In both the UK (2008) and the US (2006) routine opt-out HIV screening is recommended in areas where the prevalence of HIV exceeds a certain threshold. Hospital emergency departments (ED) and acute medical units (ACU) are obvious settings where testing can be offered. Elgalib & Sabapathy (E&S), in a systematic review focussing on 14 studies (seven from the UK; seven from the US), investigate the obstacles and the facilitators for the implementation of the strategy in these hospital settings.
A systematic review of 2013, covering 30 studies (Elmahdi & Ward(STI)), found disappointingly low levels of testing in hospital departments. At Homerton hospital, Hackney (where prevalence is 8.25%), Mody & Reeves (STI) reported levels of testing of 24.3% (2014). At an AMU in Leicester, according to Palfreeman & McNally (STI), levels of testing were at 6-22% even after introduction of a pilot (2009). However, a concerted programme with three dedicated health assistants at a hospital in Brighton (with an HIV prevalence second only to London) managed to raise level of offer to 79.8% (take-up: 96.7%). The question of the nature of obstacles to hospital-based testing was addressed by the HINTS (HIV Testing In Non-Traditional Settings) reported by Thornton & Sullivan (STI) (2012).
On the whole, the findings of E&S corroborate these earlier studies (as indicated below). Adherence to guidelines is often inadequate on account of poor ‘offer’ on the part of medical practitioners rather than weak uptake by patients (E&S; Elmahdi & Ward (STI)). Most frequently cited among the perceived obstacles are those of an ‘operational’ nature, including lack of time, shortness of patient stay, and concern over handling and provision of follow-up (E&S; Thornton & Sullivan (STI)). Also cited, in both the UK and the US, are concerns over confidentiality and privacy, related to the perception of HIV as an ‘exceptional’ condition, and the concern of staff that they lacked the specialist knowledge needed to offer the test (E&S; Thornton & Sullivan (STI)). On the positive side, important facilitators were also frequently ‘operational’ in nature: the better performing systems involved non-targeted venous sampling for laboratory testing without written consent, with patients being contacted only when positive, rather than POCTs requiring provision of results and post-test counselling. But also commonly recognized as facilitators were: the commitment and enthusiasm of medical staff, especially nurses (E&S; Phillips & Elgalib (STI)), and partnership between ED/AMU staff and local HIV or infectious diseases units.
Where levels of positivity are reported in these studies, they are often not particularly high: e.g. 2/1908 in Brighton (Buba & Richardson (STI)), 4/2251 in Hackney (Mody & Reeves (STI)).