Initiating HIV Services in ED Critical to Ending Epidemic

Previous research has determined that testing for HIV in emergency department settings is an effective way to diagnose individuals with HIV who may be otherwise hard to reach. New research has built upon this and found that jump-starting HIV treatment in the emergency department could be a key to curbing the spread of the virus.

“We already know that HIV testing in the [emergency department] is critical to achieving these targets, but testing alone is just not going to cut it,” Bhakti Hansoti, MBChB, PhD, MPH, an author of the study, said in a statement. “Testing alone will help us reach that first 90% goal, but to get to the second and third 90%, we believe EDs need to play an active role in treatment initiation.”

For the new study, published by The Lancet in EClinicalMedicine, the team conducted a cross-sectional observational study in the emergency departments of 3 hospitals in the Eastern-Cape Province of South Africa. This location was selected because the area has one of the highest burdens of HIV in the world.

The study team was led by investigators from Johns Hopkins Medicine. Between June 2017 and July 2018, the research team testing 2901 male and female patients between the ages of 18 and 70 years across the 3 emergency departments. All individuals who were positive for HIV were tested for the presence of antiretroviral therapy (ART) and for viral suppression.

In total, 811 participants were identified as positive for HIV, of which 234 (28.9%) were newly diagnosed. The overall HIV incidence for women across the 3 sites was 4.5/100 person-years (95% confidence interval [CI] 2.4-6.50) and 1.5 (CI 0.5-2.5) for men. Additionally, of 585 of the individuals with HIV who were tested for the presence of ART, 316 (54%) tested positive. For all 609 study participants with viral load data, 299 (49%) were found to be virally suppressed. These figures are significantly below the 90-90-90 targets, which call for 90% of individuals with HIV to know their status by 2020, for 90% of diagnosed individuals to be on ART, and for 90% of individuals on ART to have undetectable HIV levels in their blood.

“Our study not only observed a high prevalence and incidence of HIV among [emergency department] patients but also highlights significant attrition along the HIV care cascade for HIV positive individuals,” the authors wrote in their report.

The investigators say that based on these findings emergency departments around the world should not only implement routine HIV testing, but also train physicians and nurses to start patients on ART and provide guidance and counseling.

However, there are notable challenges to implementing HIV care services in emergency departments, which include the high volume of patients and the hesitation of providers to initiate ART in patients due to possible comorbidities and liabilities.

Despite these challenges, the investigators believe that emergency department intervention is necessary to curb the HIV epidemic, and the proof is in their data. “Our research shows there are many patients with HIV in the emergency department who are untreated, undertreated and undiagnosed,” Hansoti concluded in the statement.