EXECUTIVE SUMMARY
Researchers at Johns Hopkins Medicine discovered that EDs may need to be leveraged in different ways to effectively bring the HIV epidemic to heel. In particular, investigators say there is a need for EDs to not just perform routine testing for HIV, but also take more ownership of the counseling and treatment aspects of care. Further, investigators state that EDs can be pivotal in providing HIV testing and treatment to young men, a critical population that is much less likely to be diagnosed or virally suppressed. Further, while this research was conducted in South Africa, investigators state that many of their findings are applicable worldwide.
• Working with colleagues in three EDs in South Africa, investigators found that efforts there are falling well short of UNAIDS 2020 90/90/90 goal.
• Between June 2017 and July 2018, researchers tested 2,901 patients aged 18 to 70 years, finding that more than 800 tested positive for HIV.
• While the prevalence of HIV in women (35.3%) was much higher than in men (20.7%) who were tested, researchers found that men were twice as likely to be unaware of their HIV status and unlikely to be on antiretroviral therapy or virally suppressed.
• While many U.S. hospitals in urban areas have initiated HIV testing programs in their EDs, experts note that HIV is not just a disease of high-density, urban populations. Consequently, there are communities at risk for the disease that are missed.
Researchers from Johns Hopkins Medicine recently concluded that EDs may well be pivotal in slowing the spread of HIV infections. However, additional steps are needed to fully leverage this opportunity. Their research is presented as a follow-up to an earlier study of ED patients in South Africa that demonstrated HIV testing in EDs is an effective way to find and diagnose hard-to-reach populations with HIV.1
For the new study, researchers worked with colleagues in three EDs in the Eastern Cape province of South Africa, an area known for its high prevalence of HIV infections. What they found is that efforts there are falling well short of the UNAIDS 90/90/90 goals: 90% of patients with HIV aware of their diagnosis, 90% of these individuals on antiretroviral therapy (ART), and 90% of all people on ART to exhibit undetectable levels of the virus in their blood so that they cannot transmit HIV to others, all by 2020.
Between June 2017 and July 2018, researchers tested 2,901 patients aged 18 to 70 years, 800 of whom tested positive for HIV. Of these, 28.9% were newly diagnosed. Further, while the prevalence of HIV in women (35.3%) was much higher than in men (20.7%) who were tested, researchers found that men were twice as likely to be unaware of their HIV status and unlikely to be on ART or virally suppressed.2
While the study was conducted in South Africa, investigators noted the information is relevant to health systems around the world. For example, ending the HIV epidemic has been announced as a goal by the U.S. Department of Health and Human Services (HHS).3 One of the key messages coming out of this study is that EDs need to be much more involved in not only testing for HIV, but also counseling and treatment aspects of care to make the desired progress. To date, that is not the primary model for HIV testing and care practiced in U.S. EDs.
Researchers reported that despite considerable investment toward addressing the HIV epidemic in South Africa, the country is not even close to meeting 90/90/90 goals. From their work in EDs in the region, researchers concluded that the reason for this failure is efforts to address the epidemic are missing a critical population: young men, explains Bhakti Hansoti, MBChB, PhD, MPH, FACEP, an associate professor of emergency medicine at the Johns Hopkins University School of Medicine and the study’s lead author.
“Young men were significantly less likely to be engaged in care and significantly less likely to be virally suppressed,” Hansoti reports. “What we also found is that the HIV incidence in this population was significantly higher than what is reported.”
How does this finding carry over to U.S. EDs and elsewhere? Hansoti says that it is generally accepted worldwide that young men are less likely to engage with the healthcare system. “Existing HIV testing programs really focus on pregnant women or patients who are already engaged with the healthcare system,” she says. “This young male population that does not engage is being missed.”
The reason why EDs are so pivotal in reaching this population is they present the best chance for identifying and interacting with this hard-to-reach population, Hansoti observes. “This is the one time these patients are likely to interact [with healthcare providers],” she explains. “We are concerned that this population in particular is less inclined to go and seek out the treatment that they need [in outpatient settings]. The burden of responsibility needs to fall on the ED.”
Furthermore, investigators note that merely testing such patients for HIV in the ED is not enough. “Testing is only part of the package. Testing without treatment is not very useful,” Hansoti shares. Instead, she stresses EDs need to play an active role in treatment initiation, follow-up case management, and linking these patients to care outside the ED.
Richard Rothman, MD, PhD, vice chair of research in the department of emergency medicine and a professor of emergency medicine at Johns Hopkins, notes there has been considerable progress in recent years in the United States regarding how EDs are making a difference on HIV testing and what he calls the linkage-to-care cascade.
“With recommendations by the CDC as well as other various societies, including the ACEP, many EDs, particularly in urban, high-prevalence locations, have recognized the role they can play in helping to curb different aspects of the epidemic,” he says.
For instance, EDs in several large, academic medical centers have initiated programs through which patients are screened routinely for HIV, regardless of why they presented for care. Patients who test positive for HIV are quickly linked to care at specialized clinics that can start patients on ART and provide ongoing care and treatment.
“Most EDs that have [HIV testing] programs in place have that ability to link people into care pretty quickly,” Rothman shares. “I think one of the reasons why [the rapid initiation of ART] is being heavily advocated is because even though we give people these referrals and think people are going to get into care pretty quickly, there are often logistical delays that end up happening.”
Rothman notes there can be transportation, insurance, or other hurdles that patients struggle to navigate. To address these challenges, there is some research into the feasibility of executing a rapid start on ART from the ED, but Rothman notes such a model comes with its own challenges.
