HIV screening in the ED. When, who and why. St.Emlyn’s

Are you feeling upset that this post is not about something really cool like ECMO, laryngoscopy or RSIs? Well maybe you are and that’s OK. A lot of #FOAMed is about the really top end resuscitation stuff, but stop and think about where you can really make an impact to not just one person, but to hundreds if not thousands. If that idea of making a population change inspires you (it should) then you really have to put your public health hat on and think about how the ED can make a real difference by introducing HIV screening.

This is not a new topic to St.Emlyn’s and no doubt you will have already read Nat’s top tips on the use of public health strategies in EM. You can look at all our public health blogs here including those on infectious disease, STIs, Chemsex and PreP.

Who here performs routine HIV screening on their patients in the Emergency Department?

By now you know that this blog is about HIV screening and why I think you need to think seriously about putting this into your practice if you don’t already do so. I routinely screen for HIV. I do this because I’m an evidence-based clinician who has read the guidelines and the evidence. You’ll be thinking that since I work in an “extremely high” prevalence area it’s my routine practice.

I’m afraid to say it’s not been. In fact, I rarely request a HIV test. Obviously I do test for HIV. I do it to diagnose the obvious cases. You know the ones…the patient from sub-Saharan Africa with a cough and a funky chest xray1? Or the gay lad with a flu like illness… he’s getting one. These are diagnostic tests for particularly high risk presentations not routine HIV screening.

Why should we screen for HIV in the ED?

So HIV screening isn’t sexy (like ECMO). If we’re being totally honest routine HIV screening isn’t even an emergency so why on earth am I writing a blog post about something like that to ED clinicians? Simply I’ve had an epiphany…a conversation with a sexual health doctor… and I’ve read the 2016 NICE guidelines2 on HIV screening which have convinced me this is a great idea, certainly for my patients and hopefully yours too.

As clinicians we have a responsibility to provide appropriate care to our patients no matter which specialty we are part of. Sometimes for an ED doc that means rushing down the corridor with a patient to the cath lab whilst stuffing ticagrelor down their gob. Sometimes it’s performing the procedural sedation on the ankle dislocation. However, every so often it’s putting our holistic public health doctor hat on and thinking about screening.

It’s not like screening for disease isn’t part of our job. We screen for alcohol misuse and smoking, don’t we? We screen for dementia now so why not screen for a transmissible infection that could be passed onto someone else without appropriate treatment? This type of screening becomes all the easier to do when there’s a national guideline explaining exactly why, what, where and how we should be doing this.

Can’t we just leave it to the GU docs?

At my place we see a lot of HIV and a lot of HIV related illness in spite of the use of HAART3. We’re lucky to have a great sexual health set-up with multiple sites all over the city both centrally and in the burbs. The clinics are great and provide a one stop shop for sexual health problems but…in spite of the amazing people who work there people on the whole don’t like to be seen at GUM clinics. We know some groups are better than others at going; MSM are generally clued up about

sexual health and there are lots of services dedicated to them. However In Virchester we have a high proportion of BME residents as well as homeless, IV drug users and street workers. These groups may not attend traditional services because of either cultural reasons or a chaotic lifestyle so other places for opportunistic screening in these groups are needed. Following the revelation that not everyone who has sex goes to a sexual health clinic, NICE produced a guideline (NG60) whose aim was to increase uptake of HIV testing amongst people who are as yet undiagnosed. This 2016 guideline updated some previous work that was available and takes from the 2008 (yes 2008!) British HIV Association guidelines4 on HIV testing (note the BHIVA guidelines are currently being revised).

It’s pretty topical this week (it’s National HIV testing week)5

This week the Evening Standard had a story about Kings College hospital6 making 32 new diagnoses of HIV in their emergency department in people who didn’t suspect they had it. This is great news for the 32 patients who can now go onto treatment and live a healthier life because of it. No clearly that’s not evidence.. it’s just a newspaper story but there has been lots of work done looking at HIV screening and its benefits. Work published in NEJM suggested screening when part of general medical care can not only be cost-effective when compared to other screening programmes but also reduces the propagation of HIV.7 Although this work came out of the US, NICE’s own evidence review also found it cost-effective.8 More recently there was some work presented at own own RCEM scientific conference last year which showed following that introduction of HIV screening at Guys and St Thomas’ ED, they picked up 172 cases  (either new or lost to follow up) over the year.9 They also found the had a reduction in HIV admissions by 15%. But even more surprising (or perhaps unsurprising when we think about it) is that 54% of the new diagnoses had been previously seen in their ED. This delay in diagnosis could have life changing consequences for not just the patient in front of you but their partners who were unaware or their unborn child.

