HIV in acute care: a review of the burden of HIV-associated presentations to an Emergency Department South African Family Practice is co-published by Medpharm Publications, NISC (Pty) Ltd and Cogent, Taylor & Francis Group S Afr Fam Pract ISSN 2078-6190 EISSN 2078-6204 © 2016 The Author(s) RESEARCH South African Family Practice 2016; 58(1):13–17 http://dx.doi.org/10.1080/20786190.2015.1079027 Open Access article distributed under the terms of the Creative Commons License [CC BY-NC-ND 4.0] http://creativecommons.org/licenses/by-nc-nd/4.0 HIV in acute care: a review of the burden of HIV-associated presentations to an Emergency Department B Naickera* and RC Maharaja a Division of Emergency Medicine, University of KwaZulu-Natal, Durban, South Africa *Corresponding author, email: bavaninaicker83@gmail.com Objective: To determine the burden of human immunodeficiency virus (HIV) disease and co-infection on a district-level Emer- gency Department (ED) in KwaZulu-Natal. Methods: A retrospective chart review was conducted of the case notes of adult medical patients who presented to the ED over a three-month period. Patients presenting with HIV disease and its complications were identified. Patient demographics, disease presentation and severity, investigations and procedures undertaken, and disposition of patients in the HIV-positive cohort were assessed. Results: 428 of the 861 (49.7%) medical patients presenting to the ED were HIV positive. Some 37% of patients did not know their HIV status. In the HIV-positive cohort, the median age of presentation was 37  years, with almost equal male-to-female distribution. Of the patients seen, 57.5% were referred and 68% of patients presented after hours. In total, 80% of patients were triaged as yellow code. The predominant systems involved were the respiratory and central nervous systems, with pulmonary tuberculosis, community-acquired pneumonia and meningitis being the most common diagnoses. X-rays and laboratory testing were the most common investigations requested. Lumbar punctures, pleural paracentesis and pericardiocentesis were common emergency procedures performed. The majority (89.3%) of patients were admitted to the medical ward. Of the HIV-positive patients, 33% were on anti-retroviral therapy. ED mortality was 1.9%. Conclusion: In South Africa, very little is known about the ED’s ability to cope with the HIV epidemic. This study highlights the significant impact HIV places on the resources of an ED. Strengthening of the primary health care system with a more aggressive approach to HIV testing and ARV initiation may contribute positively to reducing the burden of HIV emergencies and co-morbid- ities presenting to the ED. MeSH: Human Immunodeficiency virus (HIV); Emergency Department, South Africa, opportunistic infections; HIV testing Keywords: Emergency Department, HIV testing, human immunodeficiency virus (HIV), opportunistic infections, presentations, South Africa Introduction Human immunodeficiency virus (HIV) is a leading cause of mor- bidity and mortality in sub-Saharan Africa. More than 33 million adults are living with this pandemic globally.1 Sub-Saharan Africa accounts for more than 22.5 million people infected with HIV, accounting for 68% of the global total. Southern Africa, which includes several countries, has amongst the highest prevalence of HIV and mortality as a result of HIV and its co-infections.1 South Africa has a generalised HIV epidemic driven largely by sexual transmission. The spectrum model indicates the preva- lence in the adult population of HIV (aged 15–49  years) to be 17.9%.2 Estimates in 2012 show there are at least 6.1 million peo- ple, predominantly female, from the age of 15 and older living with the disease. HIV is consistently in the top 10 causes of mor- tality since 2008 and accounts for 3.9% of the total mortality in South Africa.1,2 Of the South African provinces, KwaZulu-Natal has the highest number of HIV-related deaths. Tuberculosis accounts for the larg- est number of these deaths (15.7%), while HIV directly accounts for 4.4%. HIV-related mortality may well be considerably higher than recorded, as mortality data are extracted from death certifi- cates and HIV as