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Page 2 of 9 Original Research

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the quality of life, and reduces HIV transmission. Since 2015, EDs of the Nelson Mandela Academic Hospital (NMAH) and
the South African National Strategic Plan on HIV, sexually the Mthatha Regional Hospital (MRH) in the Eastern Cape
transmitted infections and tuberculosis has recommended Province, from 27 June to 03 September 2017.
provider-initiated HIV counselling and testing (HCT) to
all persons attending healthcare facilities as a standard Study site
component of medical care, including trauma, casualty, and
specialty clinics. Nonetheless, the provision of HCT The study was conducted in Mthatha, a rural town in the
6,7
in healthcare facilities is often hindered by the lack of South African province of the Eastern Cape, a region that
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standardised training and by competing clinical care supports 12.6% of the country’s population. The area faces a
priorities that prohibit effective service delivery. In addition, disproportionate burden of acute injuries and illnesses with
5,7
7
resources for HCT have largely been directed to primary high rates of HIV and tuberculosis. It is also one of SA’s
healthcare centres and antenatal clinics or are focused on poorest provinces and is a key priority area for HIV research
7
high-risk populations such as sex workers, men who have and capacity building. Both hospitals are affiliated with the
sex with men, injection drug users, and prisoners. As a Walter Sisulu University. Nelson Mandela Academic Hospital
8,9
result, individuals who do not interact with the healthcare is a large tertiary-care referral centre with 24-h trauma
system through these channels, such as young men, often services, seeing only patients requiring specialty or surgical
miss being tested. interventions referred from other district-level facilities.
Mthatha Regional Hospital is a district-level facility that
In SA, 90% of the population accesses healthcare through the provides care to walk-in patients and referrals from adjacent
public sector. For 28%, the emergency department (ED), a maternal and childcare facilities. The EDs provide 24-h
setting that provides high-volume care, is their only point of coverage and see 100–150 patients daily from the surrounding
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contact. In the United States of America, the ED is 100-km catchment area. Both sites are relatively low-resourced
recognised by the Centers for Disease Control and Prevention and not equipped with an electronic medical record (EMR)
to be a crucial venue in implementing the national HIV system, patient tracking system or standardised triage
testing strategy. Seminal studies have not only quantified processes. Furthermore, there are no providers specialising
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the burden of HIV infection in EDs but also have been critical in emergency medicine at these sites.
to shaping the US national strategy for HIV; they could
similarly address unmet testing needs in SA. 11,12,13,14 In low- Study population
and middle-income countries (LMICs), HIV prevalence in Patients presenting to the ED who were aged 18 years and
EDs may be high, for example, 19% in Papua New Guinea older and clinically stable (defined as the South African
and 50% in Uganda. 15,16 Provision of HIV testing in the ED Triage Scale designation of ‘non-emergent’) were included
could thus be a critical intervention in curbing the epidemic. in the study. Triage scores were assigned by trained study
Its acceptance in acute care settings, however, has not been staff, based on the South African Triage Scale (SATS).
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widely evaluated in sub-Saharan Africa. Studies have Patients younger than 18 years, not able to provide informed
primarily focused on rates of acceptance, without exploring consent (i.e. patients with a depressed level of consciousness
the reasons behind patients’ decisions. Ascertaining the or mentally altered) or undergoing active resuscitation were
perspectives of patients, especially of those who decline excluded.
testing, enables the identification of barriers to service
delivery and the development of effective strategies to Recruitment and sampling
increase HIV diagnosis and linkage to care.
All patients presenting to the ED during the study period
In this exploratory observational study, to determine the who met the inclusion criteria were approached by trained
feasibility of expanding an ED-based HIV testing strategy in HCT staff, informed of the ongoing study and offered a
SA, we investigated patient perspectives on accepting or point-of-care HIV test. Written informed consent was sought
declining HCT and quantified the burden of HIV infection in for testing and participation in a survey that asked about
the ED while implementing the nationally recommended reasons for accepting or declining the test. Patients with a
HCT programme. This study will assist policymakers and known HIV-positive diagnosis were asked if they had access
healthcare providers to inform the integration of HCT in the to an antiretroviral (ARV) clinic, if they were on regular
clinical care pathway and optimise HCT service delivery in treatment and whether they were aware of having developed
this venue, resulting in early engagement in care and AIDS or being virally suppressed. Data were also collected
treatment initiation, ultimately reducing HIV-associated on patient demographics, presenting complaint, presenting
morbidity and mortality. symptoms and past medical history.

Methods HIV counsellors approached all eligible patients in a large
waiting room after they underwent initial triage and
The Walter Sisulu Infectious Diseases Screening in Emergency administrative processes. Patients consenting to the study
Departments (WISE) Study was a prospective observational were escorted to a private room for testing if possible,
study. HIV counselling and testing was implemented in the whereas patients assigned a bed were tested at the bedside

http://www.sajhivmed.org.za 203 Open Access