hiv antibody seroprevalence in the emergency department at port moresby general hospital, papua new...

Emergency Medicine Australasia

(2005)

17

359ndash362

Blackwell Science LtdOxford UKEMMEmergency Medicine Australasia1035-68512005 Blackwell Publishing Asia Pty Ltd 2005174359362Original Article

HIVAIDS in the ED at Port Moresby GH PNGC Curry

et al

Correspondence Dr Chris Curry Fremantle Hospital Alma Street Fremantle WA 6160 Australia

Email chriscurry1compuservecom

Chris Curry FACEM Emergency Physician Visiting Professor in Emergency Medicine Paul Bunungam MB BS Medical Officer Carolyn

Annerud FACEP Assistant Clinical Professor in Emergency Medicine Diro Babona MB BS Director of Serology Laboratory

O

RIGINAL

R

ESEARCH

HIV antibody seroprevalence in the emergency department at Port Moresby General Hospital Papua New Guinea

Chris Curry

13

Paul Bunungam

4

Carolyn Annerud

23

and Diro Babona

5

1

Fremantle Hospital Fremantle Western Australia Australia

2

John A Burns School of Medicines University of Hawaii Hawaii USA

3

School of Medicine and Health Sciences University of Papua New Guinea

4

Emergency Department and

5

Serology Laboratory Port Moresby General Hospital Port Moresby Papua

New Guinea

Abstract

Objective

To determine the prevalence of HIV antibody in patients presenting to the ED at PortMoresby General Hospital in Papua New Guinea

Method

Three hundred patients in whom blood samples were taken for investigation of illness orinjury between April and July 2003 were surveyed for HIV antibodies Sex age andpresenting illness were recorded

Results

Fifty-four tests (18 95 confidence interval [CI] 14ndash23) were positive Forty-sevenper cent were men and 53 were women The most common presenting illnesses wererespiratory tract infections (37) and gastrointestinal tract infections (26) Because ofresource constraints results were not linked to patients and there was no follow up

Conclusion

These limited data support the prediction that the developing HIVAIDS epidemic inPapua New Guinea will be serious

Key words

emergency medicine

epidemic

HIV

AIDS

Papua New Guinea

public health

Introduction

There is widening concern at the increasing transmis-sion of HIV in Papua New Guinea (PNG) The problemwas highlighted in a major study by the AustralianAgency for International Development AusAID in2002 entitled lsquoPotential economic impacts of an HIV

AIDS epidemic in Papua New Guinearsquo

1

Althoughacknowledging the paucity of information includingthe underestimation of numbers involved the reportconcluded that PNG is poised on the brink of a seriousepidemic Data available from surveillance at PortMoresby General Hospital (PMGH) Port MoresbyPapua New Guinea of blood donors attenders at the

C Curry

et al

360

sexually transmitted infections (STI) clinic and womenin antenatal care indicate low but rapidly increasingnumbers

2

During 1998ndash1999 the prevalence in blooddonors and in patients attending the STI clinic morethan doubled from 009 to 025 and from 3 to 7respectively Prevalence in women attending the ante-natal clinic doubled in the same period to 035

The prevalence of HIV among patients admitted toPMGH the tertiary referral teaching hospital for PNGis not known although the hospital identifies most newcases The high coexistence of HIV with tuberculosis(TB) is recognized but expenditure of limited resourceson testing patients admitted with TB is difficult to jus-tify in the absence of antiretroviral therapy

3

HIV anti-body (HIV Ab) testing is not undertaken for many sickand dying patients at PMGH

In the ED at PMGH there is no reliable registrationof patients and records are not kept The number ofpatients presenting to the ED and the number managedand discharged by the ED are not known Our estimateis that the ED might see 30 000 patients per year Mostof the workload is a result of infectious diseasesTrauma is a relatively small part The prevalence ofprimary conditions at handovers during the period ofthe present study were malaria 26 respiratory dis-eases 26 gastroenteritis dysentery typhoid 13trauma from falls vehicles knives 4 assault anddomestic violence 3 snakebite 2 (C Curry and CAnnerud unpubl data)

Doctors working in the ED have observed an increas-ing number of patients presenting with severe illnessesthat could be associated with HIVAIDS in particularrespiratory tract infections and diarrhoea This impres-sion has serious implications for staff in the ED becauseof the potential for needle-stick injuries Constraints onresources and supply mean that the ED does not prac-tise universal precautions indeed at times there werenot even gloves available Contemporary antiretroviraldrugs for post-exposure prophylaxis were not availableBeyond the ED there are major implications for thehospital and the broader community Because a signif-icant number of patients are managed by the ED andare discharged without a formal hospital admissionED-specific information on the prevalence of HIV infec-tion is required

