Transforming HIV Outcomes: Croydon's Opt-Out Testing success
Introduction
Croydon University Hospital has more than 500 beds and serves a population of approximately 360,000 people providing a wide range of services including acute hospital care, specialist healthcare, and community services.
Croydon is an area of extremely high HIV prevalence (>5/1000) with areas of significant socio-economic deprivation and had the highest rate of late HIV diagnosis in London in 2012.
Late diagnosis of HIV means being diagnosed with HIV when the immune system is already significantly weakened, with a CD4 count below 350 cells/mm3. These patients are at risk of severe life-changing opportunistic infections and cancers.
We manage a large cohort of HIV positive patients (>1000), many of whom are from groups that are disproportionately diagnosed late including heterosexuals, Black Africans, and older adults.
Our cohort is 65% Black-African, 50% female and 60% over 50 years age.
These groups are often missed by traditional HIV testing sites such as antenatal and sexual health services and significant numbers of patients were only being diagnosed after developing AIDS defining illnesses leading to hospitalisation.
Our prospective HIV inpatient database started 2005 showed that up to 70% of these patients had received a blood test in our hospital and could have been diagnosed earlier.
Methods
Collecting data prospectively on all inpatient admissions and outpatients from 2005 allowed us to benchmark patient outcomes prior to any interventions.
In 2011 we proved universal HIV testing was acceptable (91% agreed) by carrying out surveys in over 100 inpatients.
Working with AIDSMAP in 2013 we interviewed patients for an article `Tales of the late diagnosed'. A common theme was a feeling their HIV test should have been done routinely and before they got ill.
Between 2017 and 2019 most of our inpatient work involved patients who were not accessing care, many had high rates of poor mental health. In 2019 we also presented data showing that 1 in 3 HIV outpatients had significant levels of depression, anxiety or insomnia.
Effective multi-disciplinary team collaboration between the HIV, Clinical Biochemistry, Emergency Department (ED) and IT teams has been the key to successful development of our Standard Operating Procedure, implementation and sustained high levels of testing.
All patients undergoing venepuncture have an HIV test automatically added to blood request unless they opt-out. Posters highlighting the program are displayed throughout the department. A separate blood sample is sent to the biochemistry lab for a highly sensitive single assay 4th generation HIV test. Duplicate testing within 6 months is blocked unless overridden. All non-negative HIV results are sent to the HIV team. Patients with a reactive result are contacted to attend for point of care same day instant HIV test and if confirmed are linked to care immediately.
Our work from patient databases and mental health surveys provided evidence for a business case to implement opt-out HIV testing in ED and for a second complimentary business case for an enhanced mental health support team consisting of consultant psychiatrist, specialist mental health nurse and psychologist. Perseverance was essential in gaining approval and funding.
Results / outcomes
Funding was approved early 2020 and we launched the program May 2020.
Prior to our program a local audit showed 9/1047 inpatients were tested for HIV. Opt-in HIV testing had been tried but has been proven to be unsustainable leading to the updated 2020 BHIVA HIV Testing guidelines recommending Opt-Out methodology. Using the opt-out method, we have sustained 97% testing rate for over 5 years, carrying out over 200,000 tests, diagnosing more cases than all other testing sites combined. We are now managing over 100 additional HIV positive patients, either newly diagnosed or re-engaged.
Rates of AIDS Defining Illnesses (ADIs) in newly diagnosed HIV inpatients has fallen from 78% (2005-2010), 46.5% (2017-2019) to 27% (2020 onwards). Average inpatient stay has reduced from 35 days to 10 days, ITU admissions from 16% to <3%, mortality to <3%, readmission rate from 31% to 10%.
This prompt recognition and treatment of opportunistic infections has directly led to improved outcomes and reduced healthcare inequalities in our population.
In the pretesting era (2017) we identified 92 positive partners for 250 index patients (37%) partner positivity rate. Post implementation the first 23 partners we tested were all HIV negative. We have found a marked reduced partner positivity rate from 37% to 8% in the post testing era, showing tantalising progress towards the 2030 target of zero new HIV transmissions.
The quality of HIV care has also been improved as we are aware of any HIV positive patient (ours or from other centres) attending the hospital, so we are aware of any ED attendance with illness, drug overdose or mental health crisis. We hold an MDT with our embedded specialist mental health team twice monthly to improve quality of care.
Awareness of hospitalisation also means we can reduce drug-drug interactions with anti-retroviral therapy in any admitted patients.
Conclusions / next steps
Opt-out HIV Testing is sustainable maintaining 97% testing rate since 2020 and is critical to patient safety.
It has transformed patient outcomes in an area which had the highest rate of late diagnoses in London in 2012, reducing severe healthcare inequalities adversely affecting our population.
Earlier recognition of HIV in inpatients is vital for recognition of any opportunistic infections as survival is linked to prompt recognition and treatment.
We have identified opportunistic infections in patients who had visited the ED and had been discharged. For example, Cerebral toxoplasmosis and PCP treated as outpatients.
There are numerous examples of patients who would have been wrongly diagnosed, including fever in a returning traveller thought to have malaria, weight loss and diarrhoea patient referred for endoscopy (later cancelled as diarrhoea settled with anti-retroviral therapy).
The reduction in ADI presentations saves money and resources because of reduced hospitalisation and readmissions from later complications like Immune Reconstitution Inflammatory Syndrome.
The reduction in ADIs may explain the apparent reduction in partner positivity as ADIs often lead to extremely high HIV viraemia and therefore increased infectiousness. Of course, earlier diagnosis will also reduce the duration of partners’ exposure. We have identified several expectant fathers as being HIV positive whose pregnant partners had had a negative HIV test in first trimester and would not normally be retested, thereby preventing possible seroconversion in pregnancy and a double HIV transmission. A situation unfortunately that has happened in the past.
In terms of scalability, 3 waves of national expansion have now identified over 7,000 cases of Blood Bourne Virus helping progress towards the 2030 targets of zero new HIV transmissions, zero preventable HIV deaths and elimination of hepatitis.
Normalisation of testing using this approach has increased HIV awareness and is helping to tackle HIV stigma nationally.
