The geography of emergency department-based HIV testing in South Africa: Can patients link to care?

Bhakti Hansoti; Anant Mishra; Aditi Rao; Lucy Chimoyi; Andrew D Redd; Steven J Reynolds; David F Stead; John Black; Roshen Maharaj; Elizabeth Hahn; Pamela Mda; Nomzamo Mvandaba; Yandisa Nyanisa; Victoria Chen; Katie Clark; Sofia Ryan; Thomas C Quinn

doi:10.1016/j.eclinm.2021.101091

The geography of emergency department-based HIV testing in South Africa: Can patients link to care?

EClinicalMedicine. 2021 Aug 19:40:101091. doi: 10.1016/j.eclinm.2021.101091. eCollection 2021 Oct.

Authors

Bhakti Hansoti¹, Anant Mishra¹, Aditi Rao¹, Lucy Chimoyi², Andrew D Redd^{1

3}, Steven J Reynolds^{1

3

4}, David F Stead^{5

6}, John Black^{5

7}, Roshen Maharaj^{5

8}, Elizabeth Hahn¹, Pamela Mda⁹, Nomzamo Mvandaba⁵, Yandisa Nyanisa⁵, Victoria Chen¹, Katie Clark¹, Sofia Ryan¹, Thomas C Quinn^{1

3}

Affiliations

¹ The Johns Hopkins University, 1800 Orleans St, Baltimore, MD 21287, USAs.
² Implementation Research Division, The Aurum Institute, 29 Queens Rd, Parktown, Johannesburg, 2194, South Africa.
³ Division of Intramural Research, National Institute of Allergy and Infectious Diseases, 31 Center Dr #7A03, Bethesda, MD 20892, USA.
⁴ Department of Family Medicine and Health Sciences, Faculty of Medicine, University of Cape Town, Anzio Rd, Cape Town 7925, South Africa.
⁵ Department of Medicine, Faculty of Health Sciences, Walter Sisulu University, Umtata Part 1, Mthatha, South Africa.
⁶ Department of Medicine, Frere and Cecilia Makiwane Hospitals, Amalinda Main Rd, Braelyn, East London 5201, South Africa.
⁷ Department of Medicine, Livingstone Hospital, Stanford Road, Korsten, Port Elizabeth 6020, South Africa.
⁸ Department of Emergency Medicine, Livingstone Hospital, Port Elizabeth, South Africa, Stanford Road, Korsten, Port Elizabeth 6020, South Africa.
⁹ Nelson Mandela Hospital Clinical Research Unit, Sisson St, Fort Gale, Mthatha 5100, South Africa.

Abstract

Background: Emergency Departments (EDs) can serve as clinical sites for identification of new HIV infections and their entry into care. We examined if HIV-positive patients who present to EDs in South Africa are able to successfully link to care.

Methods: We conducted a one-year longitudinal prospective cohort study in four hospitals across the Eastern Cape, South Africa, with participants followed between July 2016 and July 2018. All adult, non-critical patients presenting to the ED were systematically approached, asked about their HIV status, and, if unknown, offered a point-of-care (POC) HIV test. All HIV-positive patients were further consented to participate in a follow-up study to assess subsequent linkage to care and distance from "home" to ED. Linkage to care was defined as self-reported linkage (telephonic) or evidence of repeated CD4/viral load testing in the National Health Laboratory System (NHLS) at either the 6- or 12-months post index ED visit.

Findings: A total of 983 HIV-positive patients consented to participate in the study. In the 12 months following their ED visit, 34·1% of patients demonstrated linkage to care (335/983), 23·8% did not link to care (234/983), and 42·1% (414/983) were lost to follow-up. Though not statistically significant, a high percentage of young men (27/50, 54%) and those presenting with a trauma-related complaints (100/205, 48.8%) did not link to care. A considerable proportion of patients (105/454, 23·2%,) resided 50 or more kilometers from their index ED sites, though there was not a significant difference in linkage to care rate between those who lived closer or further from the ED.

Interpretation: We have shown that strategies to improve linkage to care from the ED should consider the high rates of poor linkage among young men and those presenting to the ED with trauma. Furthermore, innovative linkage to care solutions will need to account for the unique geographical consideration of this population, given that many ED patients will need to continue care at a site distant from the diagnosis site.

Funding: This research was supported by the South African Medical Research Council, the Division of Intramural Research, the National Institute of Allergy and Infectious Diseases, National Institutes of Health, and the Johns Hopkins Center for Global Health.

Keywords: Emergency departments; HIV; HIV testing; Linkage to Care; South Africa.