Objective

To determine the prevalence of HIV infection in patientspresenting to the ED at Port Moresby General Hospital

Method

An anonymous survey for HIV Ab serology was under-taken in patients who required venepuncture for inves-tigation of illness or injury in the ED at PMGH betweenApril and July 2003 Three hundred patients were testedAlthough this was a convenience sample determined byavailable resources it has significant power The previ-ously reported prevalence of HIV in the STI clinic atPMGH was 7 A sample of 300 has 85 power (like-lihood) for detecting a real prevalence that is 5 greaterthan this baseline that is a prevalence of 12Approval was given by the Hospital administration andby the Research Committee of the School of Medicineand Health Sciences University of Papua New GuineaPort Moresby Papua New Guinea Samples were takenon an opportunistic basis by a range of staff whensample bottles were available Sex age and illness datawere collected on a proforma sheet by the attending staffwhen each specimen was taken HIV antibody wastested for in the serology laboratory at the Central PublicHealth Laboratory Port Moresby Papua New GuineaScreening was done using the Serodia test by FujirebioDiagnostics Tokyo Japan All repeatedly reactive sam-ples were then retested with two more different assaysCapillus from Trinity Biotech Bray Ireland and Deter-mine from Abbotts Laboratories Tokyo Japan If thesamples were repeatedly reactive in all three differentassays then it was confirmed positive This is a WorldHealth Organization (WHO)-approved HIV testing algo-rithm If any of the tests were negative the result wasreported as negative consistent with WHO practice toavoid the reporting of false positives

There was no linking of results to patients and there-fore there was no follow up of positive results

Results

Of 300 blood samples tested for HIV Ab 54 (18 95CI 14ndash23) were repeat reactive positive and 246 werenegative Ten of the latter had one or more tests positivebut at least one negative test

Sex

The sex distribution of the sample was 53 men and47 women Sex was recorded for 47 of the 54 HIV Ab-positive patients of whom 22 (47) were male and 25(53) were female

HIVAIDS in the ED at Port Moresby GH PNG

361

Age

An age or an estimate of age by patient or investigatorwas recorded for 212 of the 300 patients The age rangefor HIV Ab-positive serology was 18ndash60 years A break-down of results according to age group is provided inTable 1 The proportions that were positive for agegroups do not show statistically significant differences(

c

2

-statistic 1093

P

-value 0053)

Presenting illness

Of the 54 HIV Ab-positive patients 20 (37) had pre-sented with a respiratory tract infection most fre-quently pulmonary TB Fourteen (26) had presentedwith diarrhoea andor oral thrush and four (7) withheadache confusion or muscle weakness

Discussion

This is the first HIV prevalence survey of patients in aPNG ED It is a small study that points towards a majorthreat to the health and economic status of PNGBecause of severely limited resources including aninability to provide antiretroviral treatment or to followup discharged patients it had to be done without thecontemporary ethical requirements of the rich worldfor pretest counselling patient consent and post-testfollow up

Experienced researchers have predicted that HIVwill spread rapidly in PNG because of the prevalenceof multiple sexual partners sex violence poverty andpoor public understanding of the disease and how itis transmitted

4ndash8

The significance of these factors hasrecently been reviewed by Bates

et al

3

A prevalenceof 18 for HIV Ab in patients having a blood test inthe ED at PMGH is therefore a cause for concern inspite of difficulties in interpreting the data If thenumber presenting to the ED and having a blood test

is 15 000 per year this represents 2700 cases peryear

The present study has substantial limitations Thelimited resources and overcrowding within the PMGHED presented major logistic challenges and so the sim-plest possible investigation strategy was used Even socollection of samples was irregular and unsystematicLogistic difficulties in the supply of specimen bottlesin getting samples to the laboratory and in testing sam-ples impacted on the number that were processed Lim-ited patient information was sought but even thencollection of data was incomplete For many patientsage was unknown and therefore estimated by a memberof staff

Many of the HIV-positive patients presented withillnesses that could be described as AIDS definingThe prevalence of respiratory tract infection and gas-trointestinal tract infection in the ED patient popula-tion is high however and one cannot make theassumption that all these patients will be HIV-positiveFor patients admitted with TB there was a view thatthe prevalence of HIV was so high that testing for itwas not justified Indeed there was a general reluc-tance to undertake HIV testing both in those whoappeared well and in those who had illnesses thatmight be associated with HIV

It is not known to what extent the population pre-senting to the ED at PMGH was representative of thepopulation at large Patients present to hospitals in thelate stages of severe illness leading to high rates of HIVinfection in PMGH ED patients compared with otherpopulations studied Even so a high general populationprevalence of HIV is required to have this impact on theED and our findings are consistent with previousobservations of an annual doubling of HIV prevalence

