UNIVERSITE DE VERSAILLES SAINT QUENTIN-EN-YVELINES

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

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

3. HIV-screening in France • Easy access to free HIV-testing services • 5 million HIV tests performed each year for 65 million inhabitants • However, late diagnosis remains common • 6,500 new HIV diagnoses in 2011 • 1/3 with AIDS or CD4 lymphocytes <200/µL

4. 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

5. Nontargeted HIV-screening in healthcare settings • Promoted by national heath agencies • United States in 2006 • United Kingdom • France in 2010 • 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 2006 2010

6. 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

7. 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

8. 138,691 Patients seen in Emergency Departments (May 09–Sept 10) 60,280 (43.5%) Excluded 78,411 (56.5%) Eligible 57,449 (73.3%) Not offered 20,962 (26.7%) Offered screening 7,733 (36.9%) Refused 13,229 (63.1%) Accepted 12,754 (16.3% of those eligible) Screened 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)

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

12. Characteristics of Patients with New HIV Diagnoses in EDs or National HIV-Case Surveillance *Multiple imputation was used to estimate missing data for previous HIV tests

13. Complementary study to evaluate the covariates of HIV-RT refusal: 7 EDs, 1404 consultants, 655 eligible, 404 accepters (61%), 251 refusers

14. 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. • 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.

15. Conclusions ED-based HIV-RT–screeningis 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

16. Acknowledgments • Multidisciplinary investigating team: Kayigan Wilson d’Almeida, Gerald Kierzek, Pierre de Truchis, Stéphane Le Vu, Dominique Pateron, Bertrand Renaud, Caroline Semaille, 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