a subsidiary cause of death is not well docu- mented.3 It is postulated that the burden of HIV-related medical emergen- cies, although currently unknown, is dictated by HIV prevalence, the availability of anti-retrovirals, and the expertise of the primary health system. Despite the widespread introduction of highly active antiretroviral therapy (HAART), patients continue to present with the disease and its complications. In South Africa, very little is known about the ability of emergen- cy departments (ED) to cope with such a pandemic. There are no major studies evaluating the burden of HIV and HIV-associated emergencies in South Africa. A few studies relevant to HIV and its acute presentations have been conducted in other African coun- tries.4–6 These studies documented the demographic profile, symptomology, common anatomical systems affected and hos- pital length of stay. Only one of the studies was conducted in an emergency department.5 Our study aimed to assess the demo- graphic and disease profile of HIV-positive patients presenting to the ED and ED resource utilisation in treating HIV disease and its complications. Methods A retrospective chart review was conducted on all adult medical patients presenting to the emergency department of an urban district-level hospital in KwaZulu-Natal from March 2014 to May 2014. A simple descriptive analysis of the data was undertaken. mailto:bavaninaicker83@gmail.com http://orcid.org/0000-0002-8442-5879 14 S Afr Fam Pract 2016; 58(1):13–17 Inclusion criteria All adult medical patients who presented to the Emergency Department over the stipulated three-month period. Patients excluded Patients presenting with trauma and surgical conditions were excluded. Medical patients below the age of 11 were also excluded, as these patients were not seen in the Emergency Department. Data collection Eligible patients were identified from the ED registry and doctors’ ward-round books. The required data were then extracted onto a standardised data-collection tool form. The quality of data collected was dependent on the availability and accuracy of case notes. Incomplete documentation and illegible notes were identified. The following data were collated and analysed: number of HIV-positive patients, HIV-negative patients and patients with unknown status. In the HIV-positive cohort: patient demograph- ics, referral from clinics or ED walk-ins, time of day of presentation (working hours were defined as 08h00 to 16h00 on weekdays), triage acuity, anti-retroviral (ARV) usage, resource utilisation and patient disposition were assessed. All data were collected and transferred onto an Excel spreadsheet. Statistical analysis was undertaken using Microsoft Excel (Micro- soft, Richmond, USA) and STATA Version 13 (Stata Corp, College Station, TX, USA). Ethics Ethics approval was granted by the University of KwaZulu-Natal, Ethics committee (Ref. BE018/14) and KwaZulu-Natal, Depart- ment of Health (Ref. HRKM 96/14). Results From the ED registry, 428 patients with a confirmed diagnosis of HIV were included in the study. The consort diagram is shown as Figure 1. Table 1 lists the demographic variables studied. The respiratory and central nervous systems were most commonly involved in disease presentation. Figure 2 depicts a comprehensive review of the various systems involved. Table 2 compares the final diagno- ses per system in the HIV-positive and HIV-negative cohorts. Some patients presented with multisystem pathology. ED resource utilisation and emergency procedures performed are depicted in Table 3. Final disposition from the ED is depicted in Table 4. The causes of mortality were secondary to: • tuberculosis; • community-acquired pneumonia; • meningitis; • cardiac failure; • cerebrovascular accident. Discussion South Africa currently faces a quadruple burden of disease. HIV and HIV-associated co-infection contributes significantly to this burden of disease.7 In this study, approximately 50% of patients were HIV positive. This is above the national and provincial aver- age.7 The majority of patients were between 11 and 45  years, in keeping with national statistics.1,2 HIV transmission in SA is pre- dominantly via the sexual route, confirming