162 HIV Testing Practices and Provider Attitudes in Belize Emergency Care

Belize has the highest HIV prevalence in Central America and 4th highest in the Caribbean, impacting 1.2-1.5% of the general population and up to 13% in at-risk populations. As of 2014, less than 25% of the childbearing population in Belize has been tested for HIV or knows their HIV status. Only half of those diagnosed with HIV are on highly active antiretroviral therapy (HAART). Almost half (48%) of the cases of newly diagnosed HIV present in advanced stages of the disease (CD4<200). The majority of newly diagnosed HIV cases are in the urban Belize District (65%), which is served by Karl Heusner Memorial Hospital (KHMH) in Belize City. KHMH is the national referral facility, with an annual Accident and Emergency (A&E) volume of 25,000 visits/year. In the global setting, emergency settings often serve as the only access to care for urban populations without regular access to health care and represent an important target for HIV screening. The goals of this novel investigation are to evaluate current testing practices and provider attitudes towards HIV testing in the emergency care setting. A retrospective chart review was completed of all A&E visits with a rapid HIV test sent at KHMH from July 1, 2015 to December 31, 2015. Information was abstracted into a secure electronic database on patient demographics, visit chief complaint and disposition, HIV test results, follow-up and stage of diagnosis. To assess reported provider practices and attitudes, a questionnaire was developed using questions from prior validated surveys and reviewed by local key stakeholders and content area experts. Research staff administered the questionnaire in structured interviews with 13 emergency providers at the A&E of KHMH. Responses were analyzed using basic computational software. During the study period, 154 HIV tests were sent, for a testing rate of 1.2%. The majority of those tested were women (61%), over half of whom were pregnant (51.5%), and an average age of 31 years old. Of all HIV tests sent, 13 were positive, a rate of 1.0% of all visits and 8.4% of all tests sent, and 5 were new diagnoses of HIV. Of all new HIV diagnoses, three were diagnosed at an advanced stage (CD4<200). All 5 newly diagnosed patients had follow-up visits or repeat emergency visits and two began medical treatment. All emergency providers had treated a patient with HIV and 85% had sent an HIV test within the last 30 days. The majority of providers (62%) reported minimal to some prior training in HIV care. However, most providers (92%) felt very or somewhat comfortable counseling about HIV testing and believed all patients with clinical suspicion should be tested for HIV. Most providers (85%) believed patient privacy was a barrier to HIV testing and an additional 77% believed patient willingness to be tested and time were barriers to testing. In contrast, nearly all providers (92%) did not believe cost was a testing barrier. KHMH A&E HIV testing is lower than WHO recommendations for high prevalence populations. Patients with new diagnoses of HIV in A&E were tested based on clinical suspicion and presented in late stages of disease. Providers overall felt comfortable testing for HIV but lacked specific HIV training, revealing a need for increased education. Increasing A&E HIV testing could aid in early diagnosis of HIV and linkage to care in populations at high risk for HIV. Next steps include development of a provider education curriculum and evaluation of provider changes in HIV screening practices.