۱- Background

۲- Methods

۳- Results

۴- Discussion

۵- Conclusion

References

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 the 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 cross-sectional 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 the presence of antiretroviral therapy (ART) and the presence of viral suppression (≤ ۱۰۰۰ copies/ml). HIV incidence was estimated using a multi-assay algorithm, validated for a subtype C epidemic.
Findings
Of the 2901 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.
Interpretation
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. Furthermore, despite developing an optimal testing environment, we were only able to enrol a small sub-set of the ED population. Given the high HIV prevalence and high attrition in the ED population, HIV services in the ED should also develop strategies that can accommodate large testing volumes and ART initiation.

Background

In recent years, significant strides have been made to develop and implement innovative strategies to improve the HIV care cascade, which refers to the percentage of people in a population that know their HIV status, are on antiretroviral therapy (ART), and are virally suppressed [1]. Compelling evidence from clinical and population studies supports HIV treatment as prevention [2]. Global increases in ART use have been shown to prevent viral transmission via the reduction in viral loads after the initiation of ART [3]. Furthermore, in the treatment as prevention paradigm, populationlevel viral suppression is strongly associated with decreases in HIV incidence [4]. Countries, such as South Africa, that shoulder the highest burden of HIV infection in the world, have implemented universal prevention, testing, and treatment policies to help curb the epidemic [5]. However, in Southern Africa, an estimated 86% of people living with HIV know their status, 61% are accessing ART, and only 47% are virally suppressed [6]. Despite sustained efforts for over two decades, critical coverage gaps remain. The Emergency Department (ED) in particular, is a key clinical venue where patients missed by current HIV testing and treatment programs can be accessed. It is well established that ED populations have a higher prevalence of HIV infection (both in the US and in low- and middleincome countries [LMICs]) than in the local community and other clinic-based facilities [7].