Bassett IV, Giddy J, Nkera J, Wang B, Losina E, Lu Z, Freedberg KA, Walensky RP. Routine voluntary HIV testing in Durban, South Africa: the experience from an outpatient department. J Acquir Immune Defic Syndr. 2007 Oct 1;46(2):181-6.
To evaluate the yield of a routine voluntary HIV testing program compared with traditional provider-referred voluntary counseling and testing (VCT) in a hospital-affiliated outpatient department (OPD) in Durban, South Africa.
A prospective cross-sectional comparison of two observational groups: a 14-week "standard of care" period in which OPD physicians referred patients for VCT, followed by a 12-week "intervention" period during which all patients registered at the OPD were given an educational intervention and offered a rapid HIV test at no charge.
McCord Hospital in Durban, South Africa is an urban medical center located in KwaZulu Natal, the South African province with the highest HIV prevalence. The hospital's OPD population is approximately 70% black African Zulu speakers, approximately 20% Indian patients, and approximately 10% white patients. Approximately 40% of patients are repeat visitors to the OPD and receive their regular outpatient care there; the rest of the patients present episodically or for a single visit. Patients pay a fee for medical care in the OPD; during the study period, this fee was 140 South African Rand (ZAR), or (~$19.26 in 2005 US dollars). McCord Hospital has an HIV treatment clinic that became a President's Emergency Plan for AIDS Relief (PEPFAR)-funded ARV treatment site in July 2004; ARV availability did not change significantly over the course of the study. The VCT site is located in the hospital complex, about 300 yards from the OPD, and requires a new queue and small fee (25 ZAR or ~$3.60 if referred from the OPD; 50 ZAR or ~$7.10 if self-referred). This site is also used for counseling of CD4 count results and psychosocial assessment prior to initiation of ARVs.
Adults 18 years or older in the OPD. In the intervention period, adults were approached from the urgent care side (as opposed to the emergent side) of the OPD because they were capable of consenting and ambulating to a private counseling room.
Beginning in January 2005, the OPD began offering routine voluntary HIV testing to all adult patients > 18 years. HIV tests were offered at no extra charge to all patients registered for care in the OPD, regardless of chief complaint or demographics. Patients received a handout at daytime registration in English and Zulu informing them that they would be offered an HIV test during their visit. This handout included an HIV test/study consent form. Three trained HIV counselors led educational activities in the waiting room twice daily to reach most patients. Education sessions included information about HIV transmission, prevention, and testing, and were given in English and Zulu. Consenting patients were taken to 1 of 2 private counseling rooms, where they received brief pretest counseling and underwent a rapid HIV test (Determine, Abbott). Positive rapid test results were immediately confirmed with a second rapid test kit (Smart Check, World Diagnostics). Counselors advised patients with indeterminate rapid test results to undergo an enzyme-linked immunosorbent assay (ELISA). Patients who tested positive by two rapid testing kits were provided with information about HIV infection and the HIV-related services at McCord Hospital, with referral to the HIV clinic at the hospital. If patients were interested, counselors escorted them to the HIV clinic about 400 yards away, where they could have blood drawn for a self-paid CD4 cell count, with results available approximately one week later. A detailed survey was administered to a convenience sample of approximately every other tested patient. The surveys, available in English and Zulu, inquired about demographic information such as age, ethnicity, education, employment, and four specific HIV knowledge statements. For patients who declined HIV testing, age and gender were noted whenever possible, and a convenience sample of these patients was also surveyed. Cost estimates were based on the screening and confirmatory test kits, HIV counselor and project manager salaries, and counseling space.
The study looked at acceptability of HIV testing, HIV prevalence, knowledge, and cost.
During the 14-week standard of care period, 162 adults were seen on average per day in the OPD. OPD physicians referred 435 adults for HIV testing, of whom 137 (31.5%) were actually tested at the hospital VCT site within four weeks of referral. Of those tested, 102 (74.5%) were found to be HIV-infected. Women comprised about 70% of the OPD population: 50.5% of those referred for testing, 54.0% of those tested, and 52.3% of those found to be infected. Of the 102 patients found to be HIV-infected during this period, 58 (56.9%) underwent CD4 cell count testing at the VCT site; the median CD4 count was 123 cells/mm3 (interquartile range [IQR]: 48 to 247 cells/mm3).
