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Closing the Gap on Missed Opportunities for HIV Testing in Africa

Nelly Mugo, MBChB, MMed, MPH

Head, Sexual Reproductive Adolescent Child Health Research Program
Centre for Clinical Research
Kenya Medical Research Institute (KEMRI)
Nairobi, Kenya

Nelly Mugo, MBChB, MMed, MPH, has no relevant conflicts of interest to report.

View ClinicalThoughts from this Author

Released: December 22, 2021

Undiagnosed HIV infection increases late diagnosis of HIV/AIDS, which delays initiation of antiretroviral therapy (ART), increases HIV-related morbidity and mortality, and increases the risk for HIV transmission. Timely diagnosis can lead to rapid initiation of ART, breaking this chain.

At the 18th European AIDS Conference (EACS 2021), data from Europe, Africa, and Asia were presented evaluating the missed opportunities for HIV testing in hospitals and the benefits of increasing access to HIV testing in emergency departments (EDs). The findings from these studies were in agreement regarding the importance of increased testing of previously undiagnosed individuals with HIV, including patients who rarely interface with health services.

Izmir, Turkey
Özkaya and colleagues reported on their cross-sectional study among individuals diagnosed with HIV after being tested in 2018-2019. They did this to assess missed opportunities for earlier diagnosis during the year prior to testing positive.

Among the 137 individuals with HIV who were interviewed, HIV testing was indicated in 50% of clinic visits but was not offered in 89% of visits when indicated. The opportunity to test for HIV was missed in 78% of patients in ≥1 clinic visit. At the time of diagnosis, 75% of patients had an AIDS-defining illness.

Nairobi, Kenya
Aluisio and colleagues evaluated acceptability and uptake of HIV testing among patients presenting to the ED with injury during a 3-month period in 2021. Investigators found that 605 of 646 (94%) patients eligible for HIV testing were not offered an HIV test.

When offered HIV testing, acceptance was high. Of 49 patients offered testing, 44 (90%) were tested, of whom one third were younger than 25 years of age (recognized as the age group with the highest HIV incidence in sub-Saharan Africa) and one half had never used a condom. HIV prevalence was 12%, almost 3-fold higher than the national baseline HIV prevalence (reported at 4.9% in the last national survey). The lack of access to HIV testing for individuals presenting with injury in the ED presents a missed opportunity for early testing and identification of previously undiagnosed individuals.

London, United Kingdom
To identify populations at risk of HIV infection in the United Kingdom, national guidelines recommend opt-out HIV testing in select geographic locations in London. To implement this strategy, an HIV test was added to all adult ED blood order sets. Informational posters were placed in the ED waiting areas, and staff were trained on asking for verbal consent from patients for HIV testing.

In evaluating this strategy, Rizvi and colleagues reported that 74% of ED adult attendees were tested for HIV. There were 152 positive HIV tests; 50% were already linked to care but did not disclose this when accessing care in the ED. In addition, 22 (16%) of those known to be HIV positive prior to being tested in the ED were not virally suppressed, 19 (13%) were lost to follow-up, and 13 (9%) were newly diagnosed. Of those patients newly diagnosed, 10 (77%) had late-stage HIV disease.

As presented at EACS 2021, investigators implemented different strategies for delivery of HIV testing to ED in diverse geographical regions, supporting the opportunity to find previously undiagnosed HIV-infected individuals with this increased testing strategy.

Your Thoughts?
How often are patients in your institution’s ED offered HIV screening? Join the discussion by posting a comment. For more details on this and other key HIV issues from EACS 2021, review more CCO Conference Coverage, including Capsule Summary slidesets, video recaps with expert faculty, and other ClinicalThought commentaries highlighting US and global perspectives.

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