Dr David Itua Uhuebor

Question:
A South African Relevant, Comprehensive, Current, Evidence Based, Level
appropriate paper to the ED Medical and Nursing Staff at a Secondary level
Provincial Hospital in Polokwane concerning the unique position of the ED in
providing HIV testing as a Public Health Service to Society.

Introduction
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Limpopo province of the nine provinces in South Africa has the fourth largest population. 1 It
is considered to be a poor province with approximately 87% of its population living in the
rural areas.1 Polokwane is in the Capricorn district municipality of Limpopo with a population
of 508 272 which is the largest population in the five municipalities of Capricorn with a
gender distribution of more females than males and an ethnic population of 96.40% Black
Africans with the greatest percentage of the population between the ages of 0 39 years of
age.2
Capricorn district municipality has in the public health sector 86 clinics, 3 Community
Health Centres, 31 Mobile services, 8 district hospitals, no regional hospital, 2 provincial
hospitals and 1 specialised hospital.1Of the 8 district hospitals (which is above the average
number per district), 2 are in Polokwane in addition to the two provincial hospitals
(Polokwane / Mankweng Hospital Complex: two hospitals situated 30 kilometres apart in
Polokwane and Turfloop).

1, 3

The utilisation of primary health care facility level care has

remained at a persistently low level of 1.9 visits per year and a nurse clinic workload of 13
patients per day1 which may be attributed to the proximity of the health facilities resulting in
direct transfer of patients from the clinics and district hospitals directly to the provincial
hospital complex.

A hospital is expected to provide services to patients based on its

category, however in reality, the Polokwane /Mankweng Hospital Complex offers secondary
level care in addition to dealing with primary and tertiary cases. In a retrospective study that
evaluated the emergency department (ED) in the Polokwane / Mankweng Hospital
Complex, a total of 41 768 patients consulted at the ED between 2006 / 2007. 1
The total number of persons living with HIV in South Africa increased from an estimated
4.21 million in 2001 to 5.38 million in 2011. 4 The emergency department serves a point of
entry into the health care system in Polokwane/Mankweng Hospital and it represents an
opportunity to diagnose HIV infection in individuals presenting acutely to the emergency
department 5.
In 2006, the Centre for Disease Control (CDC) released revised recommendations for HIV
testing that recommend routine screening of patients ages 13 64 in all health care
settings, including hospital emergency departments; 6 directed towards promoting further
reduction of HIV acquisition and transmission. 7 The guidelines released by CDC give
explicit emphasis to the role of emergency physicians, based on the fact that the
emergency department (ED) in most cases represents the only source of medical care for
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many patients and serves often times as the primary site for routine health care to
communities at risk for HIV.7 ED are often busy and fast-paced environments and HIV
testing is often perceived to be impractical due to pre- and post- test counselling
requirements, as well as difficulties in ensuring access to care. 5 Despite the time and
practical limitations inherent in ED practice, many studies suggest that routine HIV
counselling, testing, and referral in the ED may be feasible and effective. 7
This paper reviews various studies and relates it to the context of South Africa in a way that
is relevant to the ED in the provincial hospital in Polokwane, with a comprehensive, current
and evidence-based finding concerning the unique role of the ED in providing HIV testing
as a public health service to the society.

ROLE OF THE EMERGENCY DEPARTMENT AND EMERGENCY HEALTH CARE

WORKERS IN HIV TESTING
HIV and AIDS is one of the most important challenges facing South Africa today. 8 As it is in
the case of Polokwane, Limpopo, HIV disproportionately affects populations of colour and
lower socio-economic background that are likely to be without a regular source of care or
have a history of barriers to care and for whom the ED may provide their first or only
interaction with a health care provider.7,9 This in itself may contribute to delayed diagnosis
and further transmission of HIV.9

Rationale for the ED as a Critical Site

Emergency health care workers serve as a vital link to the population at high risk for HIV
infection in Polokwane. They have the opportunity to initiate HIV preventive services for
millions of people who have no other point of entry into the health care system and to
promptly identify unrecognized HIV infections by directing at-risk patients to HIV testing and
appropriate counselling.7
Prevention to date is the is the only means of reducing the acquisition and transmission and
early awareness of HIV status is the first step in obtaining appropriate medical care and
allows patients to receive timely prevention counselling and therapeutic interventions. 10 The
emergency department is strategic in encouraging patients to be tested and know their HIV
status.7
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PUBLIC HEALTH BENEFITS OF HIV TESTING IN THE ED

In the past, the quick diagnosis of HIV infection was not of particular great use to the
individual with a poor prognosis since there was no effective treatment available 5 other than
reduced high-risk behaviours in certain populations

