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Specialists highlight need to strengthen the HIV testing system

13 Jul 2022

BY Ruwan Laknath Jayakody Addressing identified barriers to hospital-based human immunodeficiency virus (HIV) rapid diagnostic testing (RDT) through policy and administrative support, and scaling up hospital-based HIV testing further while ensuring sustainability, are recommended. These recommendations were made in a paper on “HIV prevalence among medical in-ward patients in the National Hospital of Sri Lanka (NHSL) in Colombo with the assessment of patient acceptance, the feasibility, and challenges of the hospital-based rapid HIV diagnostic test” which was authored by W.S.C. Dileka, K.A.C.R. Wijesekara, and N. Widanage (all three are acting consultant venereologists), G. Weerasinghe, G. Samaraweera, T. Rathnayaka, L.I. Rajapakse, H.P. Perera, and C.J. Jayakody (all six are consultant venereologists), and K.Y.D. Perera (a registrar in medical administration) and published in Sri Lanka Journal of Sexual Health and HIV Medicine 6 in December 2020. The reported cumulative number of HIV diagnoses by the end of 2018 was 3,200 and among them, 992 were from the Colombo District, per the relevant 2017 Annual Report, while new HIV cases reported in the country are rising with 350 new HIV cases detected in 2018 and the majority (23.4%) being from the Colombo District. Sri Lanka has taken a proactive stance to end the acquired immunodeficiency syndrome (AIDS) epidemic in 2025, five years ahead of the global target, per the aforementioned Annual Report and in line with the UNAIDS concept of 90.90.90 by 2020, 90% of the people living with HIV (PLHIV)  PLHIV should know their sero status by the end 2020 as currently, in Sri Lanka, only 68% of the PLHIV know their status resulting in a gap of 22%. To reduce this gap and to achieve the target, the scaling up of HIV testing is important. Hence, Dileka et al. carried out a descriptive, demonstration study in selected medical wards of the NHSL for a three-month period from August to October 2019. All patients over the age of 18 who were admitted to the selected medical wards were included as participants.  HIV testing was carried out using a fourth-generation rapid HIV test (Alere HIV combo) which detects HIV One and Two antibodies and P24 antigen with a relatively short window period of two to three weeks. The results were interpreted in 20 minutes.  HIV rapid test positive patients were offered further investigations according to the national HIV testing algorithm after detailed counselling. HIV diagnosis was based on the nationally accepted HIV testing algorithm. The study sample included almost an equal proportion of male (50.2%) and female (49.2%) subjects, while 24% were above 65 years of age. The mean age of the participants was 50.9 (the majority above 45) with an age range of 18-94. However, from each age category, there was more than 10% participation (age distribution satisfactory throughout all age categories). Among them, the majority were married (66.5%) while 13.9% were widows. A total of 90% of the study sample claimed the Western Province as their area of residence (expected target population), while there was a minimal representation from the other provinces. Of the 3,520 patients approached, 3,395 had given consent to carry out the test with a 96% acceptance rate (highly satisfactory). Altogether, there were 3,395 rapid HIV tests carried out during the study period. Among them, 12 were rapid diagnostic test positive. Then, those 12 were further investigated for the confirmation test and eight were found to be confirmed as having the HIV infection, giving rise to a 0.23% of HIV prevalence among the study sample. The majority of the confirmed positive patients were from the Western Province (five) and were male (five). The mean age of the rapid test positive cases was 46.5-years with an age range of 24-60. Of them, six patients were above 35, and only one was below 25, while three were married. The presenting complaints and symptoms of the diagnosed HIV patients included chronic kidney disease, alcohol withdrawal fits, fever, cough, dyspnoea (difficult or laboured breathing), chest pain, the swelling of the left lower limb, abdominal pain, loss of appetite, pyrexia of unknown origin (temperature greater than 38.3 °C on several occasions accompanied by more than three weeks of illness and the failure to reach a diagnosis after one week of investigation) and a body rash. It is evident that the majority (six) were admitted due to non-AIDS defining conditions where HIV testing is not routinely offered. Even though the majority (six) were not presented with an AIDS defining or HIV indicator condition, five of them had their CD 4 cell (T/white blood cells) counts