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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 53  |  Issue : 2  |  Page : 287-289
Relevance of opt-out screening for HIV in emergency and pre-surgery patients in a tertiary care center in Northern India: A pilot study


1 Department of Immunopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
4 Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication12-Jun-2010
 

   Abstract 

Objective: A preliminary opt-out screening study for HIV was conducted in a tertiary care hospital in India according to Center for Disease Control (CDC) guidelines. A total of 876 cases were screened for HIV during August 2007 to December 2007 using tests approved by the National AIDS Control Organization (NACO). Results: Data indicates that the prevalence of HIV in emergency and pre-surgical setting was 21 per thousand at the tertiary care center. Positivity rate in the pediatric population was 20.9 per thousand while in adults it was 21.4 per thousand. Most patients were totally unsuspected. Nearly 40000 patients seek admission annually to the emergency department alone. Thus nearly 700 to 800 patients may be missed every year if one does not resort to such a practice. Conclusion: Since India has the second largest number of HIV cases in the world, opt-out screening program and testing in an emergency setting, as recommended by CDC, is extremely relevant. Logistics of implementation of this policy need to be worked out at a national level.

Keywords: HIV, opt-out screening, screening

How to cite this article:
Minz RW, Singh S, Varma S, Mathuria S N, Aggrawal R, Sehgal S. Relevance of opt-out screening for HIV in emergency and pre-surgery patients in a tertiary care center in Northern India: A pilot study. Indian J Pathol Microbiol 2010;53:287-9

How to cite this URL:
Minz RW, Singh S, Varma S, Mathuria S N, Aggrawal R, Sehgal S. Relevance of opt-out screening for HIV in emergency and pre-surgery patients in a tertiary care center in Northern India: A pilot study. Indian J Pathol Microbiol [serial online] 2010 [cited 2017 Jan 17];53:287-9. Available from: http://www.ijpmonline.org/text.asp?2010/53/2/287/64334



   Introduction Top


The National AIDS Control Organization (NACO), in India, augmented by the state AIDS societies, are involved in surveillance, safe blood supply, strengthening sexually transmitted diseases (STD) treatment services, preventing mother-to-child transmission of Human Immunodeficiency Virus (HIV), etc., but the much awaited plateau has still not been reached in most states. [1],[2]

It is well known that 'high-risk groups' do face a proportionately higher risk of infection, yet many go undiagnosed till late in the course of disease. [3] HIV/AIDS is also a difficult challenge for practicing surgeons worldwide. Patients also risk being infected by surgeons and other healthcare workers and vice versa.[4] According to the prevalent practice in the institute, all surgeons prefer to know the HIV status of the patient undergoing major surgery so that they can use special disposable drapes and augment universal precautions. Recently, Center for Disease Control (CDC) has revised the guidelines for HIV testing and introduced 'opt-out screening' expanded screening in healthcare settings with streamlined procedures for consent and pretest information doing away with written consent and permitting patients to opt out of the test if they so desire. [5] The CDC has laid down clear guidelines for different groups of patients who can be offered opt-out screening.

Several studies now document that "many HIV-infected patients make numerous healthcare visits in acute care and primary care settings but are not tested for HIV until late in the course of their disease; too late to derive optimal benefit from antiretroviral therapy". [6],[7] The present communication describes the results of an opt-out screening program in an emergency setup and in pre-surgical patients reporting primarily to the medical emergency and neurosurgery units, respectively.


   Materials and Methods Top


In the present preliminary study, a total of 846 serum samples were received in department of a tertiary care hospital during the period of August 2007 to December 2007 as a part of 'opt-out screening' program. The selection was random in case of emergency patients. However, all patients undergoing neurosurgery were included in the study. Out of these 846 samples, 239 belonged to pediatric population (0 to 14 years of age) and rest 607 samples were adults. Approximately 30% of the patients were to undergo surgical intervention, rest were from the medical emergency departments undergoing investigations for jaundice, suspected tuberculosis, suffering from opportunistic infections like candida, wasting etc. The patients were recruited from neurosurgery unit as they pose extra risk to the surgeon. Patients, even with a low degree of suspicion, were tested for HIV infection and it was not a blind study. All the samples were tested for HIV by rapid kits e.g. Signal HIV test, Comb AIDS test (Span diagnostics, Surat, India), Immunocomb II HIV test, (Orgenics, Israel). Any serum found reactive by the first assay was retested using two other assays based on a different antigen preparation as recommended by NACO i.e. N EVA rapid test, (Cadila Pharmaceuticals, India) and finally by an indirect micro ELISA (J Mitra and Co., India).


