Tailoring HIV testing in a setting of late HIV diagnosis: is the tide turning?

Introduction: Routine HIV testing in areas of high HIV prevalence has been shown to be both cost effective and to avert downstream morbidity and mortality from 'late' HIV diagnosis (defined as CD4 cell count <350 cells/ml). In the London borough of Waltham Forest in 2010, late HIV diagnoses were resulting in high morbidity with associated lengthy and costly hospital admissions. Methods: A retrospective analysis of all new HIV diagnoses was undertaken within a two-phased quality improvement project 2010-13. Newly diagnosed patients in 2010 were characterized, including immunological state, presence of HIV-related illness and department where they presented. After an intervention to set up an opt-out, walk-in rapid HIV testing service in outpatients, an analysis was conducted of numbers of tests, prevalence and immunological state of newly diagnosed patients in 2013. Results: A total of 91 patients were diagnosed with HIV, January December 2010, 70% of which were a late diagnosis, including 48% defined as 'very immunosuppressed' (CD4 count <100 cells/ml). Of these, 51 out of 91 patients (56%) had attended hospital services in the 5 years before diagnosis, including 204 outpatient department attendances. After the intervention, rates of late diagnosis in 2013 had reduced to 46%, and rates of those diagnosed 'very immunosuppressed' had reduced from 48% to 8%. Conclusions: HIV testing in outpatients is feasible and acceptable to patients and can be offered alongside routine outpatient care. The rate of positive HIV tests in this group of patients in the authors' setting has been much higher than the HIV positivity rate of larger scale HIV testing interventions in other hospital settings. This approach also provides a model for more integrated care of HIV-positive patients.