- Researchers surveyed Ontario healthcare providers about rapid HIV testing in emergency rooms
- Most participants saw benefits, but nearly half also predicted challenges, especially doctors
- Perceived barriers included time, the need for informed consent, and appropriate environment
Testing is a cornerstone of HIV treatment and prevention. People who have a negative test result can speak to their healthcare provider about options for staying negative. People who test positive can be swiftly referred for care and treatment for HIV (antiretroviral therapy, ART).
When HIV treatment is used as directed, the amount of HIV in the blood—the viral load—falls to very low levels within several months of initiation in most people. These very low levels are commonly called “undetectable.” Continued adherence to ART helps to maintain viral suppression. This has at least two benefits, as follows:
- It improves the health of the person with HIV: Laboratory analyses of blood show an improvement in overall health and a dramatically decreased risk of AIDS-related infections. The effect of ART is so tremendous that researchers predict that many ART users will have near-normal life expectancy.
- It prevents the transmission of HIV: Well-designed studies over the past decade have found that ART users whose HIV is suppressed do not transmit the virus to their sexual partners.
Thus, a suppressed viral load has both individual and societal benefits.
How is Canada doing?
Research by the Public Health Agency of Canada (PHAC) indicated that at the end of 2022 there were 65,270 people living with HIV in Canada. This population was distributed as follows:
- 89% knew that they have HIV
- 85% of people who knew their infection status were taking ART
- 95% of people taking ART had a suppressed level of HIV
Therefore, about 1 in 10 people with HIV in Canada did not know their HIV status by the end of 2022.
PHAC further estimates that in 2022 there were 1,848 new HIV infections. This represents an increase of 15% from estimates done in 2020. PHAC stated that these numbers for 2022 are equivalent to five new HIV infections daily.
As mentioned, research indicated that an estimated 11% of people with HIV in Canada do not know that they have the virus. The reality for many people in this situation is that the virus will gradually weaken their immune system and eventually their overall health. Since these people are not aware of their HIV status, they may not seek care until they are quite ill. Many Canadians do not have a general practitioner or family doctor. Therefore, undiagnosed people whose HIV is degrading their health may seek care in the emergency department of a hospital. In such a setting, HIV testing is important for this population.
In the emergency room (ER)
A team of researchers from hospitals in Toronto and Thunder Bay surveyed and interviewed healthcare providers at four hospitals in these cities about implementing rapid HIV testing in the ER.
A total of 187 healthcare providers responded to the survey. According to the research team, “80% felt implementing rapid HIV testing would be helpful in the emergency department.” Many participants said that it would be useful to have resources to help link patients who test positive to care. However, participants noted that time available in the ER is limited and some healthcare providers may not be knowledgeable about HIV testing.
Some participants encouraged the integration of peer support workers into the staff of emergency departments in order to facilitate the linkage of newly diagnosed patients to care and treatment.
Study details
Researchers implemented the study at four major hospitals in Ontario:
- Thunder Bay Regional Health Sciences Centre
- St. Michael’s Hospital
- Toronto General Hospital
- Toronto Western Hospital
Participants included staff who worked in the ER, including physicians, nurses, social workers, mental health professionals and laboratory personnel.
Researchers sent out an anonymous web-based survey that included the option of providing contact information so that interviews could take place. Surveys were sent to 560 staff, and 187 (33%) were completed. A total of 27 interviews were conducted, evenly distributed across the four hospitals and different professions.
Data for the study were collected between February 2020 and August 2021.
Results
Although most participants (70%) were familiar with HIV testing, only 20% had experience conducting an HIV test.
Barriers to testing
- Most participants noted that HIV testing would be useful in the ER, but nearly half stated that there would be challenges implementing such testing. The most common issue cited was lack of time.
- Some ER staff felt uncomfortable disclosing positive results to patients in the ER.
- Doctors were more likely than nurses to suggest that there would be barriers to implementing HIV testing in the ER.
- Some participants felt that they lacked sufficient knowledge about HIV testing processes and procedures, including what the researchers called “a perceived need for consent.”
- The researchers noted that the ER is generally a hectic environment and some participants felt that such an environment “was not conducive to disclosing sensitive information such as an HIV test result.” Conversely, the researchers stated that “many staff noted that patients may prefer to receive their results in an emergency department where they are familiar with the staff and environment.”
- Some participants were uncertain whether the ER is the right place for HIV testing; they felt that the ER should be reserved for what they called “emergencies.” However, other participants noted that some patients may not have access to care outside of the ER. In such cases, these participants felt that offering HIV testing within the ER would be appropriate.
Most participants recognized that HIV testing in the ER is important, particularly for some populations that are not able to access care in other places. However, the researchers stated that “participants universally felt that within the current system it would be challenging for providers to offer testing, communicate results, and organize follow-up due to time constraints.”
Advantages of testing
Participants felt that offering HIV testing in the ER would help to improve the health of not only individual patients but ultimately people in the community. Making rapid HIV testing a common procedure in the ER may also help decrease stigma that has historically been associated with HIV testing.
Overcoming barriers
Participants identified the need for staff training about HIV testing. They also expressed the need for tools to educate patients, such as posters and pamphlets about HIV testing.
As medical staff in the ER have limited time, some participants felt that it would be useful to have community workers experienced with HIV testing or peer support workers available for ER staff to call upon when HIV testing was offered.
In addition, the researchers stated that “participants felt that increased systemic and organizational resources, including additional staff and established linkage to care pathways, would be needed to avoid impact on workflow [within the ER].” They also stated that “participants felt clear institutional testing guidelines would be essential for implementation.”
Bear in mind
The present study has many strengths. However, one weakness is that only 33% of people who received the survey completed it. It is possible that this low response rate may not have captured a representative opinion of healthcare providers in the ER.
The research team recommended that “hospitals ensure clear [HIV] testing guidelines and establish follow-up care pathways.” They also encouraged the implementation of educational initiatives for staff and patients around HIV testing.
—Sean R. Hosein
Resource
Understanding Canada’s progress towards global HIV targets – Public Health Agency of Canada (PHAC)
REFERENCES:
- Kent JT, Ritchie LMP, Klaiman M, et al. Barriers and facilitators to the implementation of rapid HIV testing in Canadian emergency departments: a mixed methods study. Canadian Journal of Emergency Medicine. 2024 Jul;26(7):463-471.
- Kiran T, Daneshvarfard M, Wang R, et al. Public experiences and perspectives of primary care in Canada: results from a cross-sectional survey. CMAJ. 2024 May 20;196(19): E646-E656.
- de Wit K, Tran A, Clayton N, et al. A longitudinal survey on Canadian emergency physician burnout. Annals of Emergency Medicine. 2024 Jun;83(6):576-584.