the high rates in the reproductive age group in our study.1,2,8 Of note, over 3% of Figure 1: Patient profile. Table 1: Demographic profile of HIV-positive patients Demographic variables HIV positive 95% CI n (%) Age (years) Median (range) 38 (13–89) 11– ≤ 30 146 (34.1) 29–39 31– ≤ 45 157 (36.6) 32–41 46– ≤ 65 111 (26) 22–30 > 65 14 (3.2) 1.5–4.9 Gender M 210 (49) 44–54 F 218 (51) 46–56 Mode of presentation Referred 242 (56.1) 51–61 Walk in 186 (43.5) 39–49 Time of arrival Working hours 137 (32) 27–36 After hours 291 (68) 63–72 Triage acuity Red 7 (1.64) 0.4–2.8 Orange 63 (14.7) 11–18 Yellow 344 (80.4) 77–84 Green 14 (3.3) 1.6–5 No. of patients on ARVs 142 (33.1) 28–38 Figure 2: Disease aetiology per system. HIV in acute care: a review of the burden of HIV-associated presentations to an Emergency Department 15 patients over the age of 65 were HIV positive. This could be attrib- uted to the use of ARVs, which prolongs life span and slow pro- gress of the HIV disease itself, and possibly due to increased sexual risk behaviour in this age group. 8,9 We found an almost equal distribution of HIV disease between males and females. This is in contrast to previous studies that indi- cated a higher prevalence in females.1,2 This may be attributed to more extensive HIV campaigns, de-stigmatisation of HIV, targeted school education programmes and an expanded ARV pro- gramme.10 Most patients were referred from primary and community health centres to the ED. However, a significant number of HIV-positive patients presented directly to the ED. The severity of illness, pri- mary healthcare centres (PHCs) being closed after hours, and patients demanding access to a doctor could have contributed to patients accessing the ED directly in this study. More than two-thirds of patients presented after hours. This has significant logistical, human resource and financial implications for an emergency department. ED staffing is often reduced after hours; senior staff such as emergency medicine consultants and senior nurses are often not physically present after hours. Ancil- lary services such as CT scans and laboratory testing are also not readily available after hours. This prolongs ED length of stay and can result in ED overcrowding. In this study, the following factors could have contributed to in- creased after-hours ED visits: delays in ambulance transport of patients accepted from clinics; most PHC clinics in the catchment area are closed after hours; patients’ perception that there is a shorter ED waiting time after hours. The ED uses a nurse-driven South African Triage Scale (SATS) as an objective tool to determine severity of illness. The SATS uses phys- iological and clinical discriminators to assess disease acuity.11 Table 2: Comparison of disease profile in the HIV-positive and negative groups Note: *Meningitis subdivided into specific aetiology. Final diagnosis by system involved HIV positive HIV negative p-value n % n % Respiratory 230 43.1 21 19.1 0.002 Pulmonary tuberculosis 116 21.7 3 2.7 Pneumocystis Jiroveci pneumonia 13 2.4 0 0 Community-acquired pneumonia 74 13.9 12 10.9 Pneumonia (unspecified) 27 5.1 6 5.5 Neurological 166 31.1 33 30.0 < 0.001 Meningitis* 85 15.9 8 7.3 Tuberculous meningitis 31 5.8 2 1.8 Cryptococcal meningitis 23 4.3 0 0 Acute bacterial meningitis 27 5.1 6 5.5 Unspecified 4 0.7 0 0 Seizures 26 4.9 16 14.5 Psychosis 50 9.4 6 5.5 Space-occupying lesions 5 0.9 3 2.7 Gastrointestinal 66 12.4 21 19.1 0.427 Gastroenteritis 44 8.2 12 10.9 Abdominal pain unspecified 22 4.1 9 8.2 Cardiovascular 34 6.4 17 15.5 0.026 Cardiac failure 15 2.8 5 4.5 Cardiomyopathy 2 0.4 0 0 Pericardial effusion 10 1.9 2 1.8 Acute coronary syndrome 2 0.4 7 6.4 Venous thromboembolism 5 0.9 3 2.7 Dermatological 6 1.1 1 0.9 0.429 ARV induced 4 0.7 – – Other 2 0.4 1 0.9 Renal 18 3.4 12 10.9 0.281 Renal impairment 16 3.0 5 4.5 Urinary tract infection 2 0.4 3 2.7 Other – – 4 3.6 Infections (sepsis unspecified source) 14 2.6 5 4.5 16 S Afr Fam Pract 2016; 58(1):13–17 sex practices. Despite these extensive roll-out campaigns by local and national health authorities, only a third of patients in this study were on HAART. Analysis of the disease profile in our cohort indicates