Improving detection of undiagnosed HIV through routine screening in a central London emergency department

Abstract

HIV is a global public health issue. Routine testing for HIV should be performed on all 16–59 years old attending emergency departments (EDs) in high-prevalence areas in the UK.In August 2020, Charing Cross Hospital ED, situated in an ‘extremely high-prevalence’ area, had no formal guidelines on HIV testing. We aimed to increase HIV testing in 16–59 years old attending our ED to 25% by August 2021 through a quality improvement project, based on the Methodology for Improvement Model, performing six Plan–Do–Study–Act cycles over a 12-month period.An initial ED staff survey revealed 55% (n=22/40) of respondents were unsure of national HIV testing guidelines. Barriers to good testing practice included: lack of clarity on protocols for consent and indication, cost and perceived stigmatisation of patient groups. Interventions were employed at regular intervals, including employment of an HIV nurse advocate, inclusion of HIV tests in a blood test careset during ED triage, and updated trust guidelines that reflect national guidelines.Overall, we did achieve our original 12 month aim, with an average testing rate of 28% of our target group between September 2020 and August 2021. Extending the project to January 2022 has resulted in continued improvements in monthly testing rates, reaching 44% in December 2021. Further analysis revealed interventions led to a statistically significant and sustained increase in monthly testing rates on seven occasions.Valuable lessons were learnt in sustaining improvements in a busy department, changing long-held beliefs regarding consent for testing, and education around HIV care in the UK. Project write-up was formatted using the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE) template.

Systematic Review: Strategies for Improving HIV Testing and Detection Rates in European Hospitals

“…The studies were published between 2012 and 2023. The majority of the studies were conducted in the United Kingdom (n = 14) [ 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ], followed by France (n = 4) [ 48 , 49 , 50 , 51 ], Italy [ 52 , 53 ], Spain [ 32 , 54 ], the Netherlands [ 33 , 55 ], and Ireland [ 56 , 57 ] (each n = 2), while the other countries (Poland [ 58 ], Portugal [ 59 ], and Switzerland [ 60 ]) contributed one study each. The study settings primarily revolved around capitals or major teaching hospitals.…”

“…The study settings primarily revolved around capitals or major teaching hospitals. The studies were conducted in the emergency department (ED; n = 14) [ 32 , 34 , 35 , 41 , 42 , 48 , 49 , 50 , 54 , 55 , 56 , 57 , 59 , 60 ], inpatient department (IPD; n = 8) [ 33 , 37 , 39 , 40 , 45 , 46 , 52 , 53 ], outpatient department (OPD; n = 5) [ 37 , 43 , 44 , 47 , 51 ], or a combination of OPD with ED or IPD (n = 2) [ 36 , 58 ]. The primary strategy studied was a test-all strategy (n = 15), of which over half were conducted in the ED (n = 9) [ 32 , 34 , 35 , 48 , 49 , 55 , 56 , 57 , 59 ], followed by IPD (n = 3) [ 38 , 39 , 40 ] or OPD settings (n = 3) [ 36 , 37 , 58 ].…”

“…Another key strategy used was indicator-condition-based testing (n = 8) [ 33 , 43 , 44 , 45 , 46 , 52 , 53 , 54 ]. The remaining studies primarily evaluated key-population-targeted testing (n = 2) [ 51 , 60 ], organizing a facility for rapid testing in the OPD (n = 1) [ 47 ], nurse-based point-of-care testing (n = 1) [ 50 ], or plan–do–check–act (PDCA) learning cycles (n = 2) [ 41 , 42 ]. Many studies consisted of multiple strategies.…”

“…Although almost all interventions incorporated teaching efforts, only three studies used teaching as a primary intervention, which led to increased HIV testing rates when used in indicator condition strategies in the abovementioned Spanish and Dutch studies [ 32 , 33 ], but not in a Polish study with a test-all strategy [ 58 ]. Plan–do–check–act (PDCA) cycle interventions in two ED-based studies increased testing rates and found 0.30% and 0.08% HIV prevalence, respectively, after implementing the addition of blood testing and incorporation of nursing staff into the HIV testing services [ 42 ], and through teaching, appointing an HIV advocate nurse, and adding HIV testing to a predefined care set [ 41 ]. Offering volunteer point-of-care testing in the OPD or ED also helped with the HIV case identification [ 47 , 50 ].…”

“…All controlled studies showed an increase in the HIV testing rates following the intervention [ 32 , 33 , 37 , 40 , 41 , 42 , 44 , 45 , 50 , 54 ], and nearly all of them reported increased HIV case-finding [ 32 , 40 , 50 , 54 , 59 ]. In all but one study, the increases were the result of a multifaceted intervention including PDCA, point-of-care testing, electronic prompts, and/or nurse assistance.…”