1

The WHO has warned that 1 million people in PNGcould be affected by HIVAIDS within 10 years

9

Witha population of 55 million there is the potential for theepidemic in PNG to compare with the worst experiencesin Africa An ED prevalence of 18 is consistent with

Table 1

Breakdown of HIV results by age group in the 212 cases for which age was recorded

Age (years) HIV-negative HIV-positive Proportion positive for age group 95 confidence interval (exact)

10ndash19 5 4 044 014ndash079

20ndash29 59 10 014 007ndash025

30ndash39 55 8 013 006ndash023

40ndash49 31 13 029 017ndash045

50ndash59 15 2 012 015ndash036

60ndash69 9 1 010 001ndash044

Total 174 38 018 013ndash024

C Curry

et al

362

these predictions and might indicate that the situationis worse than has been estimated

Conclusion

The prevalence of HIV infection in PMGH ED patientsis high This presents a hazard to staff in the ED wherethere is risk of needle-stick injury overcrowding andinsufficient resources to practise universal precautionsOur findings and those of other investigators indicatethat there is the potential in PNG for an economic andhumanitarian disaster As PNGrsquos nearest and wealthiestneighbour the extent to which Australia responds tothis epidemic will be critical to minimize its impact

Acknowledgements

Thanks to the medical officers in the ED and the tech-nical staff at the Central Public Health Laboratory fortheir involvement and to Associate Professor SimonBrown for assistance with statistics and manuscript

Author contributions

CC was the main author PB was the main researcherCA was the assistant researcher and DB contributedwith laboratory support

Competing interests

There are no conflicts of interest

Accepted 9 January 2005

References

1 Gordon J

Potential Economic Impacts of an HIVAIDS Epidemicin Papua New Guinea

Report for AusAID by the Centre forInternational Economics 2002 Available from URL httpwwwausaidgovaupublicationspdfhivaids_pngpdf[Accessed 25 February 2003]

2 World Health Organization

National AIDS Council and theNational Development of Health 2000

PNG National ConsensusReport on STI HIV and AIDS Epidemiology 2000 Availablefrom URL httpwwwwprowhointdocumentsti_pngdoc[Accessed 25 February 2003]

3 Bates I Fenton C Gruber J

et al

Vulnerability to malaria tuber-culosis and HIVAIDS infection and disease Part 11 determi-nants operating at environmental and institutional level Review

Lancet Infect Dis

2004

4

368ndash74

4 Allen B Can we predict the impact of HIVAIDS in rural Melane-sia and Southeast Asia In Linge G Porter D (eds)

No Place forBorders The HIVAIDS Epidemic and Development in Asia andthe Pacific

Sydney Allen and Unwin 1997 114ndash25

5 Caldwell J

AIDS in Melanesia

AusAID Special Seminar HIVAIDS and Development in Asia and the Pacific CanberraAustralia 2000

6 Dwyer J Lovell-Jones S Editorial the gathering storm that is theHIV epidemic in Papua New Guinea

Aust NZ J Med

1997

27

3ndash5

7 Hide R HIV incidence more serious than we imagined

Science

1998

280

5371

8 Riley I

Lessons from Sexually Transmitted Disease Epidemics

Ausaid Special Seminar HIVAIDS and Development in Asiaand the Pacific Canberra Australia 2000

9

The Weekend Australian

21ndash22 August 2004 Editor Neighbour-hood Port Moresby

C Curry

et al

360

sexually transmitted infections (STI) clinic and womenin antenatal care indicate low but rapidly increasingnumbers

2

During 1998ndash1999 the prevalence in blooddonors and in patients attending the STI clinic morethan doubled from 009 to 025 and from 3 to 7respectively Prevalence in women attending the ante-natal clinic doubled in the same period to 035

The prevalence of HIV among patients admitted toPMGH the tertiary referral teaching hospital for PNGis not known although the hospital identifies most newcases The high coexistence of HIV with tuberculosis(TB) is recognized but expenditure of limited resourceson testing patients admitted with TB is difficult to jus-tify in the absence of antiretroviral therapy

3

HIV anti-body (HIV Ab) testing is not undertaken for many sickand dying patients at PMGH

In the ED at PMGH there is no reliable registrationof patients and records are not kept The number ofpatients presenting to the ED and the number managedand discharged by the ED are not known Our estimateis that the ED might see 30 000 patients per year Mostof the workload is a result of infectious diseasesTrauma is a relatively small part The prevalence ofprimary conditions at handovers during the period ofthe present study were malaria 26 respiratory dis-eases 26 gastroenteritis dysentery typhoid 13trauma from falls vehicles knives 4 assault anddomestic violence 3 snakebite 2 (C Curry and CAnnerud unpubl data)