11

. In the mid-1990s things changed

because there was documented evidence of the benefits of combined anti-retroviral therapy
that improved the health of HIV-infected individuals by lowering the HIV viral load which
reduced risk of transmission to others.
More recently, evidence of the public health benefits of HIV testing in the emergency room
is emerging:
a) Behaviour change following HIV testing:
People who are newly diagnosed with HIV infection are a critical population for
prevention interventions, particularly individuals with co-occuring sexually transmitted
infections (STIs).12 The knowledge of HIV status has been associated with a
reduction in risk behaviour in HIV-positive individuals, with less evidence of benefits
in HIV-negative individuals.5 Although the majority of HIV infections occur in southern
Africa, there is little research available on the behavioral characteristics of people
who seroconvert for HIV in this region 13. One study of Kenyan commercial sex
workers showed that women who sero-converted for HIV demonstrated significant
reductions in risk practices, with further risk behaviors diminishing over advancing
HIV disease14. Furthermore, from the United kingdom and the United states there is
good evidence that HIV testing and counselling is an effective strategy to reduce the
risk of onward transmission among people with diagnosed HIV, through increased
condom use with partners of unknown or negative HIV status and having fewer
sexual partners15-17. Randomized control trials done in the United States show that
rapid testing, nurse-initiated testing and brief counselling that are practical for the
emergency department situation resulted in similar impact on sexual risk behaviour
following testing when compared with standard testing and counselling 18,19. In a
meta-analysis of eight studies from the United States comparing the rates of selfreported unprotected intercourse of HIV-positive persons both aware and unaware of
their status, it was found that the rates of unprotected intercourse were 53% lower in

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individuals who were aware of their HIV status compared to those unaware of their
status. 20
b). Reduced Morbidity and Mortality: In a series of studies done by Kelen et al it was
discovered that Emergency-department based HIV testing detected a significant
number of new HIV infections earlier than it would have otherwise being detected 21.
The effect was translated into a significantly high number of patients entering into
treatment programmes as against those referred from other health care sites. The
conclusion thereof was that the emergency department as in this case, Polokwane
could play a major role in the strategy of a government in early detection of HIV,

21

which reduces morbidity and mortality ultimately. The advent of Highly Active Antiretroviral Therapy (HAART) has improved the prognosis for individuals with HIV
infection7. In countries where antiretroviral therapy is highly available, access to
treatment has greatly reduced HIV-related morbidity and mortality in a data
analysed from 70 European HIV centres, there was a fall in HIV-related deaths from
14.6 per 100 person years pre-HAART to 1.5 post-HAART and over the same study
period,22 the number of persons diagnosed with AIDS defining-illnesses fell from 27.4
per 100 pre-HAART to 2.6 per 100 late-HAART22.
c). Increased Life Expectancy: According to the World Health Organisation (WHO),
global average life expectancy increased to 68 years from 66 years between 2000
and 200923. Reduction in AIDS-related deaths across Europe has contributed to
improved life expectancy of individuals infected with HIV 5. The predicted life
expectancy with effective antiretroviral therapy varies; however with mathematical
modelling, studies estimate that life can be prolonged for another 20 to 50 years for
individuals who start therapy at 20 years of age 2326.
The figures released by the WHO for South Africa shows that life expectancy
dropped to 54 years from 56 years 27. Up to 50% reduction in life expectancy is
estimated in patients with CD4 < 200 cells/m3 at the time of starting therapy 2325. HIV
testing that ensures early diagnosis is therefore a key strategy to prevent
progression of HIV to advanced stage of the disease 5 with the resultant public health
benefit of improved life expectancy.

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d). Cost-effectiveness: The cost-effectiveness of HIV testing is dependent on factors