below 200 cells per microlitre (cells/μl). Therefore, the risk of ending up as a missed opportunity of HIV diagnosis is higher. Further, the majority (five) were in the World Health Organisation’s (WHO) stages Three and Four at the time of diagnosis and one patient died just after confirmation. The average number of tests carried out by each research assistant was 12.5 tests per hour. However, the total number of admissions for each medical ward of the NHSL varied between 25 to 35 per day with a mean of 24.6. A rapid test takes 20 minutes to give the results. Therefore, it was expressed that they (medical officers, nursing officers and nursing sisters) need a dedicated person to carry out HIV rapid testing amidst all the admissions in the ward. Further, the maintenance of the register/s of the receiving and utilising of the test kits, and the maintaining of the rapid test return of patients, were highlighted as an additional burden during heavy work seasons. Nursing officers highlighted that consent taking was not consistently carried out by first contact medical officers and that therefore, the test was not carried out among certain admissions. Some doctors were reluctant to request HIV testing from a patient even though they have come across patients with certain indicator illnesses. This is because of the feeling that it is a highly stigmatised disease that would be concentrated among a high risk population. They were thinking that it is out of their scope. Further, they were of the view that this was not a suitable place to request HIV testing with the limited availability of time and the heavy workload. The majority of the participating staff thought that they had not received adequate knowledge regarding HIV and HIV testing in prior, even though some have participated in advocacy and training programmes. They were interested if there is ongoing training since this is a new area. The majority of the medical officers were reluctant to disclose the positive results to the patient even though this is a screening test. They believed that breaking bad news for a serious lifetime illness may make for an uncomfortable situation. The hospital setting was an ideal setting to track more patients in need who may not otherwise be approached through traditional health care settings such as the STD clinic settings. The NSACP has, per the National Strategic Plan for sexually transmitted infections and HIV, introduced multiple strategies targeting to reduce the remaining gap of HIV case detection in the country. However, the positivity rate of 0.23% of this study is higher than the current testing strategies used for the general public such as STD clinic samples (0.1%), tuberculosis screening (0.13%), prison screening (0.06%), and blood donor samples (0.1%), per the NSACP’s Strategic Information Management Unit’s 2018 Annual Report, while in contrast, this strategy is second only to the case-finding hybrid model, which has been introduced to detect key populations with HIV. Therefore, this is one of the highest yielding programmatic strategies implemented in the country so far.  Moreover, only two out of eight patients were having a HIV indicator condition to offer HIV testing. However, the baseline CD4 cell count was less than 200 cells/μl in five patients (62.5%) and these patients were included into the WHO stages III and IV at the time of diagnosis. Therefore, early testing irrespective of having an indicator condition could lead to early disease identification and treatment, and reduced disease-related morbidity and mortality, thereby preventing missed opportunities. Following the positive screening with the HIV rapid test, the pathway to confirmation and follow up was streamlined according to the national HIV testing guidelines in order to prevent the unnecessary worries of false-positive patients and to avoid the delay in the management of confirmed cases and loss due to delay in follow up. The average number of tests carried out by an allocated person was 12.5 per hour. When compared to the mean admission per ward (24.6), this test can be easily performed at the bedside or on admission by a trained healthcare worker.  The analysis revealed that most healthcare workers were reluctant to engage in extra work considering it as an over burden due to the heavy workload. Further, the lesser number of HIV test requests were coming from first contact doctors due to them feeling uncomfortable to offer the HIV test to the patients as well as difficulties in post-test counselling which were identified as barriers and challenges. The requirement of continuous update or advocacy programmes to health care staff was highlighted as areas to improve in order to ensure the sustainability of the programme.


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