Modest Public Health Impact of Nontargeted HIV Screening in 29 Emergency Departments Anne-Claude Crémieux, Kayigan Wilson d’Almeida, France Lert UNIVERSITE DE VERSAILLES SAINT QUENTIN-EN-YVELINES

Competing interests Grants for consultancies, workshops, or travel to meetings from:  Novartis  Janssen-Cilag  Sanofi-Aventis  Heraeus  Astra-Zeneca

HIV-screening in France  Easy access to free HIV-testing services  5 million HIV tests  5 million HIV tests performed each year for 65 million inhabitants  However, late diagnosis remains common 6,500 new HIV diagnoses in /3 with AIDS or CD4 lymphocytes <200/µL

HIV-infected people unaware of their infection in 2010  Estimation in France: 33% (50,000/150,000) of individuals living with HIV  UK and US 20–25% of those living with HIV

Nontargeted HIV-screening in healthcare settings  Promoted by national heath agencies United States in 2006 United Kingdom France in 2010 Supported by studies showing  Supported by studies showing People unaware of their infection or diagnosed at late stages did not belong to traditional high-risk groups Cost-effectiveness of this strategy  However, the efficacy of this strategy Remained controversial (Haukoos, JAMA 2010) Never tested on a large-scale Poorly implemented

The goals of our study (2009–2010)  Assess the public health impact of nontargeted HIV- rapid test-screening among ED patients in the metropolitan Paris region (11.7 million inhabitants) Metropolitan Paris region: 50% of France’s new HIV diagnoses 25% of inhabitants visit an ED annually  Estimate the 2009–2010 undiagnosed-HIV prevalence in the metropolitan Paris region

Study methods (May 2009–Sept 2010)  Performed in 29 EDs (50% of all patients seen at EDs in the region)  6-week period in each ED (randomly assigned)  HIV-rapid test (OraQuick, whole blood) offered to all 18–64-year-old patients (opt-in), along with a self- administered questionnaire (demographics, sexual behavior, HIV- testing history)  HIV-RT performed on a 24-hour basis By the local ED-nursing team When needed, assisted by a member of the research team (present on site for 8 H every day)  RT results Negative results delivered by nurses Positive results disclosed by ED doctor; blood collected for ELISA/WB, follow-up visit with an on-site infectious disease specialist within 72 hours

138,691 Patients seen in Emergency Departments (May 09–Sept 10) 78,411 (56.5%) Eligible 60,280 (43.5%) Excluded 20,962 (26.7%) Offered screening 13,229 (63.1%) Accepted 7,733 (36.9%) Refused 12,754 (16.3% of those eligible) Screened 57,449 (73.3%) Not offered 11,356 Questionnaires filled out  HIV-screening performed by the ED team alone in 14/29 EDs and with research assistant support in 15 ED  High acceptance rate (62.8% vs 63.5%) in both groups  16.3% of eligible patients were tested Similar to other ED studies performed in US Higher for ED teams working alone (27% vs 12.5%, p<0.01)

37 (0.29%) Confirmed infection (ELISA, Western Blotting) 18 New diagnoses 0.14% (95% CI 0.008–0.22) (12 linked to care) 16 Repeated diagnoses 38 HIV-RTs reactive 1 False-positive result (viral hepatitis) 3 Excluded secondarily* Newly diagnosed HIV infections 12,754 Patients screened * Patients excluded because they were unable to give informed consent when RT were ordered for diagnostic purposes by the ED physican.

Variable New HIV Diagnoses in EDs* (N=18) n (%) [95% CI] National HIV-Case Surveillance* (N=3008) n (%) [95% CI] Age, mean, (95% CI)32.9 [28.4–37.4]37.3 [36.8–37.7] Previous HIV test13 (72.2) [46.5–90.3]1519 (50.5) [48.7–52.3] HIV-related symptoms8 (44.4) [21.5–69.2)]1024 (34.0) [32.3–35.8] CD4 lymphocyte count <2005 (27.8) [6.5–49.1]424 (14.1) [12.9–15.4] 200–3503 (16.7) [3.6–41.4]284 (9.4) [8.4–10.5] >3504 (22.2) [6.4–47.6)]634 (21.1) [19.6–22.6] Unknown (lost for follow up)6 (33.3) [13.3–59.0]1667 (55.4) [53.6–57.2] *Multiple imputation was used to estimate missing data for previous HIV tests Characteristics of Patients with New HIV Diagnoses in EDs or National HIV-Case Surveillance

Complementary study to evaluate the covariates of HIV-RT refusal: 7 EDs, 1404 consultants, 655 eligible, 404 accepters (61%), 251 refusers ParameterOR [95% CI) Age0.998 [0.98–1.01] Sex Female1 Male1.20 [0.82–1.76] Country of birth France1 Sub-Saharan Africa1.31 [0.71–2.39] Previous HIV-test reported No1 Yes2.04 [1.37–3.04] Self-perceived HIV risk vs general population High self-perceived risk1 Low self-perceived risk12.02 [2.60–55.58] Don’t know3.42 [0.71–16.45]

Undiagnosed-HIV Prevalence in France Based on Nontargeted Screening in Emergency Departments  Standardization method was used to take into account the difference between the ED-tested population and the general population of the Paris region.  After standardization, the overall expected prevalence of undiagnosed-HIV infections in the metropolitan Paris region was estimated to be 0.09% (95% CI 0.04–0.13).  That rate corresponds to 6,742 [2,996–9,739] 18–64 year olds unaware of their infections among the 7.5 million 18 – 64- year-old inhabitants. nationwide, undiagnosed-HIV infections in 18–64 year olds would be close to 15,300 (about 10% of the 150,000 persons living with HIV),  Since this region harbors 44% of France’s new HIV diagnoses, the expected number of nationwide, undiagnosed-HIV infections in 18–64 year olds would be close to 15,300 (about 10% of the 150,000 persons living with HIV), far below the available figure of 50,000 (one-third of those living with HIV) unaware of their infection.

Conclusions  ED-based HIV-RT–screening is feasible and can reach large numbers of patients.  Nontargeted screening identified only a few new diagnoses, often at late stages, and, unexpectedly, most newly diagnosed patients belonged to high-risk groups and had been tested previously.  Undiagnosed HIV infections were found almost exclusively in high-risk populations and with a lower than expected prevalence.  Universal testing strategy should be questioned in France.  ED nurse-based repeated-targeted screening of subpopulations thought to be at higher risk deserves further investigation

Acknowledgments  Multidisciplinary investigating team: Kayigan Wilson d’Almeida, Gerald Kierzek, Pierre de Truchis, Stéphane Le Vu, Dominique Pateron, Bertrand Renaud, Caroline S le, Vanina Bousquet, Yann Le Strat, François Simon, Didier Guillemot, France Lert  Emergency Department teams of the 29 hospitals participating in the study  Monitoring team (J Leblanc, S Mas…)  Infectious disease and virology specialists of the 29 hospitals  OraSure Technologies Inc, Bethlehem, Pennsylvania  ANRS  Sidaction