Doctors working in the ED have observed an increas-ing number of patients presenting with severe illnessesthat could be associated with HIVAIDS in particularrespiratory tract infections and diarrhoea This impres-sion has serious implications for staff in the ED becauseof the potential for needle-stick injuries Constraints onresources and supply mean that the ED does not prac-tise universal precautions indeed at times there werenot even gloves available Contemporary antiretroviraldrugs for post-exposure prophylaxis were not availableBeyond the ED there are major implications for thehospital and the broader community Because a signif-icant number of patients are managed by the ED andare discharged without a formal hospital admissionED-specific information on the prevalence of HIV infec-tion is required

Objective

To determine the prevalence of HIV infection in patientspresenting to the ED at Port Moresby General Hospital

Method

An anonymous survey for HIV Ab serology was under-taken in patients who required venepuncture for inves-tigation of illness or injury in the ED at PMGH betweenApril and July 2003 Three hundred patients were testedAlthough this was a convenience sample determined byavailable resources it has significant power The previ-ously reported prevalence of HIV in the STI clinic atPMGH was 7 A sample of 300 has 85 power (like-lihood) for detecting a real prevalence that is 5 greaterthan this baseline that is a prevalence of 12Approval was given by the Hospital administration andby the Research Committee of the School of Medicineand Health Sciences University of Papua New GuineaPort Moresby Papua New Guinea Samples were takenon an opportunistic basis by a range of staff whensample bottles were available Sex age and illness datawere collected on a proforma sheet by the attending staffwhen each specimen was taken HIV antibody wastested for in the serology laboratory at the Central PublicHealth Laboratory Port Moresby Papua New GuineaScreening was done using the Serodia test by FujirebioDiagnostics Tokyo Japan All repeatedly reactive sam-ples were then retested with two more different assaysCapillus from Trinity Biotech Bray Ireland and Deter-mine from Abbotts Laboratories Tokyo Japan If thesamples were repeatedly reactive in all three differentassays then it was confirmed positive This is a WorldHealth Organization (WHO)-approved HIV testing algo-rithm If any of the tests were negative the result wasreported as negative consistent with WHO practice toavoid the reporting of false positives

There was no linking of results to patients and there-fore there was no follow up of positive results

Results

Of 300 blood samples tested for HIV Ab 54 (18 95CI 14ndash23) were repeat reactive positive and 246 werenegative Ten of the latter had one or more tests positivebut at least one negative test

Sex

The sex distribution of the sample was 53 men and47 women Sex was recorded for 47 of the 54 HIV Ab-positive patients of whom 22 (47) were male and 25(53) were female


361

Age


c

2

-statistic 1093

P

-value 0053)

Presenting illness


Discussion



4ndash8


et al

3






1


9


Table 1



10ndash19 5 4 044 014ndash079

20ndash29 59 10 014 007ndash025

30ndash39 55 8 013 006ndash023

40ndash49 31 13 029 017ndash045

50ndash59 15 2 012 015ndash036

60ndash69 9 1 010 001ndash044

Total 174 38 018 013ndash024

C Curry

et al

362


Conclusion


Acknowledgements




Competing interests



References

1 Gordon J







et al


Lancet Infect Dis

2004

4

368ndash74




5 Caldwell J

AIDS in Melanesia



Aust NZ J Med

1997

27

3ndash5


Science

1998

280

5371

8 Riley I



9




361

Age


c

2

-statistic 1093

P

-value 0053)

Presenting illness


Discussion



4ndash8


et al

3






1


9


Table 1



10ndash19 5 4 044 014ndash079

20ndash29 59 10 014 007ndash025

30ndash39 55 8 013 006ndash023

40ndash49 31 13 029 017ndash045

50ndash59 15 2 012 015ndash036

60ndash69 9 1 010 001ndash044

Total 174 38 018 013ndash024

C Curry

et al

362


Conclusion


Acknowledgements




Competing interests



References

1 Gordon J







et al


Lancet Infect Dis

2004

4

368ndash74




5 Caldwell J

AIDS in Melanesia



Aust NZ J Med

1997

27

3ndash5


Science

1998

280

5371

8 Riley I



9



C Curry

et al

362


Conclusion


Acknowledgements




Competing interests



References

1 Gordon J







et al


Lancet Infect Dis

2004

4

368ndash74




5 Caldwell J

AIDS in Melanesia



Aust NZ J Med

1997

27

3ndash5


Science

1998

280

5371

8 Riley I



9



hiv antibody seroprevalence in the emergency department at port moresby general hospital, papua new...

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