Patient acceptance of HIV testing services in rural emergency departments in South Africa

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Abstract

Background

South Africa faces the highest burden of HIV infection globally. The National Strategic Plan on HIV recommends provider-initiated HIV counselling and testing (HCT) in all healthcare facilities. However, HIV continues to overwhelm the healthcare system. Emergency department (ED)-based HCT could address unmet testing needs.

Objectives

This study examines the reasons for accepting or declining HCT in South African EDs to inform the development of HCT implementation strategies.

Method

We conducted a prospective observational study in two rural EDs, from June to September 2017. Patients presenting to the ED were systematically approached and offered a point-of-care test in accordance with national guidelines. Patients demographics, presenting compaint, medical history and reasons for accepting/declining testing, were recorded. A pooled analysis is presented.

Results

Across sites, 2074 adult, non-critical patients in the ED were approached; 1880 were enrolled in the study. Of those enrolled, 19.7% had a previously known positive diagnosis, and 80.3% were unaware of their HIV status. Of those unaware, 90% patients accepted and 10% declined testing. The primary reasons for declining testing were ‘does not want to know status’ (37.6%), ‘in too much pain’ (34%) and ‘does not believe they are at risk’ (19.9%).

Conclusions

Despite national guidelines, a high proportion of individuals remain undiagnosed, of which a majority are young men. Our study demonstrated high patient acceptance of ED-based HCT. There is a need for investment and innovation regarding effective pain management and confidential service delivery to address patient barriers. Findings support a routine, non-targeted HCT strategy in EDs.

Related collections

Most cited references 20

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Rates of HIV testing and diagnosis in South Africa: successes and challenges.

Leigh F Johnson, Thomas M Rehle, Sean Jooste … (2015)

UNAIDS aims for 90% of HIV-positive individuals to be diagnosed by 2020, but few attempts have been made in developing countries to estimate the fraction of the HIV-positive population that has been diagnosed.

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HIV and tuberculosis in prisons in sub-Saharan Africa.

Lilanganee Telisinghe, Salome Charalambous, Stephanie Topp … (2016)

Given the dual epidemics of HIV and tuberculosis in sub-Saharan Africa and evidence suggesting a disproportionate burden of these diseases among detainees in the region, we aimed to investigate the epidemiology of HIV and tuberculosis in prison populations, describe services available and challenges to service delivery, and identify priority areas for programmatically relevant research in sub-Saharan African prisons. To this end, we reviewed literature on HIV and tuberculosis in sub-Saharan African prisons published between 2011 and 2015, and identified data from only 24 of the 49 countries in the region. Where data were available, they were frequently of poor quality and rarely nationally representative. Prevalence of HIV infection ranged from 2·3% to 34·9%, and of tuberculosis from 0·4 to 16·3%; detainees nearly always had a higher prevalence of both diseases than did the non-incarcerated population in the same country. We identified barriers to prevention, treatment, and care services in published work and through five case studies of prison health policies and services in Zambia, South Africa, Malawi, Nigeria, and Benin. These barriers included severe financial and human-resource limitations and fragmented referral systems that prevent continuity of care when detainees cycle into and out of prison, or move between prisons. These challenges are set against the backdrop of weak health and criminal-justice systems, high rates of pre-trial detention, and overcrowding. A few examples of promising practices exist, including routine voluntary testing for HIV and screening for tuberculosis upon entry to South African and the largest Zambian prisons, reforms to pre-trial detention in South Africa, integration of mental health services into a health package in selected Malawian prisons, and task sharing to include detainees in care provision through peer-educator programmes in Rwanda, Zimbabwe, Zambia, and South Africa. However, substantial additional investments are required throughout sub-Saharan Africa to develop country-level policy guidance, build human-resource capacity, and strengthen prison health systems to ensure universal access to HIV and tuberculsosis prevention, treatment, and care of a standard that meets international goals and human rights obligations.

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An incentivized HIV counseling and testing program targeting hard-to-reach unemployed men in Cape Town, South Africa.

Mweete Nglazi, Robin Wood, Katharina Kranzer … (2012)

In Southern Africa, men access HIV counseling and testing (HCT) services less than women. Innovative strategies are needed to increase uptake of testing among men. This study assessed the effectiveness of incentivized mobile HCT in reaching unemployed men in Cape Town, South Africa. A retrospective analysis of HCT data collected between August 2008 and August 2010 from adult men accessing clinic-based stationary and non-incentivized and incentivized mobile services. Data from these 3 services were analyzed using descriptive statistics and log-binomial regression models. A total of 9416 first-time testers were included in the analysis as follows: 708 were clinic based, 4985 were non-incentivized, and 3723 incentivized mobile service testers. A higher HIV prevalence was observed among men accessing incentivized mobile testing [16.6% (617/3723)] compared with those attending non-incentivized mobile [5.5% (277/4985)] and clinic-based services [10.2% (72/708)]. Among men testing at the mobile service, greater proportions of men receiving incentives were self-reported first-time testers (60.1% vs. 42.0%) and had advanced disease (14.9% vs. 7.5%) compared with men testing at non-incentivized mobile services. Furthermore, compared with the non-incentivized mobile service, the incentivized service was associated with a 3-fold greater yield of newly diagnosed HIV infections. This strong association persisted in analyses adjusted for age and first-time versus repeat testing [risk ratio: 2.33 (95% confidence interval: 2.03 to 2.57); P < 0.001]. These findings suggest that incentivized mobile testing services may reach more previously untested men and significantly increase detection of HIV infection in men.

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Author and article information

Journal

Journal ID (nlm-ta): South Afr J HIV Med

Journal ID (iso-abbrev): South Afr J HIV Med

Journal ID (publisher-id): HIVMED

Title: Southern African Journal of HIV Medicine

Publisher: AOSIS

ISSN (Print): 1608-9693

ISSN (Electronic): 2078-6751

Publication date (Electronic): 22 July 2020

Publication date Collection: 2020

Volume: 21

Issue: 1

Electronic Location Identifier: 1105

Affiliations

[1 ]Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America

[2 ]Nelson Mandela Academic Clinical Research Unit, Mthatha, South Africa

[3 ]Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, United States of America

[4 ]Division of Intramural Research, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, United States of America

[5 ]Department of Medicine, Frere and Cecilia Makiwane Hospitals, East London, South Africa

[6 ]Department of Medicine, Faculty of Health Sciences, Walter Sisulu University, East London, South Africa