During the 12-week intervention period, 166 adult patients were seen on average per day in the OPD. A total of 2,912 HIV tests were offered, with 1,414 patients (48.6%) patients accepting HIV testing. Among those tested, 463 (32.7%) were HIV-infected. Compared with the standard of care period, there was a significantly increased rate of case identification during the intervention period (~39 vs. ~8 new cases per week; p< 0.0001). Of the 463 patients found to be HIV-infected during this period, 150 (32.4%) of 463 underwent self-paid CD4 cell count testing at the VCT site and 137 (91.3%) of 150 returned for the results. The median CD4 count was 140 cells/mm3 (IQR: 50 to 302 cells/mm3; p=0.41 compared with the standard of care period). The average age of those who were HIV-infected was 37 years, compared with 44 years for patients who tested negative (p< 0.0001). Nine female patients (0.6%) had indeterminate rapid HIV test results. Eight of these women agreed to an ELISA and returned for results; five (62.5%) of eight tested positive and three (37.5%) of eight tested negative by ELISA from samples drawn during the initial visit.
Fifty-four percent (766 of 1,414) of patients who accepted HIV testing during the intervention period were also tested by means of a survey. Of these, 32 patients reported testing HIV-positive previously and were excluded from the analysis of the survey data. Of the remaining respondents for whom complete data were available, 465 (64.2%) of 724 were female. Among those tested and surveyed, 464 (64.9%) of 715 had never been tested before. Survey results were then used to estimate prevalence of HIV in patient subgroups. A greater proportion of surveyed male patients were HIV-infected compared with female patients (86 [33.2%] of 259 male patients, 95% confidence interval [CI]: 27.5 to 38.9 vs. 108 [23.3%] of 465 female patients, 95% CI: 19.4 to 27.1; p=0.073). Patients in the 30- to 39-year-old age group had the highest prevalence (76 [40.4%] of 188, 95% CI: 33.4 to 47.4; p<0.0001), whereas those ≥50 years old had the lowest prevalence (28 [13.3%] of 210, 95% CI: 8.7 to 17.9; p<0.0001). Single patients had the highest HIV prevalence (124 [42.6%] of 291, 95% CI: 36.9 to 48.3; p<0.0001); those married without children had the lowest prevalence (1 [7.1%] of 14, 95% CI: 0.0 to 20.6; p<0.0001). Those who scored 4 of 4 on the test of HIV knowledge had a lower HIV prevalence compared with those who scored less than perfect (17 [18.5%] of 92 patients, 95% CI: 10.6 to 27.4 vs. 177 [28.0%] of 633 patients, 95% CI: 24.5 to 31.5; p=0.055). There was no difference in HIV prevalence based on employment status, previous HIV testing, or knowing someone with HIV, or on HIV treatment. The average age of the patients who declined HIV testing was 46.3 years, compared with 41.5 years for those who accepted (p< 0.0001). Eleven percent (163 of 1,498) of patients who declined testing were surveyed. The most common basis (66%) for declining was that patients did not view themselves at risk for HIV, citing the following specific reasons: "not at risk," "tested before," and "I am too old."
The direct cost of the 3.5-month standard of care period, during which 470 patients were tested, was 27,800 ZAR (~$3,825). The cost per person tested in HIV clinic during this period was $8.13. The cost per HIV-infected patient identified was $12.18. The direct cost of the routine HIV testing program for a three-month period, which tested 1,414 patients, was $10,941. The cost per person tested in the OPD during the program was $7.74. The cost per HIV-infected patient identified was $23.33.
The authors conclude that routine voluntary HIV testing at the point of care in an OPD in Durban, South Africa was able to identify nearly five times as many new cases per week as HIV testing by physician referral to an adjacent hospital-affiliated VCT site.