   Results Top


Out of 607 adult patients, 13 patients were positive for HIV with a positivity rate of 2.14%. In the pediatric population on the other hand, 5 out of 239 (2.09%) were positive. The overall positivity was 2.1% (21 per thousand). [Table 1] gives the details of the patients tested: The positive patients from the emergency included those with varied diagnosis such as lymphadenopathy, hepatitis C infection, wasting, carcinoma of the cervix, tuberculous meningitis, fever, pneumonia. An orphan child from Mother Teresa's home also tested positive. Another child showing signs of failure to thrive was also found to be suffering from retroviral infection.

A patient of non-Hodgkin's lymphoma had been on treatment for several months and was already on chemotherapy. He was tested only when he became febrile. Only one child had a risk factor, i.e. the parent had died of AIDS. Thus, out of 18 tested positive, 17 totally unsuspected patients showed HIV infection. All patients were referred to the antiretroviral therapy center (ART) for treatment. No patient was denied surgery but extra precautions were taken for HIV positive patients


   Discussion Top


National Family Health Survey (NFHS), released by NACO, estimates the national adult HIV prevalence to be approximately 0.36% in the country. [2] It is obvious that the prevalence is much higher in a hospital setting even in unsuspected population. In 2006, CDC published recommendations for a major change in the approach to testing for HIV infection in the United States and expanded screening in healthcare settings with streamlined procedures for consent and pretest information. [5] The CDC's specific recommendations for healthcare settings included all persons aged between 13 to 64 years, all patients initiating treatment for tuberculosis or sexually transmitted diseases, prospective new sex partners and others. Further, CDC recommended that HIV testing should be repeated annually in high-risk patients. It is envisaged that HIV testing in India would become a part of routine service in the high-risk states in near future, especially when free treatment is being given to all patients. CDC released the new guidelines to encourage testing to pick up early or undiagnosed patients with retroviral infection. Since HIV is now treatable and NACO provides free drugs, it would actually be unethical to deny them treatment.

In a recent study from USA, HIV infection was detected among 11.6% of patients referred by healthcare providers for testing, compared with 1.2% of patients who were offered routine screening. Further, the disease was more advanced in patients referred by providers. A CD4 count <200 cells/mL was observed in 82% of provider-referred patients, compared with 45% of the patients identified through routine screening. [8] We did not include the CD4 counts in this particular study. However, they were done to initiate therapy in all cases as desired by the physician. Our value of 2.1% is distinctly higher than the NACO figure of 0.36%. According to the recommendations of CDC, if the prevalence is <1 per thousand, testing should be discontinued. In this study positivity rate is 21 per thousand. On an average, 40000 patients seek emergency help annually, which means that approximately 700 to 800 HIV infections may be missed in a year. Thus, the value of screening in emergency setting cannot be overemphasized.

According to statistics, an average of 7 to 9 years elapse before diagnosis is made but patients continue to transmit the disease to spouse, partners etc. Early diagnosis and therapy confers distinct survival advantages especially if the CD4 counts are maintained at the time of starting therapy. HIV screening can contribute substantially to timely diagnosis of patients with acute illness, early treatment, hence limit transmission and cause change in behavior.

The health research and educational trust (HRET), in partnership with the American Hospital Association (AHA), have developed a practical guide for clinicians and administrators seeking to incorporate routine HIV testing in their emergency departments. [9] This document outlines different approaches, considerations and resources for making HIV testing routine in emergency departments. The society of general internal medicine makes similar recommendations. [10] Rapid tests using whole blood have a distinct advantage. [11] Out of more than a million Americans living with AIDS, 25% go undiagnosed [12] The CDC recommended universal testing and counseling for HIV in September 2006. [13] American college of physicians and HIV medical association (HIVMA) issued guidance to routinely screen patients for HIV in December 2008. According to Openhaver, implementing recommendations of CDC is the only way to reduce the decade long yearly rate of 40000 new HIV cases in the United States. [14] Voluntary counseling and testing in women, and treatment for those who require it, has eliminated mother-to-child transmission of HIV in the United States and a similar concept needs to be applied to other patients because late initiation of therapy often results in poorer response and untreated persons are more likely to transmit the virus to others. Stringer et al.[15] have recommended universal nevirapine upon presentation in labor to prevent mother-to-child HIV transmission in high prevalence setting. Kitahata et al.[16] recently emphasized that early treatment is far superior for survival vis-a-vis late treatment.