that more of these patients should have been on ARVs. Furthermore, 37% of patients who presented to the Emergency Department were not aware of their HIV status. Fear of the test result, risky sexual behaviour and stigmatisation still remain core barriers to HIV testing.15 With decentralisation of the ARV pro- gramme, primary health care clinics and community health care workers are often the first point of contact for HIV testing and education. The primary health care system in the catchment area will have to be reviewed and a more aggressive approach to test- ing and ARV initiation will need to be instituted. More aggressive testing would identify more patients with HIV-associated diseases and may paradoxically increase the burden of patients presenting to the ED. In high-prevalence areas, emergency departments may present with an opportunity for HIV testing. For those patients with undiagnosed HIV, and those who are not yet infected, the impact of HIV testing offers immediate clinical benefit as well as educational intervention for preventative measures.16 In general, whilst routine rapid HIV testing is not considered a key component of emergency care, a targeted, practical framework for EDs is required to integrate HIV testing as one of its core functions. Limitations This was a retrospective chart review and relied on the accuracy of the data recorded. Missing patients’ records from the ED and hospital registry could have influenced our results, as missing information was not included in the data analysis. The study was performed over a short period in a single centre and was limited to the public sector. Conclusion In South Africa, very little is known about the burden of HIV on emergency departments and its ability to cope with the HIV epidemic. HIV-related emergencies place a significant impact on the resources and burden of disease of an ED. Strengthening of the primary health care system with a more aggressive approach to HIV testing and ARV initiation may contribute positively to reducing the burden of HIV-associated emergencies and co- morbidities presenting to the ED. References 1. World Health Organisation. UNAIDS report on the global AIDS epidemic 2010. 2013 Dec 7 [cited 2015 Jan 11]. Available from: http:// www.unaids.org/globalreport/Global_report.htm. 2. UNAIDS. HIV and AIDS estimates. 2012 [cited 2015 Jan 10]. Available from: http://www.unaids.org/en/regionscountries/countries/southaf- rica/. 3. Statistics South Africa, Mortality and causes of death in South Africa. Findings from death notification. 2010 [cited 2015 Jan 8]. Available from: http://www.statssa.gov.za. 4. Tanon A, Eholie S, Binan Y, et al. Medical emergencies related to HIV/ AIDS in tropical zones: a prospective study in Cote d'Ivoire (1999–2000). Med Trop (Mars). 2006;66(2):162–6. 5. Chandra A, Firth J, Greenberger E, et al. HIV-related presentations to the emergency centre in Botswana. Afr J Emerg Med. 2012;2(4):163–164. 6. Thinyane K, Cooper V. Clinical profiles of HIV-infected, HAART-naive patients admitted to a tertiary level hospital in Maseru, Lesotho. Inter- net J Infect Dis. 2013 [cited 2015 Jan 11];11(1). Available from: https:// ispub.com/IJID/11/1/14457. 7. Bradshaw D, Groenewald P, Laubscher R, et al. Initial burden of disease estimates for South Africa, 2000. S Afr Med J. 2003;93(9):682–8. More than 95% of patients were triaged as moderate and high-acuity presentations, indicating the severity of illness pre- senting to the ED. Respiratory and neurological pathology were the most common systems affected in the HIV-positive cohort. Opportunistic infections accounted for most of the disease pres- entations. This compares to other studies, which found that respira- tory complaints and opportunistic infections were amongst the most common causes for hospital presentation.4–6 In the HIV-nega- tive cohort, the neurological, respiratory and gastrointestinal tract systems were the most commonly involved and more disease presentations were of a non-infective aetiology. A total of 1 217 investigations and procedures were performed on the HIV-positive cohort. Almost all patients had laboratory and radiological investigations. Lumbar puncture, pleural paracente- sis