There is no widely accepted quality-rating system for study designs such as this, and it is unknown if changes observed between the standard of care and intervention periods were due to the intervention itself or the population that was seen at that time. Other study limitations include: 1) patients tested in the urgent care side of the OPD in the intervention period were typically healthier than those on the emergent side, possibly leading to an underestimate of the overall prevalence of disease and failing to diagnose those who could benefit most immediately from ARV treatment; 2) older chronically ill patients who were repeat visitors made up a significant minority of patients in the OPD, which may limit the number of new HIV cases that can be identified in the long term; 3) the survey results are based on a subset of all patients tested and may be biased; and 4) the study took place in a semiprivate hospital, which likely has a lower prevalence of HIV compared with public facilities, making it difficult to generalize results.
An estimated 5.3 million South Africans are infected with HIV.(1) Although more than 50% of primary health facilities provide VCT, only 1 in 5 South Africans who are aware of VCT has been tested for HIV infection.(2,3) Pilot programs integrating VCT into rural primary health facilities in Kenya and South Africa are underused, despite the increasing availability of ARV.(4,5) Botswana has implemented an opt-out approach, in which all patients are tested at point of contact with the medical community unless they decline. Testing uptake in four prenatal clinics implementing this strategy in Botswana has increased from 76% to 92%.(6) Additionally, in the United States, where HIV is an order of magnitude less prevalent than in South Africa, the cost of HIV testing is significantly lower than the cost of care and treatment of patients once they are identified.(7,8)
This study supports the position that HIV testing offered routinely to all adults in a health care setting, rather than testing based exclusively on physician assessment or pregnancy status, significantly improves case finding and should be implemented more widely. Increased acceptance of testing may reflect a normalization of testing, because all patients are offered the test, regardless of age, ethnicity, or chief complaint as part of the OPD package of care. Interestingly, the median CD4 count at time of presentation in this study was similar in the standard of care and intervention groups, indicating that routine testing did not identify patients at an earlier stage of illness. Still, diagnosis of HIV-infected individuals and linkage to care are critical to improving individual health and to secondary prevention efforts aimed at slowing the HIV epidemic. Routine testing as performed in this study requires a dedicated team of counselors, which may not be feasible in all settings. However, this sort of activity does not require extensive medical training and may free up nurses and doctors for other care and treatment activities. Finally, although the cost per HIV case identified was twice as high in routine care, it was still low, especially in comparison with ARV treatment. Cost-effectiveness studies on routine testing strategies in developing settings are needed.
- United Nations Program on HIV/AIDS/World Health Organization. AIDS epidemic update, December 2005.Accessed February 12, 2006.
- Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS voluntary HIV counselling and testing in a black township South Africa. Sex Transm Infect 2003;79:442-447.
- Shinsasa O, Simbayi LC. Nelson Mandela/HSRC study of HIV/AIDS: South African National HIV Prevalence, Behavioral Risks and Mass Media, Household Survey, 2002. Cape Town, South Africa: Human Sciences Research Council; 2002. No abstract available.
- Pronyk PM, Kim JC, Makhubele MB, et al. Introduction of voluntary counselling and rapid testing for HIV in rural South Africa: from theory to practice. AIDS Care 2002;14:859-865.
- Forsythe S, Arthur G, Ngatia G, et al. Assessing the cost and willingness to pay for voluntary HIV counselling and testing in Kenya. Health Policy Plan 2002;17:187-195.
- Centers for Disease Control and Prevention. Routinely recommended HIV testing at an urban urgent-care clinic--Atlanta, Georgia, 2000. MMWR Morb Mortal Wkly Rep. 2001;50:538-541. No abstract available.
- Walensky RP, Losina E, Malatesta L, et al. Effective HIV case identification through routine HIV screening at urgent care centers in Massachusetts. Am J Public Health.2005;95:71-73.
- Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States--an analysis of cost-effectiveness. N Engl J Med 2005;352:586-595. No abstract available.