   Acknowledgments Top


The study was funded by the Director Postgraduate Institute of Medical Education and Research, Chandigarh, India.

 
   References Top

1.Health minister launches third phase of NACP, UNAIDS/NACO/WHO. 6 th July 2007 Ministry of health and family welfare. Available from: http://pib.nic.in/release/release.asp?relid=29036 . [last cited on 2007 Jul 10].  Back to cited text no. 1      
2.HIV/ AIDS epidemiological surveillance and estimation report for the year 2005, NACO; April 2006. Available from: http://www.nacoonline.org/fnlapil06rprt.pdf . [last cited on 2007 Mar 9].  Back to cited text no. 2      
3.Jenkins TC, Gardner EM, Thrun MW, Cohn DL, Burman W. Risk-base human immunodeficiency virus (HIV) testing fails to detect the majority of HIV-infected persons in medical care settings. Sex Transm Dis 2006;33:329-33.  Back to cited text no. 3      
4.Ol Olaopade EO, Salami MA, Afolabi AO. HIV/AIDS and the surgeon. Afr J Med Sci 2006;35:7-83.  Back to cited text no. 4      
5.Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, clark JE. Revised recommendations for HIV testing in adults, adolescents and pregnant women in health care settings. SMMWR Recomm Rep 2006;55:1-17.  Back to cited text no. 5      
6.Beckwith CG, Flanagan TP, del Rio C, Simmons E, Wing EJ, Carpenter Charles CJ, et al. It is time to implement routine, not risk-based, HIV testing. Clin Infect Dis 2005;40:1037-40.   Back to cited text no. 6      
7.Bayer R, Fairchild AL. Changing the paradigm for HIV testing--the end of exceptionalism. N Eng J Med 2006;355:647-9.  Back to cited text no. 7      
8.Lyss SB, Branson BM, Kroc KA, Couture EF, Newman DA, and Weinstein RA. Detecting unsuspected HIV infection with a rapid whole blood HIV test in an urban emergency department. J Acquir Immun Defic Syndr 2007;44:435-42.   Back to cited text no. 8      
9.Health Research and Education Trust: Practical Guide for Emergency Department Services. Available from: http://www.edhivtestguide.org 10 th August 2008  Back to cited text no. 9      
10.Society of General Internal Medicine: Importance of HIV screening in health care setting. Available from: www.sgim.org/go/HIV. 10th August 2008  Back to cited text no. 10      
11.Gupta A, Chaudhary VK. Whole-Blood Agglutination Assay for on-site detection of Human Immunodeficiency Virus Infection. J Clin Microbiol 2003;41:2814-21.   Back to cited text no. 11  [PUBMED]  [FULLTEXT]  
12.Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003 [abstract T1-B1101]. Presented at: 2005 National HIV Prevention Conference; Atlanta: 2005.  Back to cited text no. 12      
13.CDC′s revised recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings; Fact Sheet: Centers for Disease Control and Prevention - Thursday, September 21, 2006.   Back to cited text no. 13      
14.Openhaver MM, Fisher JD. Experts outline ways to decrease the decade-long yearly rate of 40,000 new HIV infections in the US. AIDS Behav 2006;10:105-14.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  
15.Stringer JS, Sinkala M, Goldenberg RL, Kumwenda R, Acosta EP, Aldrovandi GM. Universal nevirapine upon presentation in labor to prevent mother-to-child HIV transmission in high prevalence settings. AIDS 2004;18:939-43.  Back to cited text no. 15      
16.Kitahata MM, Gange SJ, Abraham AG, Merriman B, Saag MS, Justice AC, et al. Effect of Early versus Deferred Antiretroviral Therapy for HIV on Survival. N Engl J Med 2009;360:1815-26.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
S Sehgal
Department of Immunopathology, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: Director Postgraduate Institute of Medical Education and Research, Chandigarh, India, Conflict of Interest: None


DOI: 10.4103/0377-4929.64334

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