Assessment of the HIV Enhanced Access Testing in the Emergency Department (HEATED) program in Nairobi, Kenya: a quasi-experimental prospective study

Abstract

Background: Persons seeking emergency injury care are often from higher-risk and underserved key populations (KPs) and priority populations (PPs) for HIV programming. While facility-based HIV Testing Services (HTS) in Kenya are effective, emergency department (ED) delivery is limited, despite the potential to reach underserved persons.

Methods: This quasi-experimental prospective study evaluated implementation of the HIV Enhanced Access Testing in Emergency Departments (HEATED) at Kenyatta National Hospital ED in Nairobi, Kenya. The HEATED program was designed as a multi-component intervention employing setting appropriate strategies for HIV care sensitization and integration, task shifting, resource reorganization, linkage advocacy, skills development and education to promote ED-HTS with a focus on higher-risk persons. KPs included sex workers, gay men, men who have sex with men, transgender persons and persons who inject drugs. PPs included young persons (18-24 years), victims of interpersonal violence, persons with hazardous alcohol use and persons never HIV tested. Data were obtained from systems-level records, enrolled injured patient participants and healthcare providers. Systems and patient-level data were collected during a pre-implementation period (6 March - 16 April 2023) and post-implementation (period 1, 1 May - 26 June 2023). Additional, systems-level data were collected during a second post-implementation (period 2, 27 June - 20 August 2023). HTS data were evaluated as facility-based HIV testing (completed in the ED) and distribution of HIV self-tests independently, and aggregated as ED-HTS. Evaluation analyses were completed across reach, effectiveness, adoption, implementation and maintenance framework domains.

Results: All 151 clinical staff were reached through trainings and sensitizations on the HEATED program. Systems-level ED-HTS among all presenting patients increased from 16.7% pre-implementation to 23.0% post-implementation periods 1 and 2 (RR = 1.31, 95% CI: 1.21-1.43; p < 0.001). Among 605 enrolled patient participants, facilities-based HTS increased from 5.7% pre-implementation to 62.3% post-implementation period 1 (RR = 11.2, 95%CI: 6.9-18.1; p < 0.001). There were 440 (72.7%) patient participants identified as KPs (5.6%) and/or PPs (65.3%). For enrolled KPs/PPs, facilities-based HTS increased from 4.6% pre-implementation to 72.3% post-implementation period 1 (RR = 13.8, 95%CI: 5.5-28.7, p < 0.001). Systems and participant level data demonstrated successful adoption and implementation of the HEATED program. Through 16 wk post-implementation a significant increase in ED-HTS delivery was maintained as compared to pre-implementation.

Conclusions: The HEATED program increased overall ED-HTS and augmented delivery to KPs/PPs, suggesting that broader implementation could improve HIV services for underserved persons already in contact with health systems.

Keywords: Africa; HIV; HIV testing; Kenya; emergency medical services; health systems.

Figure 1:

Study Population^{† †} Systems level and patient participant level data are mutually inclusive

Figure 2.

HIV Services With Implementation of the HIV Enhanced Access Testing in the Emergency Department Program ^†Risk ratios outcomes based on comparison of data aggregating post-implementation periods 1&2 with the pre-implementation period as the baseline. ^‡Emergency Department HIV Testing Delivery aggregates both facility-based HIV testing and distribution of HIVST kits ^§Eligible People Living With HIV included those not currently on antiretroviral treatments and discharged from the hospital alive ^¶Key populations include sex workers, men who have sex with men, gay persons, transgender persons, and persons who inject drugs. Priority populations include persons 18-24 years of age, victims of interpersonal violence, persons who screened positive for hazardous alcohol use on the Alcohol Use Disorders Identification Test, persons never previously HIV tested

Figure 3.

HIV Testing Cascade Pre- and Post-implementation of the HIV Enhanced Access Testing in the Emergency Department Program Stratified by Key and Priority Populations^{† †}Key populations (KP) include sex workers, men who have sex with men, gay persons, transgender persons, and persons who inject drugs. Priority populations (PP) include persons 18-24 years of age, victims of interpersonal violence, persons who screened positive on the Alcohol Use Disorders Identification Test (AUDIT-C), persons never previously HIV tested

Figure 4.

Systems Level HIV Testing Services Delivery Across Study Periods^{† †}Biweekly average proportion of persons who received HIV testing services with associated 95% confidence intervals