So what’s in the guideline then?

There’s a lot of information in NICE guidelines as you would expect (some for GP practices some for commissioners etc) but the bit that were interested in can be found in sections 1.1.5- 1.17.

Essentially, the guideline talks about general HIV testing with the UK and then divides the screening you need to perform based on the local prevalence. If you’re not sure what your local prevalence is here’s a link to a really good website with all the local data so you can find your own areas.10 (it might make for a good QIP)

What every hospital should do

In all areas (and I think this means any prevalence rate in the UK), offer and recommend HIV testing on admission to hospital, including emergency departments, to everyone who has not previously been diagnosed with HIV and who:

  • has symptoms that may indicate HIV or HIV is part of the differential diagnosis
  • is known to be from a country11 or group with a high rate of HIV
  • if male, discloses that they have sex with men, or is known to have sex with men, and has not had an HIV test in the previous year
  • is a transwoman who has sex with men and has not had an HIV test in the previous year
  • reports sexual contact (either abroad or in the UK) with someone from a country with a high rate of HIV
  • discloses high-risk sexual practices, for example the practice known as ‘chemsex’12
  • is diagnosed with, or requests testing for, a sexually transmitted infection
  • reports a history of injecting drug use
  • discloses that they are the sexual partner of someone known to be HIV positive, or of someone at high risk of HIV (for example, female sexual contacts of men who have sex with men

This seems pretty sensible advice. Focusing screening on higher risk groups seems to make sense in lower prevalence areas. As with all NICE guidelines ultimately this has to be cost effective screening for your local health economy else it wouldn’t be recommended.

What about those hospitals in areas with higher prevalence?

Interestingly when the local prevalence rates start climbing (and my local prevalence is extremely high), the cost effectiveness of a different screening strategy means the indications for screening change. This all depends on whether you work in a “high” or an “extremely high” prevalence rate area. NICE define a high prevalence as over 2 per 1000. It defines an extremely high prevalence as over 5 per 1000 population (as I’ve said previously you can find your local prevalence rates here)

So what if I work in a high prevalence area?

NICE recommend offering HIV testing on admission to hospital (which includes emergency departments) to everyone who has not previously been diagnosed with HIV and who is undergoing blood tests for another reason. This seems doable. An extra bottle when taking blood. An extra couple of seconds of time. I guess one of the things you need to consider though is how will the results be managed but there’s some helpful guidance on this from our College13.

What if you’re in an extremely high prevalence area?

You need to do everything the high prevalence area does but it also goes onto to say that anyone in an extremely high prevalence area should be offered an HIV test (even if blood would not necessarily be taken).This seems less doable. Screening 100k plus patients a year is a lot of extra time, would need extra staff and equipment and probably is not implementable without extra resources IMO. There is also the follow-up of all these patients that you must consider. Luckily I have a very proactive sexual health team who is willing to follow up all the positive and negative test results from the ED so that’s one less thing to worry about and if you’re looking to introduce this I would strongly advise you to get help from them. Some places may only follow up the positive test results and use a “no news is good news” approach. I’m less comfortable with this approach as people may assume they are negative but may have simply had their results lost or may not have even been tested so this approach could inadvertently put others at risk.

Ok we’re thinking about testing our patients… do I need to counsel them?

As with all tests you need to explain the reason you’re doing it and explain to the patient the benefit of knowing their HIV status. Clearly no one should be compelled to having a test and should be able to opt out. There is always concern about the need for formal pre-test counselling, however for about 10 years now the advice both from BHIVA and the Department of Health has been that formal counselling for HIV testing is not required. We need to think about HIV testing in the same way we think about pregnancy testing. 

So in summary

I think these guidelines make a lot of sense.

A step wise approach to HIV screening in hospitals depending on local prevalence rates.

Embedding HIV screening as a routine part of ED practice may help reduce the stigma associated with testing for the disease.

We have a captured audience in the emergency department and are the perfect place for public health initiatives like this.

