In conversation with Claire O'Connell
A positive HIV result is certainly a landmark event in a patient’s life, but early diagnosis and treatment can mean a normal life expectancy. And if a person with HIV knows their status, they can take steps to minimise the risk of passing the virus on to others.
That’s why the Mater-Bronx Rapid HIV Testing project, a collaboration between UCD, the Mater Misericordiae Hospital and the Jacobi Medical Centre in the Bronx New York, is encouraging participants to get a HIV test and ‘know your status’.
Since September 2012, more than 2,800 people attending the Mater’s Emergency Department have taken part in the screening study, which asks participants to watch an educational video, answer questions about their risk factors and take a rapid HIV test.
Early diagnosis is considered to be best practice,” says project lead at the Mater Dr Gerard O’Connor, a Lecturer in Emergency Medicine at UCD School of Medicine & Medical Science. Yet most of the study participants at the Dublin site didn’t know their HIV status, he notes: “So a big goal of the study in Dublin is trying to increase awareness of testing and normalise it, so that it is seen as pretty routine.”
How does it work? People attending the Emergency Department are asked if they want to take part in the research study. If they do, they watch a set of short videos on an interactive laptop that explain the project and the process and implications of HIV testing. They complete an online survey and they are offered a HIV test, which involves a quick swab inside the mouth - and 20 minutes later the result is ready.
The immediacy of the result is important, explains Dr O’Connor, who is a Specialist Registrar in Emergency Medicine and Clinical PhD Research Fellow with the HIV Molecular Research Group led by Dr Paddy Mallon. “It means you are not asking people to come back in a day or two, they have the answer pretty much there and then. And if it’s positive, the person is immediately linked into care.”
So far, the rate of positive testing has been in single digits per 1,000 tests. “Our rates of HIV positive acquisition are comparable to what they have been seeing in the US,” says Dr O’Connor. “And the people we have diagnosed so far have had really robust, high CD4 counts so they are hopefully going to stay healthy long into the future now that they are getting the appropriate care. Plus they are now in a position to take precautions and reduce the risk of passing HIV on to others in the community.”
The questionnaires have also been yielding some interesting findings, based on interim analysis of about 1,500 surveys. They indicate that less than one-fifth of those who have multiple sexual partners say they always use condoms. The answers also help to identify how people want to engage with the video itself, and that will help future design of the screening, explains DrO’Connor.
The project, which receives funding from an investigator-initiated unrestricted research grant through healthcare company Gilead Sciences, is now attracting interest from other sites. “We have been asked to roll it out to Manchester and Modena, and in that case Dublin will be the hub in a hub-and-spoke type model,” says Dr O’Connor. “And we have had interest from Sydney, they also want to implement this type of project.”
And the ultimate aim of the Mater project is to prove that screening can be done, even in a challenging environment like an Emergency Department:
“The ultimate short-term impact would be to argue with health policymakers to say that this is a good idea, we have proven it works, we think you should fund this.”
Injecting drug users are a high-risk group for HIV infection as well as several other clinical problems, but this group is poorly described in the medical literature, according to Dr O’Connor. So another branch of his research is looking to analyse that cohort in the Mater’s Emergency Department more closely.
We have a lot of injecting drug users in the Mater - unfortunately they get caught up in this spiral and for many of them, they never had a chance,” he says.
The new project, PRESIDNT (Prospective Epidemiological Study in to Injecting Drug Users in North Dublin), will build on preliminary research at the Mater and will build up one of the largest cohorts of its type in the world, explains Dr O’Connor.
A key outcome will be to understand the types of infection that injecting drug users are likely to experience. “Most of the previous literature would say injecting drug users are infected with Gram positive bacteria, but we have found a lot of Gram negative organisms, so we want to explore that further,” says Dr O’Connor. “Also many of them develop pneumonia, so we are looking into maybe vaccinating them as soon as they come to the Emergency Department.”
More generally, he would like to build up evidence for prioritising certain types of care for injecting drug users who present. “I would like to see some mechanism where anyone coming to an Emergency Department with injecting drug use is by definition high risk for death, so we could perhaps have more effective intervention perhaps with an improved linkage to community services.”