such as HIV prevalence, testing and counselling costs amongst others 5 .With the
high burden of HIV in South Africa testing strategies would have a strong impact on
cost-effectiveness. In a recent analysis done in 2010 of the cost-effectiveness of HIV
counselling and testing strategies it showed that nurse-initiated routine screening
with rapid HIV testing and brief counselling (that is feasible for the setting of the
emergency department (ED) in the Polokwane / Mankweng Hospital Complex) was
cost-effective compared with standard HIV testing and counselling strategies 28.
The projected lifetime cost of treatment and care of HIV-infected individuals is
substantial because the cost of treatment and care for individuals diagnosed late
with HIV is considerably high 5. A Canadian study reported that HIV-infected patients
with CD4 less than 75 cells/mm3 cost over 2.5 times more per month to treat
compared to patients with CD4 greater than 200 cells/mm3, with the cost of inpatient hospitalisation care accounting for most of the difference 29. In the Capricorn
district municipality where Polokwane / Mankweng Hospital complex is located in,
the primary health care expenditure increased by R104 over a period of four years 1.
This cumulative increase reflects in the national budget of South Africa in the 2012
estimates of national expenditure, R121 billion was allocated to the Department of
Health in the year 2012/2013 as against the R113 billion in 2011. 30 The allocation to
health alone is 12.2% of the national budget of R1.06 trillion and as stated by the
Finance Minister Pravin Gordham, the medium term priorities in health spending
include comprehensive HIV/AIDS treatment and prevention programmes. 30
e). Effect of Anti-retroviral therapy on HIV Incidence Rates: Routine HIV testing at
the emergency department has the promise of identifying infected individuals earlier. 6
There is growing evidence that the combination of early diagnosis and fast tracking
on anti-retroviral therapy can both substantially improve the health of those infected
with HIV by reducing the viral load which prevents transmission of new infections
thereby reducing HIV incidence at the population level 5, 6.
A meta-analysis was carried about by researchers at the WHO which estimated that
the transmission rate from an individual on anti-retroviral therapy is approximately
0.5 per 100 person-years, compared to 5.6 per 100 person-years for an individual
not on anti-retroviral treatment 29. Quite a number of mathematical models have
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estimated a substantial decrease (3763%) in HIV incidence with anti-retroviral

behaviour31,33. Despite its drawback, these data has led some to advocate for greater
antiretroviral therapy use in the prevention of HIV

34

so as to benefit the general

population.
f). Promoting greater good to the Society through HIV testing: HIV testing in the
emergency department as it relates to the PMHC would not only provide a gateway
to HIV prevention, care and treatment but also provide public health benefits based
on the knowledge of the HIV status at the level of the individual, the community and
the population35.
- For the Individual: there is enhanced ability to reduce the risk of acquiring or
transmitting HIV infection; access to HIV care, treatment and support; and the
protection of unborn infants (providing access to interventions for preventing motherto-child transmission)35.
- For the Community: the wider knowledge of HIV status and its links to interventions
can lead to a reduction in denial, stigma and discrimination and to a collective
responsibility and action35.
-

At the population level: the knowledge of the epidemiological trends of HIV infection

can influence the policy environment, normalize HIV/AIDS and reduce stigma and
discrimination35.
Other societal benefits that could result from HIV testing in the emergency
Department of Polokwane / Mankweng Hospital Complex are: The opportunity to
prepare the minds of family and loved ones to plan for future orphan care and make
a will35. The ease of acceptance of HIV serostatus and the development of coping
strategies by the individual and the larger population would encourage the
normalisation of HIV/AIDS and further reduce stigmatization 35. It would also facilitate
referral to social and peer support and promote access to early medical care for
opportunistic infections, sexually transmitted infections, highly active anti-retroviral
therapy and preventive therapy for tuberculosis 35. The pre-test and post-test
counselling would promote and facilitate behaviour change 7 and increase access to
family planning services including condoms 35.

CONCLUSION AND RECOMMENDATIONS

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The Emergency Department represents the only source of medical care for many patients

which has shifted the responsibility for preventive care to the emergency department health
care worker36. Individuals who visit the ED for routine medical care are an especially
important target group for HIV counselling, testing, and referral because early knowledge of
HIV status is crucial to preventing the spread of infection. 7 Emergency care personnel are
on the front line of HIV counselling, testing, and referral for a segment of the population that
might otherwise never receive such services 7. For many individuals who are at risk for HIV
infection, the emergency physician or nurse may be the only health care provider they see.
The Centre for Disease Control has recognized the unique and critical role that emergency
physicians and other healthcare workers can play in reducing the acquisition and
transmission of HIV and is asking for increased involvement of the ED community in HIV
counselling, testing, and referral 7. Despite the limitation of time in EDs, many studies have
shown that routine HIV counselling, testing, and referral in the ED is feasible and is
effective7.
The most important and significant potential impediments that might be associated with
instituting ED-based HIV testing programme at the Polokwane / Mankweng Hospital
Complex (as described by the CDC-convened ED focus group, as well as others) include
time, sufficient personnel, allocation of responsibility, cost, and reimbursement 37,38.
Although these barriers represent challenges - these obstacles will likely disappear as the
practical problems associated with ED-based testing specific to PMHC and the community
being served are solved, and providers, hospital administrators, and public health
policymakers gain an increased appreciation of the critical impact emergency physicians,
nurses and other health care workers can have on the HIV epidemic 7.

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