Initiatives for earlier HIV diagnosis: opt-out ER and home testing

24 April 2017. Related: Conference reports, HIV prevention and transmission, BHIVA 23rd Liverpool 2017.

Simon Collins, HIV i-Base

Several studies presented important and sobering results about HIV testing.

Sarah Parry reported on the importance of routinely moving to opt-out testing for blood borne viruses (HIV, HBV and HCV) for people accessing the emergency department the Royal London Hospital, a high prevalence setting. [1]

From November 2015 to August 2016, more than 6,200/24,900 attendees were tested (25% uptake), of which 257 (4.1%) were positive for one virus and 15 people had coinfection. Of these, 86 people (33%) required linkage to care (n=16 HIV, 26 HBV and 44 HCV) as either new diagnoses (n=10, 7 and 13 respectively) or in people who were disengaged from care (n=5, 11 and 17 respectively). Data was not available for all patients. See Table 1.

A high proportion of linkage patients (29%, 25/86) had advanced disease (CD4 <350, APRI >1 or FibroScan F3/4) including five people with AIDS-defining infections and three people with hepatocellular carcinoma (HCC).

Engagement in care was easiest for HIV and most difficult for HCV (where 11% of cases were in people without permanent housing).

Unfortunately, there were seven deaths, five or which were directly BBV-related.

A second study on opt-out HIV testing in an ER setting was also presented by Hannah Alexander from King’s College Hospital.

This included almost 50% uptake during the first 31 weeks from August 2016 (more than 12,600 HIV tests out of >25,600 people overall). Of these, 102 were HIV positive, with 19/102 being new diagnoses, 77/102 were known positive, with 5/77 having disengaged from care and 6/102 were not traceable.

Of the new diagnoses, 18/19 are now engaged in care. Mean CD4 count was 233 cells/mm3 (range 13 to 738) including six people with AIDS-defining illnesses (toxoplasmosis, 3; cryptococcal meningitis, 1 and PCP, 2) and two people were in seroconversion.

Notably, HIV had been considered as a differential diagnosis in only 2 cases.

By comparison, over the same period, 15 people were newly diagnosed at the sexual health clinic for the same hospital (out of almost 6000 tests). People diagnosed in the ER setting were more likely to have lower CD4 count (mean 233 vs 522 cells/mm3) and less likely to be gay men (4/19 vs 9/15).

Results from a home testing programme were reported by Michael Brady from the Terrence Higgins Trust. [3]

During a six-week pilot study from June to August 2016, almost 5,000 home tests (Biosure) were sent out, with results reported by just over 3,000 people (62%) – despite two text message prompts. Most tests (98%) went to men, 99% of whom identified as gay, with 96 tests requested by cis women, with 16 requests from trans women and 6 from trans men. Only 168 people (3.4%) were Black African and 91% were from urban settings (ie where access to GUM testing would be easier).

Most test requests were generated in response to social media marketing (34% from Grindr, 34% from Facebook, 24% of other and 7% from the THT website) – with 85% accessed by a mobile phone.

Of the 25 new HIV diagnoses reported (0.5%), one was a false-positive. Of the remaining 24 with positive results (all gay men), contact was made with 22 (92%) to confirm access to care.

Of the approximately 600 people completed an evaluation survey (12%), satisfaction was high, with 98% saying they would use the service again.

Comment

NICE guidance recommends routine testing when prevalence is greater than 0.5% (>2 to 5 per 1000) and is clearly warranted in many urban ER settings.

The high rates of undiagnosed and late-stage infections is clearly upsetting, given the UK has both free testing and treatment.

Home HIV testing appears to be very acceptable for some people. A new national self-testing study called SELPHI, with funding to distribute 10,000 tests is just starting. [4]

References:

1. Parry S et al. Routine blood-borne virus testing for HIV, hepatitis B and hepatitis C in the emergency department: the ‘new normal’? 23rd BHIVA 4-7 April 2017, Liverpool. Oral abstract O8.
   http://www.bhiva.org/documents/Conferences/2017Liverpool/Presentations/170406/SarahParry.pdf (PDF)
   http://www.bhiva.org/170406SarahParry.aspx (webcast)
2. Alexander H et al. HIV testing in a London emergency department: the first 21 weeks. 23rd BHIVA 4-7 April 2017, Liverpool. Oral abstract O9.
   http://www.bhiva.org/documents/Conferences/2017Liverpool/Presentations/170406/HannahAlexander.pdf (PDF)
   http://www.bhiva.org/170406HannahAlexander.aspx (webcast)
3. Brady M. HIV self-testing: feasibility and acceptability of a large scale national service. 23rd BHIVA 4-7 April 2017, Liverpool. Oral abstract O7.
   http://www.bhiva.org/documents/Conferences/2017Liverpool/Presentations/170406/MichaelBrady.pdf (PDF)
   http://www.bhiva.org/170406MichaelBrady.aspx (webcast)
4. SELPHI – A study of free self-tests for HIV in England & Wales.
   http://www.selphi.org