Routine HIV testing in the emergency department: tough lessons in sustainability

Abstract

ObjectivesRoutine HIV testing in nonspecialist settings has been shown to be acceptable to patients and staff in pilot studies. The question of how to embed routine HIV testing, and make it sustainable, remains to be answered. MethodsWe established a service of routine HIV testing in an emergency department (ED) in London, delivered by ED staff as part of routine clinical care. All patients aged 16 to 65 years were offered an HIV test (latterly the upper age limit was removed). Meetings were held weekly and two outcome measures examined: test offer rate (coverage) and test uptake. Sustainability methodology (process mapping; plan-do-study-act (PDSA) cycles) was applied to maximize these outcome measures. ResultsOver 30 months, 44 582 eligible patients attended the ED. The mean proportion offered an HIV test was 14%, varying from 6% to 54% per month over the testing period. The mean proportion accepting a test was 63% (range 33-100%). A total of 4327 HIV tests have been performed. Thirteen patients have been diagnosed with HIV infection (0.30%). PDSA cycles having the most positive and sustained effects on the outcome measures include the expansion to offer blood-based HIV tests in addition to the original oral fluid tests, and the engagement of ED nursing staff in the programme. ConclusionsHIV testing can be delivered in the ED, but constant innovation and attention have been required to maintain it over 30 months. Patient uptake remains high, suggesting acceptability, but time will be required before true embedding in routine clinical practice is achieved.Keywords: HIV testing, Emergency Department, non-specialist settings, sustainability methodology, feasibility, acceptability Accepted 12 June 2013 IntroductionThe UK HIV epidemic is characterized by a high proportion of late-stage diagnoses, and of a persistently high proportion of undiagnosed infections [1]. Guidance from the National Institute for Health and Clinical Excellence follows that from the British Association for Sexual Health and HIV, and the British HIV Association, in calling for more widespread testing, including routine HIV testing in general medical settings in areas where HIV prevalence exceeds 0.2% [2][3][4][5].The HIV Testing in Non-traditional Settings (HINTS) study was one of several Department of Health-funded studies commissioned to evaluate the acceptability, feasibility and effectiveness of implementing these guidelines. Routine HIV testing services were established in four contexts, all in high-prevalence areas in London, UK: an emergency department (ED), an acute assessment unit, an out-patient department, and a primary care centre. Over SHORT COMMUNICATION 6 4 months, 6194 patients were offered HIV tests (51% of all age-eligible patients). The uptake was 67%, with 4105 tests performed. Eight individuals (0.19%) were newly diagnosed with HIV infection and all were transferred to care. Of 1003 questionnaire respondents, the offer of an HIV test was acceptable to 92%. In all settings, additional specialist staff and/or infrastructura...

The late‐presenting HIV‐infected patient 30 years after the introduction of HIV testing: spectrum of opportunistic diseases and missed opportunities for early diagnosis

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