Targeting the HIV Epidemic in South Africa: The Need for Testing and Linkage to Care in Emergency Departments

Abstract

Background: The Eastern Cape province of South Africa has one of the highest burdens of HIV in the world. Emergency Departments (EDs) can serve as optimal clinical sites for identification of new HIV infections and entry into care. We sought to determine the current burden of HIV disease among ED patients in the Eastern Cape. Methods: We conducted a prospective observational study in the EDs of three Hospitals in the Eastern Cape province of South Africa from June 2017 to July 2018. All adult, non-critical patients presenting to the ED were systematically approached and offered a Point-Of-Care (POC) HIV test in accordance with South African guidelines. All HIV-positive individuals had their blood tested for presence of anti-retroviral therapy (ART) and viral suppression (≤1,000 copies/ml). HIV incidence was estimated using Limiting Antigen Avidity assay. Results: Of the 2,901 patients for whom HIV status was determined (either known HIV-positive or underwent POC HIV testing), 811 (28.0%) were HIV positive, of which 234 (28.9%) were newly diagnosed. HIV prevalence was higher in Mthatha [34% (388/1134) at Mthatha Regional Hospital and 28% (142/512) at Nelson Mandela Academic Hospital], compared to Port Elizabeth [22% (281/1255) at Livingstone Hospital]. HIV incidence was estimated at 4.5/100 person years (95% CI: 2.4,6.50) for women and 1.5 (CI 0.5,2.5) for men. Of all HIV positive individuals tested for ART (585), 54% (316/585) tested positive for the presence of ARTs, and for all HIV positive participants with viral load data (609), 49% (299/609) were found to be virally suppressed. Conclusions: Our study not only observed a high prevalence and incidence of HIV among ED patients, but also highlights significant attrition along the HIV care cascade for HIV positive individuals. ED-based HIV services should be made available to engage these patients in care. Furthermore, HIV services in the ED should also develop strategies that can accommodate large testing volumes and ART initiation in a complex clinical environment. Funding Statement: Research reported in this publication was supported by the South African Medical Research Council and in part by the Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH. Declaration of Interests: The authors have no conflicts of interest to declare. Ethics Approval Statement: The study was approved by the Johns Hopkins University School of Medicine Institutional Review Board, the University of Cape Town Human Research Ethics Committee (HREC), and the Walter Sisulu University HREC. Written consent was obtained from all participants for the collection of demographic data, POC HIV testing, and sample collection if HIV positive.