burden of HIV disease among ED patients in the Eastern Cape. Methods:We conducted a prospective cross-sectional observational study in the EDs of three Hospitals in the Eastern Cape province of South Africa from June 2017 to July 2018. All adult, non-critical patients presenting to the ED were systematically approached and offered a Point-Of-Care (POC) HIV test in accordance with South African guidelines. All HIV-positive individuals had their blood tested for the presence of antiretroviral therapy (ART) and the presence of viral suppression (? 1000 copies/ml). HIV incidence was estimated using a multi-assay algorithm, validated for a subtype C epidemic. Findings:Of the 2901 patients for whom HIV status was determined (either known HIV-positive or underwent POC HIV testing), 811 (28.0%) were HIV positive, of which 234 (28.9%) were newly diagnosed. HIV prevalence was higher in Mthatha [34% (388/1134) at Mthatha Regional Hospital and 28% (142/512) at Nelson Mandela Academic Hospital], compared to Port Elizabeth [22% (281/1255) at Livingstone Hospital]. HIV incidence was estimated at 4.5/100 person-years (95% CI: 2.4, 6.50) for women and 1.5 (CI 0.5, 2.5) for men. Of all HIV positive individuals tested for ART (585), 54% (316/585) tested positive for the presence of ARTs, and for all HIV positive participants with viral load data (609), 49% (299/609) were found to be virally suppressed. Interpretation:Our study not only observed a high prevalence and incidence of HIV among ED patients but also highlights significant attrition along the HIV care cascade for HIV positive individuals. Furthermore, despite developing an optimal testing environment, we were only able to enrol a small sub-set of the ED population. Given the high HIV prevalence and high attrition in the ED population, HIV services in the ED should also develop strategies that can accommodate large testing volumes and ART initiation.

SUBMITTER: Hansoti B

PROVIDER: S-EPMC6833451 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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Targeting the HIV Epidemic in South Africa: The Need for Testing and Linkage to Care in Emergency Departments.

Hansoti Bhakti B Mwinnyaa George G Hahn Elizabeth E Rao Aditi A Black John J Chen Victoria V Clark Kathryn K Clarke William W Eisenberg Anna L AL Fernandez Reinaldo R Iruedo Joshua J Laeyendecker Oliver O Maharaj Roshen R Mda Pamela P Miller Jernelle J Mvandaba Nomzamo N Nyanisa Yandisa Y Reynolds Steven J SJ Redd Andrew D AD Ryan Sofia S Stead David F DF Wallis Lee A LA Quinn Thomas C TC

EClinicalMedicine 20190819

<h4>Background</h4>The Eastern Cape province of South Africa has one of the highest burdens of HIV in the world. Emergency Departments (EDs) can serve as optimal clinical sites for the identification of new HIV infections and entry into care. We sought to determine the current burden of HIV disease among ED patients in the Eastern Cape.<h4>Methods</h4>We conducted a prospective cross-sectional observational study in the EDs of three Hospitals in the Eastern Cape province of South Africa from Jun ...[more]

PMID: 31709410

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Project description:BackgroundEmergency Departments (EDs) can serve as clinical sites for identification of new HIV infections and their entry into care. We examined if HIV-positive patients who present to EDs in South Africa are able to successfully link to care.MethodsWe conducted a one-year longitudinal prospective cohort study in four hospitals across the Eastern Cape, South Africa, with participants followed between July 2016 and July 2018. All adult, non-critical patients presenting to the ED were systematically approached, asked about their HIV status, and, if unknown, offered a point-of-care (POC) HIV test. All HIV-positive patients were further consented to participate in a follow-up study to assess subsequent linkage to care and distance from "home" to ED. Linkage to care was defined as self-reported linkage (telephonic) or evidence of repeated CD4/viral load testing in the National Health Laboratory System (NHLS) at either the 6- or 12-months post index ED visit.FindingsA total of 983 HIV-positive patients consented to participate in the study. In the 12 months following their ED visit, 34·1% of patients demonstrated linkage to care (335/983), 23·8% did not link to care (234/983), and 42·1% (414/983) were lost to follow-up. Though not statistically significant, a high percentage of young men (27/50, 54%) and those presenting with a trauma-related complaints (100/205, 48.8%) did not link to care. A considerable proportion of patients (105/454, 23·2%,) resided 50 or more kilometers from their index ED sites, though there was not a significant difference in linkage to care rate between those who lived closer or further from the ED.InterpretationWe have shown that strategies to improve linkage to care from the ED should consider the high rates of poor linkage among young men and those presenting to the ED with trauma. Furthermore, innovative linkage to care solutions will need to account for the unique geographical consideration of this population, given that many ED patients will need to continue care at a site distant from the diagnosis site.FundingThis research was supported by the South African Medical Research Council, the Division of Intramural Research, the National Institute of Allergy and Infectious Diseases, National Institutes of Health, and the Johns Hopkins Center for Global Health.

Dataset Information

Targeting the HIV Epidemic in South Africa: The Need for Testing and Linkage to Care in Emergency Departments.

Publications

Targeting the HIV Epidemic in South Africa: The Need for Testing and Linkage to Care in Emergency Departments.

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