Modest Public Health Impact of Nontargeted HIV Screening in 29 Emergency Departments

Anne-Claude Crémieux, Kayigan Wilson d’Almeida, France Lert

UNIVERSITE DE VERSAILLES SAINT QUENTIN-EN-YVELINES

Competing interests

Grants for consultancies, workshops, or travel to meetings from:

Novartis Janssen-Cilag Sanofi-Aventis Heraeus Astra-Zeneca

HIV-screening in France

Easy access to free HIV-testing services

5 million HIV tests

performed each year for 65 million inhabitants

However, late diagnosis remains common 6,500 new HIV

diagnoses in 2011 1/3 with AIDS or CD4

lymphocytes <200/µL

HIV-infected people unaware of their infection in 2010

Estimation in France: 33% (50,000/150,000) of individuals living with HIV

UK and US20–25% of those living with HIV

Nontargeted HIV-screening in healthcare settings

Promoted by national heath agencies

United States in 2006 United Kingdom France in 2010

Supported by studies showing People unaware of their infection or

diagnosed at late stages did not belong to traditional high-risk groups

Cost-effectiveness of this strategy

However, the efficacy of this strategy

Remained controversial (Haukoos, JAMA 2010)

Never tested on a large-scale Poorly implemented

2006

2010

The goals of our study (2009–2010)

Assess the public health impact of nontargeted HIV-rapid test-screening among ED patients in the metropolitan Paris region (11.7 million inhabitants)

Metropolitan Paris region: 50% of France’s new HIV diagnoses

25% of inhabitants visit an ED annually

Estimate the 2009–2010 undiagnosed-HIV prevalence in the metropolitan Paris region

Study methods (May 2009–Sept 2010)

Performed in 29 EDs (50% of all patients seen at EDs in the region)

6-week period in each ED (randomly assigned)

HIV-rapid test (OraQuick, whole blood) offered to all 18–64-year-old patients (opt-in), along with a self-administered questionnaire (demographics, sexual behavior, HIV-testing history)

HIV-RT performed on a 24-hour basis By the local ED-nursing team When needed, assisted by a member

of the research team (present on site for 8 H every day)

RT results Negative results delivered by nurses Positive results disclosed by ED

doctor; blood collected for ELISA/WB, follow-up visit with an on-site infectious disease specialist within 72 hours

138,691 Patients seen in Emergency Departments (May 09–Sept 10)

78,411 (56.5%) Eligible

60,280 (43.5%) Excluded

20,962 (26.7%) Offered screening

13,229 (63.1%) Accepted

7,733 (36.9%) Refused

12,754 (16.3% of those eligible) Screened

57,449 (73.3%) Not offered

11,356 Questionnaires filled out

HIV-screening performed by the ED team alone in 14/29 EDs and with research assistant support in 15 ED

High acceptance rate (62.8% vs 63.5%) in both groups

16.3% of eligible patients were tested Similar to other ED studies performed in US Higher for ED teams working alone (27% vs 12.5%, p<0.01)

37 (0.29%) Confirmed infection (ELISA, Western Blotting)

18 New diagnoses 0.14% (95% CI 0.008–0.22)

(12 linked to care)

16 Repeated diagnoses

38 HIV-RTs reactive1 False-positive result (viral hepatitis)

3 Excluded secondarily*

Newly diagnosed HIV infections

12,754 Patients screened

*Patients excluded because they were unable to give informed consent when RT were ordered for diagnostic purposes by the ED physican.

Variable New HIV Diagnoses in EDs* (N=18)

n (%) [95% CI]

National HIV-Case Surveillance*

(N=3008)

n (%) [95% CI]

Age, mean, (95% CI) 32.9 [28.4–37.4] 37.3 [36.8–37.7]

Previous HIV test 13 (72.2) [46.5–90.3] 1519 (50.5) [48.7–52.3]

HIV-related symptoms 8 (44.4) [21.5–69.2)] 1024 (34.0) [32.3–35.8]

CD4 lymphocyte count <200 5 (27.8) [6.5–49.1] 424 (14.1) [12.9–15.4]

200–350 3 (16.7) [3.6–41.4] 284 (9.4) [8.4–10.5]

>350 4 (22.2) [6.4–47.6)] 634 (21.1) [19.6–22.6]

Unknown (lost for follow up) 6 (33.3) [13.3–59.0] 1667 (55.4) [53.6–57.2]

*Multiple imputation was used to estimate missing data for previous HIV tests

Characteristics of Patients with New HIV Diagnoses in EDs or National HIV-Case Surveillance

Complementary study to evaluate the covariates of HIV-RT refusal: 7 EDs, 1404 consultants, 655 eligible, 404 accepters (61%), 251 refusers

Parameter OR [95% CI)

Age 0.998 [0.98–1.01]

Sex

Female 1

Male 1.20 [0.82–1.76]

Country of birth

France 1

Sub-Saharan Africa 1.31 [0.71–2.39]

Previous HIV-test reported

No 1

Yes 2.04 [1.37–3.04]

Self-perceived HIV risk vs general population

High self-perceived risk 1

Low self-perceived risk 12.02 [2.60–55.58]

Don’t know 3.42 [0.71–16.45]

Undiagnosed-HIV Prevalence in France Based on Nontargeted Screening in Emergency Departments

Standardization method was used to take into account the difference between the ED-tested population and the general population of the Paris region.

After standardization, the overall expected prevalence of undiagnosed-HIV infections in the metropolitan Paris region was estimated to be 0.09% (95% CI 0.04–0.13).

That rate corresponds to 6,742 [2,996–9,739] 18–64 year olds unaware of their infections among the 7.5 million 18–64-year-old inhabitants.

Since this region harbors 44% of France’s new HIV diagnoses, the expected number of nationwide, undiagnosed-HIV infections in 18–64 year olds would be close to 15,300 (about 10% of the 150,000 persons living with HIV), far below the available figure of 50,000 (one-third of those living with HIV) unaware of their infection.

Conclusions

ED-based HIV-RT–screening is feasible and can reach large numbers of patients.

Nontargeted screening identified only a few new diagnoses, often at late stages, and, unexpectedly, most newly diagnosed patients belonged to high-risk groups and had been tested previously.

Undiagnosed HIV infections were found almost exclusively in high-risk populations and with a lower than expected prevalence.

Universal testing strategy should be questioned in France.

ED nurse-based repeated-targeted screening of subpopulations thought to be at higher risk deserves further investigation

Acknowledgments Multidisciplinary investigating team: Kayigan Wilson

d’Almeida, Gerald Kierzek, Pierre de Truchis, Stéphane Le Vu, Dominique Pateron, Bertrand Renaud, Caroline Semaille, Vanina Bousquet, Yann Le Strat, François Simon, Didier Guillemot, France Lert

Emergency Department teams of the 29 hospitals participating in the study

Monitoring team (J Leblanc, S Mas…) Infectious disease and virology specialists of the 29

hospitals OraSure Technologies Inc, Bethlehem, Pennsylvania ANRS Sidaction