Sustained 97% opt- out HIV testing in the emergency department: Getting to zero AIDS
HIV attacks the body’s immune system, and in late stages, causes potentially life-threatening infections and illnesses known as AIDS. Until the late ‘90s, having this virus was considered a death sentence – one with devastating effects.
Today, however, early diagnosis and treatment for HIV effectively reduce the likelihood of ill health, onward transmission and premature death. With proper, timely medical care, HIV can be well-managed, prolonging longevity and mitigating AIDS-related illnesses.
“You don’t want to see people with a treatable disease getting sick unnecessarily,” said Dr. Ian Cormack, Clinical Lead of HIV Medicine at Croydon University Hospital. “Catching them before they present with an AIDS-defining illness, will reduce clinical risk, save lives and reduce cost.”
This was the rationale behind Croydon’s rollout of opt-out HIV testing in May 2020. Previously, clinicians were responsible for asking patients if they’d like to be tested, an approach that Dr. Cormack’s 15 years of research proved unsustainable. Patients often didn’t see themselves as at risk, and those already aware of their HIV-positive status sometimes didn’t feel comfortable disclosing it to clinicians, who were themselves uncomfortable broaching the topic.
Due to the limitations of opt-in testing, and the consequential delay in diagnoses, Croydon University Hospital observed AIDS-defining illnesses in 78% of newly diagnosed HIV-positive hospitalized inpatients. Mortality rates were as high as 23% in some years, depending on the nature of the AIDS-defining illnesses. That all changed when opt-out HIV testing became the norm. By standardizing the process by which HIV tests were ordered, multidisciplinary stakeholders at Croydon were able to ensure that HIV tests are automatically requested, unless a patient explicitly opts out. Any person confirmed as HIV-positive on subsequent testing is quickly placed on the appropriate pathway to treatment and given immediate access to a team of mental health specialists for education, support and counseling.
“Normalizing opt-out HIV testing prevents people feeling ‘targeted’ to have an HIV test,” said Croydon’s Dr. Sarah Horne, consultant in emergency medicine. “This helps reduce stigma as everyone receives the same treatment, regardless of sexual orientation or physical presentation.”
Croydon University Hospital’s approach to HIV testing has enabled it to sustain a 97% testing rate for over 2 years. In that time, HIV diagnoses tripled, and patients presenting with AIDS-defining illnesses steadily declined from 78% (2005-2010) to 46% (2017-2019) to 4% (2020-2021).
Prevention of AIDS-defining illnesses in turn facilitated a sharp reduction in hospitalizations and deaths. Intensive treatment unit admissions dropped from 15% to 0% – freeing up beds for COVID-19 patients at a critical time – and mortality decreased from 23% of cases to 0%.
These data highlight the remarkable impact that opt-out testing has had on patient health, clinician satisfaction and resource utilization at Croydon University Hospital. To build on the success, in April 2022, the Croydon team helped to launch the program across all of London and other extremely high prevalence areas.
“Patients that have been diagnosed show overwhelming gratitude,” said Dr. Cormack. “A relatively inexpensive test can transform a patient’s prognosis, future and life.”
This is an initiative that could be a golden international standard for implementation at other healthcare systems. —COMMENTS FROM EHMA