and pericardiocentesis were the common emergency proce- dures performed in the ED. The need for extensive testing is an indicator of the severity and complexity of disease in HIV-positive patients presenting to the ED. Our study revealed a higher admission rate (89%) to the general medical wards than previous studies.5,6 Furthermore, 3.8% of patients were also transferred to the regional level of care directly from the ED. This further reinforces the severity and complexity of pathology in the HIV-positive population. Over the stipulated period, the ED mortality in the HIV-positive group was 1.9%, slightly higher than the overall ED mortality rate of 1%. The introduction of HAART in 2004 in the public sector has im- proved survival rates and quality of life in HIV-positive patients.12 Previous guidelines recommend HAART be commenced when CD4 counts are less than 350 cells/μL, or when a clinical criterion for AIDS-defining diseases is present.13 Recent revision of the guidelines recommend initiation of HAART treatment in patients with CD4 less than 500 cells/μL14 and in HIV-positive partners in sero-discordant relationships.13 Emphasis is also placed on safe- Table 3: HIV-positive cohort: investigations and procedures performed in the ED Investigations n = 428 (%) Blood sample testing 428 (100) X-ray 405 (94.5) ECG 85 (19.9) Ultrasound 75 (17.5) Lumbar Puncture 86 (20) Sputum testing 69 (16) CT scans 44 (10.3) Pleural paracentesis 20 (4.7) Pericardiocentesis 5 (1.2) Table 4: Disposition of patients from the ED Disposition n = 428 (%) 95% CI Discharge 22 (5.14) 3–7.2 Admitted to medical ward 382 (89.3) 86–92 Referred to regional centre 16 (3.8) 2–5.6 Died 8 (1.9) 0.6–3.1 http://www.unaids.org/globalreport/Global_report.htm http://www.unaids.org/globalreport/Global_report.htm http://www.unaids.org/en/regionscountries/countries/southafrica/ http://www.unaids.org/en/regionscountries/countries/southafrica/ http://www.statssa.gov.za https://ispub.com/IJID/11/1/14457 https://ispub.com/IJID/11/1/14457 HIV in acute care: a review of the burden of HIV-associated presentations to an Emergency Department 17 14. National consolidated guidelines for the prevention of mother-to- child transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults. 2014 [cited 2015 May 05]. Available from: http://www.sahivsoc.org/practise-guidelines/national-dept-of- health-guidelines. 15. De Koker P, Lefevre P, Matthys F, et al. Barriers to VCT despite 13 years of community-based awareness campaigns in a peri-urban township in northern Limpopo. S Afr Med J. 2010;100(6):364–5. 16. Kecojevic A, Lindsell CJ, Lyons MS, et al. Public health and clinical impact of increasing emergency department–based HIV testing: perspectives from the 2007 conference of the national emergency department Hiv testing consortium. Ann Emerg Med. 2011;58(1):S151– 159. 8. Hontelez JA, Lurie MN, Newell ML, et al. Ageing with HIV in South Africa. AIDS. 2011;25(13):1665–7. 9. Negin J, Martiniuk A, Cumming RG, et al. Prevalence of HIV and chronic comorbidities among older adults. AIDS. 2012;26(1):S55–63. 10. Fairlie L, Sipambo N, Fick C, et al. Focus on adolescents with HIV and AIDS. S Afr Med J. 2014;104(12):897–903. 11. Gottschalk SB, Wood D, DeVries S, et al. The cape triage score: a new triage system South Africa. Proposal from the cape triage group. Emerg Med J. 2006;23(2):149–153. 12. Cornell M, Technau K, Fairall L, et al. Monitoring the South African National Antiretroviral Treatment Programme, 2003–2007: the IeDEA Southern Africa collaboration. S Afr Med J. 2009;99(9):653–60. 13. Meintjes G. Adult antiretroviral therapy guidelines. S Afr J HIV Med. 2014 [cited 2015 Jan 11]. Available from: http://www.sajhivmed.org. za/index.php/hivmed/article/view/330. Received: 08-06-2015 Accepted: 28-07-2015 http://www.sahivsoc.org/practise-guidelines/national-dept-of-health-guidelines http://www.sahivsoc.org/practise-guidelines/national-dept-of-health-guidelines http://www.sajhivmed.org.za/index.php/hivmed/article/view/330 http://www.sajhivmed.org.za/index.php/hivmed/article/view/330 Introduction Methods Inclusion criteria Patients excluded Data collection Ethics Results Discussion Limitations Conclusion References