Should routine HIV testing be performed in the ED?

Yasmin Sultan 2012

HIV prevalence in East Anglia

Cambridge

East Cambs PCT

Kings Lynn

Bedford Luton St Edmundsbury

HIV prevalence per 1000 (15-59 years)

1.25 0.66 0.65 1.9 4.9 0.68

Type II diabetes prevalence /1000 (40-70 years)

3.4% over whole of East Anglia

HIV prevalence map

Number of new HIV cases per year

2008 BASHH Guideline

Recommends expanded screening in areas where prevalence >2 per 1000.

Advises screen all GP registrations and medical admissions.

In 2009, this applied to 37 PCTs , 28 of which were in London.

DOH pilot study in 2009/10 ran 10,000 tests (cost £10 each). Found 50 new cases (all high prevalence areas).

USA evidence for HIV testing Numerous studies in inner city EDs

(Denver, Boston). Cost effectiveness threshold 1 per 1000. Much higher prevalence: 2-17% (0.3%

nationally – vs UK, 0.14%). Health-seeking behaviour different. Patient demographic different. Less access to alternative primary care (vs

UK GP screening). Infrastructure and tradition of routine

screening in USA.

Resources required for screening: Types of HIV test

Lab tests▪ Who would run them? (No 24 hour virology service).▪ If run by Blood Services, staff training, test validation,

machine time.▪ Need to be run next day in batches to decrease cost.▪ All positives require sending to reference lab for serial testing.▪ Minimum cost £10.00 per test.▪ Results will take about 1 week.▪ Issues re follow-up and losses to follow-up

Near-patient testing kits▪ Miss p24 antigen so less accurate▪ Specificity lower so get 6 false positives per 7 tests done▪ Cost was £12.00 in 2006▪ Needs an HCA to run test – takes about 15 minutes per test.▪ Not recommended by BASHH for use as screening test.

Resources required: staff

Counselling required for opt-in testing.

Counselling required if test is positive.

Robust follow-up systems must be in place so that test positives can be recalled.

If using near patient testing, will need 24 hour HCA to run the tests.

Resources required: time & space

4 hour target – one more thing to squeeze in

May encourage bleeding of more patients (especially if target-driven).

May increase attendances if patients start to perceive EDs as the place to go for an HIV test.

Cost benefit analysis

How many new cases would we pick up? Difficult to assess. In last 6 years, WSH

Microbiologist has found 2 “unexpected” cases.

How many tests might we run? We bleed average 100 pts/day

Cost per test: Minimum £10.00 per (negative) test.

Cost per new HIV case detected?

Alternatives to ED screening

Screening in general practice – in UK chronic disease is managed very effectively in this setting.

Education of hospital doctors re conditions that should trigger testing

In summary

Prevalence not high enough to justify screening in most parts of UK.

Screening cost very high per case diagnosed. Who is going to pay for this?

Logistically difficult to manage follow-up in ED (but easy in General Practice).

Limited resources – more cost effective to screen for diabetes, or chlamydia, or domestic violence.

Need to ask what service EDs should be, and want to be, providing.