“It is not that simple because emergency physicians aren’t always used to starting people on this therapy. They are not very comfortable with that overall,” he explains. “Ultimately, that may be a model that works in the U.S., but we are not quite there. I think the things that need to happen are primarily educating the physicians about it, making the process as simple as possible, and then assuring ... that there is a good, warm handoff [to an outpatient provider for continued care].”
Hansoti agrees that, theoretically, it makes sense in the United States that that providers from an HIV treatment clinic would start a patient identified with HIV in the ED on ART because they have the time to provide this care without competing priorities.
“However, one of the challenges of that kind of model is that it can give ED providers the idea that it is not their problem. They did their bit by testing, and now off the patient goes,” she says. “What may be a stronger model is if the ED itself takes a little bit more ownership.”
Rather than just pass these patients on, Hansoti would like to see ED providers provide a stronger bridge leading patients into the clinic system.
“What happens in the ED is the patient comes in with their acute illness and they build a relationship or bond with that initial provider,” she says. “Then, if that initial provider also is able to tell them about their HIV diagnosis and counsels them somewhat on the need for ART, that trust is built. Then, there is that bridge to the clinic-based intervention.” Under current CDC guidelines, routine screening in the ED is not recommended if the prevalence of HIV in the population is less than 0.1%. That is why such testing in the United States is more likely to be taking place in EDs located in larger urban centers.
“The issue with that is that many places don’t even know what their prevalence [of HIV] is,” Rothman observes. “Many places that think their disease prevalence is low start doing testing, and then find out it is higher than they anticipated.”
Rothman stresses that HIV is not just a disease of high-density, urban populations. “There are important areas of the country where there are communities at risk and people are contracting HIV, and local sub-epidemics are occurring,” he explains. “They get missed for a while until testing gets initiated, and the local communities become more aware of the fact that the disease has no particular geographic prevalence.”
Hansoti sees a parallel with the opioid epidemic in this regard. “What we have learned from the opioid epidemic is that it is not an urban or a rural problem. It is an everywhere problem,” she says. “Every ED has a role in identifying patients at risk of an overdose and either linking them into care or, at the very least, providing them with naloxone.”
Similarly, with HIV, it is not that urban areas have a higher prevalence of disease; rather, the prevalence in areas that have not implemented routine testing is unclear, Hansoti notes.
“If we were to integrate the need for HIV screening as part of routine ED processes across the country, I think you would be surprised at how many people have been missed,” she offers. The types of patients who come to EDs in both urban and rural areas are all engaging in unanticipated interactions with the healthcare system either because of trauma or an acute illness or injury, Hansoti explains.
“These patients are generally at higher risk of mental health problems, substance use problems, and other health disparities and vulnerabilities,” she says. “That is true in the rural setting as it is true in the urban setting.”
Further, whether one is talking about the opioid epidemic or the HIV epidemic, the ED is set up to play a critical role, Hansoti stresses.
Hansoti and colleagues intend to study ways to make ED-based HIV testing more mainstream, and to address the challenges involved with linkage to care. This is partly in response to the observation that add-on programs funded by external agencies tend not to be sustainable.
“The funding runs out, the program becomes de-prioritized, and the provider institutions often don’t take ownership of the interventions,” she laments.
As part of this work, one idea Hansoti plans to explore is the potential of using rapid “INSTI” tests for HIV during the triage process. (Editor’s Note: Learn more about this test at: http://bit.ly/2BKROgt.) The tests, completed with just a finger prick, can deliver results within two minutes, making it relatively easy to integrate testing within the regular workflow of a busy ED, she explains.
Hansoti also wants to investigate the utility of using peer mentors during ED visits as a way to deliver education about the disease and to address the significant stigma investigators have observed regarding HIV testing and diagnoses. Further, she is interested in working with stakeholders and institutions to prioritize the availability of resources for testing and systems that can quickly tell emergency providers where a person lives, where the closest treatment provider is, and whether the person has engaged in treatment. Hansoti wants to make it easy for frontline providers to access this information quickly.
Rothman applauds HHS’s efforts to prioritize ending the HIV epidemic, but he observes that these plans have not yet been matched with the needed support required to reach the intended goal.
“Emergency departments are really a critical venue in terms of identifying many of the unrecognized patients as well as getting people on therapy who need to be on therapy. EDs are currently constrained by the relative lack of resources to basically meet the [90/90/90] targets,” he explains. “There are a lot of competing priorities in terms of what we are trying to do in taking care of the chief problems that patients present with as well as many of the chronic disease problems that patients have. I believe that emergency physicians are generally very engaged in trying to provide the best care on both ends of the spectrum.”
Further, Rothman stresses that EDs cannot be the only ones trying to figure out how to improve approaches for identifying patients with HIV and placing them into treatment. “It really has to be a whole health system approach,” he says. “To really make the change, a particular health system or hospital has to realize [it] wants to play a part. Then, engage many of the key stakeholders in trying to figure out how to put systems in place to advance testing and linkage [to care].”
REFERENCES
- Hansoti B, Stead D, Parrish P, et al. HIV testing in a South African emergency department: A missed opportunity. PLoS One 2018;13:e0193858.
- Hansoti B, Mwinnyaa G, Hahn E, et al. Targeting the HIV epidemic in South Africa: The need for testing and linkage to care in emergency departments. Lancet 2019. Available at: http://bit.ly/331ivcC. Accessed Oct. 25, 2019.
- Centers for Disease Control and Prevention. Ending the HIV Epidemic: A Plan for America. Available at: http://bit.ly/369OjOK. Accessed Oct. 25, 2019.
Investigators say there is a need for EDs to not just perform routine testing for HIV, but also take more ownership of the counseling and treatment aspects of care.
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