Patient acceptability & feasibility of HIV testing in Emergency

Departments in the UK – a systematic review & meta-analysis

Dr Nicola LunguPrincess Royal University Hospital, King’s College Hospital NHS Trust

HIV testing in ED

Why increase HIV testing?

13,500 undiagnosed39% late

Why in ED?

Overall low cost per positive testReduce stigma, public & healthcare professionals

Does HIV testing in ED work?

USA - CDC guidelines 2006All healthcare settings to provide opt-out testing aged 13-64 if HIV prevalence >0.1%

Diagnostic yield- Reported for local settings only- Depends on proportion of eligible patients

accepting HIV test

USA map Creative Commons License: Lokal_ProfilMontoy JC, Dow WH, Kaplan BC; Patient choice in opt-in, active choice, and opt-out HIV screening: RCT; BMJ; 352:h6895

Introducing HIV testing in ED: UK

Feasible Acceptable

Effective & worthwhile

- Cost- Capacity- Staff willing

- Staff- Patients

- Diagnostic yield

Milton Keynes 2.98

Barnet 2.99

Reading 3.04

Bournemouth 3.07

Coventry 3.20

Northampton 3.22

Crawley 3.22

Slough 3.45

Ealing 3.47

Blackpool 3.81

Leicester 3.82

Hounslow 3.85

Enfield 4.14

Merton 4.21

Luton 4.30

Brent 4.31

Salford 4.95

Waltham Forest 5.02

Croydon 5.36

Wandsworth 5.60

Manchester 5.81

Barking and Dagenham 6.17

Greenwich 6.42

Tower Hamlets 6.50

Newham 6.69

Haringey 7.02

Brighton and Hove 8.02

Hackney 8.11

Camden 8.16

Islington 8.25

Lewisham 8.26

Hammersmith and Fulham 8.36

Westminster 8.89

Kensington and Chelsea 9.07

Southwark 12.71

City of London 12.95

Lambeth 14.60

Oxford 2.01

Rushmoor 2.01

Thurrock 2.03

Newcastle upon Tyne 2.03

Hertsmere 2.04

Rochdale 2.05

Trafford 2.07

Havering 2.09

Norwich 2.10

Kingston upon Thames 2.13

Adur 2.13

Derby 2.14

Bristol, City of 2.14

Southampton 2.15

Lewes 2.17

Eastbourne 2.19

Wellingborough 2.26

Hastings 2.26

Bedford 2.37

Harrow 2.37

Sutton 2.37

Stevenage 2.41

Richmond upon Thames 2.46

Leeds 2.48

Sandwell 2.57

Corby 2.58

Worthing 2.60

Hillingdon 2.63

Birmingham 2.67

Bexley 2.68

Bromley 2.68

Harlow 2.78

Southend-on-Sea 2.79

Watford 2.79

Redbridge 2.80

Nottingham 2.91

Wolverhampton 2.97Local Authorities in England with diagnosed HIV prevalence >2 per 1,000

This review: Method

Universal HIV testing in UK ED

Patient AcceptabilityNumber of patients accepting a test, as a %

proportion of tests offered

FeasibilityNumber of tests offered, as a % proportion of

eligible patients

Results

Identification

Studies included in data synthesis

(n= 7)

Studies excluded: duplicate dataset (n= 1), unclear study location (n= 1)

Studies excluded: abstract not relevant

(n= 55)

Full text articles (where available) assessed

(n= 9)

Studies excluded: title not relevant

(n= 1520)

Study abstracts reviewed

(n= 64)

Studies after duplicates removed

(n= 1584)

Additional studies identified through other sources

(n= 2)

Studies identified through database searching

(n= 1871)

Screening

Eligibility

Included

Results

Combined sample: 101,975

Reporting period: 1 week – 30 months

Eligible sample: 1000 – 44,582 patients

Locations: London (5 different EDs)

Testing style:

Staff offer routine testing: 4 / Opt-out policy: 3

ResultsPatients accepting HIV testing, and being offered an HIV test, as a proportion of the eligible sample

GRADE score

1

0

1

1

2

2

1

Results

Acceptability of opt-in & opt-out testing: 54.1% (CI 40.1, 68.2)

Feasibility of routine opt-in testing:36.2% (CI 9.8, 62.4)

Discussion

If offered to patients, 54.1% accepted HIV test in ED

When staff offer opt-in test, 36.2% patients are approached

Opt-out testing: it is not known how many times practice deviated from policy, or why

Limitations

- Heterogeneous- Small number- London only- Surrogate measures

Strengths

- Large total sample- First look at UK data

Conclusion

NICE recommend universal HIV testing in EDs in high prevalence areas

Limited reports of UK and USA practice

“ED staff … value the service as a mechanism to diagnose undiagnosed HIV infection, a means of destigmatising HIV testing, and of forging relationships between departments in the hospital.” (Rayment 2013)

Creative Commons License: Sham Hardy (Flickr)

Rayment M, Thornton A, Mandalia S, Elam G, Atkins M, Jones R, et al. HIV testing in non-traditional settings--the HINTS study: a multi-centre observational study of feasibility and acceptability. PloS one. 2012;7(6):e39530.

Hempling M, Pakianathan M, Majewska W. Pilot Project evaluating HIV testing in St George’s Emergency Department. Emergency Medicine Journal. 2011;28(Suppl 1):A5.

Rayment M, Rae C, Ghooloo F, Doku E, Hardie J, Finlay S, et al. Routine HIV testing in the emergency department: tough lessons in sustainability. HIV medicine. 2013;14 Suppl 3:6-9.

Hempling MC, Zielicka-Hardy A, Ellis JP, Majewska W, Fida G. Routine HIV testing in the Emergency Department: feasible and acceptable? International Journal of STD and AIDS. 2016;27(14):1267-74.

Bath R, Ahmad K, Orkin C. Routine HIV testing within the emergency department of a major trauma centre: A pilot study. HIV Medicine. 2015;16(5):326-8.

Bath R, O'Connell R, Lascar M, Ferrand R, Strachan S, Matin N, et al. TestMeEast: A campaign to increase HIV testing in hospitals and to reduce late diagnosis. AIDS Care - Psychological and Socio-Medical Aspects of AIDS/HIV. 2016;28(5):608-11.

Hunter L, Rial CL, Larbalestier N, Paperello J. Routine HIV Testing in an Inner City Emergency Department. Annual Scientific Conference 2016: Royal College of Emergency Medicine,; 2016.

nicola.lungu@nhs.net @nicolalungu

Patient acceptability & feasibility of HIV testing in Emergency Departments in the UK – a systematic review & meta-analysisHIV testing in EDDoes HIV testing in ED work?Slide Number 4This review: MethodResultsResultsResultsResultsDiscussionConclusionSlide Number 12