It makes sense because we take blood for lots of things we don’t need (coagulation screen anyone?). Taking a bottle for something we do need is obvious and logical.. I mean, I’d like to know my HIV status far more than I would my PT any day.

I know we’re busy and at a time when we’re stretched, asking us to do more and more is probably the last thing a ED clinician wants to hear but if we really think about it.. when we realise it is just one extra bottle of blood, your patients might just that you for saving their life.

Gareth @drgarethroberts

Remember it’s World AIDS Day 1st Dec 2017

Before you go please don’t forget to…

References

1.
Pneumocystis Pneumonia. Radiopaedia Pneumocystis Pneumonia. https://radiopaedia.org/articles/pneumocystis-pneumonia. Published 2017. Accessed November 22, 2017.
2.
HIV testing: increasing uptake among people who may have undiagnosed HIV. National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/ng60. Published December 2016. Accessed November 22, 2017.
3.
Waters L, N Ahmed N, Angus B et al. British HIV Association guidelines for the treatment of  HIV-1-positive adults with antiretroviral therapy 2015 (2016 interim update). British HIV Association. http://www.bhiva.org/documents/Guidelines/Treatment/2016/treatment-guidelines-2016-interim-update.pdf. Published August 2016. Accessed November 22, 2017.
4.
UK National Guidelines for HIV Testing 2008 UK National Guidelines. British HIV Association. http://www.bhiva.org/documents/Guidelines/Testing/GlinesHIVTest08.pdf. Published September 2008. Accessed November 22, 2017.
5.
NationalHIV Testing Week. HIV Prevention England. https://www.hivpreventionengland.org.uk/campaigns/national-hiv-testing-week/. Published 2017. Accessed November 22, 2017.
6.
Lydall R. Routine check at London King’s College Hospital A&E finds 32 people who did not know they had HIV. London Evening Standard. https://www.standard.co.uk/news/health/random-check-at-london-kings-college-hospital-ae-finds-32-people-who-did-not-know-they-had-hiv-a3695921.html.
7.
Sanders G., Bayoumi AM, Vandana Sundaram MP. Cost-Effectiveness of Screening for HIV in the Era of Highly Active Antiretroviral Therapy. The New England Journal of Medicine. http://www.nejm.org/doi/full/10.1056/NEJMsa042657#t=article. Published February 10, 2005. Accessed November 22, 2017.
8.
Carmona C, O’Rourke D, Robinson S. HIV testing: increasing  uptake among people  who may have  undiagnosed HIV. HIV testing: increasing  uptake among people  who may have  undiagnosed HIV. https://www.nice.org.uk/guidance/ng60/evidence/evidence-review-1c-the-most-effective-ways-to-increase-the-uptake-of-hiv-testing-to-reduce-undiagnosed-hiv-among-people-who-may-have-been-exposed-to-it-ng60-pdf-2727984064. Published February 2015. Accessed December 22, 2017.
9.
Hunter L, Rial CL, Larbalestier N, Paperello J. Routine HIV Testing in an Inner City  Emergency Department. Royal College of Emergency Medicine Annual Scientific Conference. https://www.rcem.ac.uk/docs/Annual%20Scientific%20Conference%202016%20Presentations/Routine%20HIV%20Testing%20in%20an%20Inner%20City%20Emergency%20Department%20.pdf. Published 2016. Accessed November 22, 2017.
10.
Sexual and Reproductive Health Profiles. Public Health England. http://fingertips.phe.org.uk/profile/sexualhealth/data. Published 2016. Accessed November 23, 2017.
11.
The World Factbook: Adult HIV prevelance rates. Central Intelligence Agency. https://www.cia.gov/library/publications/the-world-factbook/rankorder/2155rank.html. Published 2016. Accessed November 23, 2017.
12.
Baombe J. All you need to know about CHEMSEX… but never dared to ask. StEmlynsblog. http://stemlynsblog.org/chemsex/. Published December 12, 2015. Accessed November 22, 2017.
13.
Management of Investigation  Results in the Emergency  Department. The Royal College of Emergency Medicine Best Practice Guideline. http://www.rcem.ac.uk/docs/RCEM%20Guidance/Management%20of%20investigation%20results%20in%20the%20ED%20-%20updated%20Jul%202017.pdf. Published July 2017. Accessed November 23, 2017.

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