Opportunities and Challenges to Emergency Department-Based HIV Testing Services and Self-Testing Programs: A Qualitative Study of Healthcare Providers and Patients in Kenya

BACKGROUND: Young people in Sub-Saharan Africa, especially males, have been insufficiently engaged through HIV Testing Services (HTS). In Kenya, younger persons are often treated in emergency departments (EDs) for injuries, an interaction where HTS and HIV self-testing (HIVST) can be leveraged. Data from stakeholders on ED-HTS and HIVST is lacking and needed to understand opportunities and barriers for HIV testing and care, and inform program implementation. METHODS: Between December 2021 and March 2022, 32 in-depth interviews (IDIs) were conducted with 16 male and 16 female patients who had been treated in the Kenyatta National Hospital (KNH) ED, half of whom had been HIV-tested. Six focus-group discussions (FGDs) were also conducted with 50 nurses, doctors, HIV testing counselors, and administrators working in the ED. All transcripts were double-coded and thematically analyzed using Dedoose software and a parallel inductive and deductive coding approach which allowed for capture of both a priori and emergent themes. RESULTS: Patients and providers agreed that ED-HTS are facilitated by friendly staff, patient education, high perceived HIV risk, and confidentiality. However, ED-HTS is limited by burdens on staff, resources, time, and space, as well as severity of patient injuries limiting ability to consent to or prioritize HIV testing. These limitations provide opportunities for ED-HIVST: particularly the ability to test at a comfortable time and place, especially when provided alongside sufficient HIV and testing education, contact with healthcare providers, and psychosocial support. Barriers for ED-HIVST where identified and as patients’ concerns about HIVST accuracy and mental health impacts of a positive test, as well providers’ identified barriers on their concerns for loss to follow up and inability to complete confirmatory testing. COM-B Model [Figure: see text] Application of the COM-B Model of Behavior Change to ED-HIVST Acceptability in Kenya CONCLUSION: ED stakeholders are receptive to HTS and HIVST, and patients desire the opportunity to use HIVST. Potential challenges—such as psychological effects of testing positive, worries about access to follow-up care, and confusion about how to self-administer testing, may be addressed through programming designed to promote education, access and ensure follow-up mechanisms. DISCLOSURES: All Authors: No reported disclosures

Assessment of substance use among injured persons seeking emergency care in Nairobi, Kenya

Introduction: Trauma is a leading cause of morbidity and mortality in Kenya. In many countries, substance use is common among patients presenting with injuries to an emergency center (EC). Objective: To describe the epidemiology of self-reported substance use among adult injured patients seeking ED care in Nairobi, Kenya. Methods: This prospective cross-sectional study, assessed patients presenting with injuries to the Kenyatta National Hospital ED in Nairobi, Kenya from March through June of 2021. Data on substance use, injury characteristics and ED disposition were collected. Substances of interest were alcohol, stimulants, marijuana, and opiates. The Alcohol Use Disorders Identification Test-Concise (AUDIT-C) tool was used to characterize hazardous alcohol use. Results: A total of 1,282 patients were screened for participation, of which 646 were enrolled. Among participants, 322 (49.8%) reported substance use in the past month (AUDIT-C positive, stimulants, opiates, and/or marijuana). Hazardous alcohol use was reported by 271 (42.0%) patients who screened positive with AUDIT-C. Polysubstance use, (≥2 substances) was reported by 87 participants in the past month. Median time from injury to ED arrival was 13.1 h for all enrolees, and this number was significantly higher among substance users (median 15.4 h, IQR 5.5 - 25.5; p = 0.029). Conclusions: In the population studied, reported substance use was common with a substantial proportion of injured persons screening positive for hazardous alcohol use. Those with substance use had later presentations for injury care. These data suggest that ED programming for substance use disorder screening and care linkage could be impactful in the study setting

Facility-Oriented Simulation-Based Emergency Care Training in Kenya: A Practical Approach for Low- and Middle-Income Countries

One of the major obstacles to delivering effective emergency care in developing countries is a lack of adequate training. Facility-oriented, simulation-based emergency care training programs developed locally present an opportunity to improve the quality of emergency care in low- and middle-income countries. We describe the development and implementation of the emergency care course in Kenya and the strengths, weaknesses, opportunities, challenges, and recommendations for locally developed facility-oriented simulation-based emergency care training

HIV self-testing acceptability among injured persons seeking emergency care in Nairobi, Kenya

Background Emergency department-based HIV self-testing (ED-HIVST) could increase HIV-testing services to high-risk, under-reached populations. Objectives This study sought to understand the injury patient acceptability of ED-HIVST. Methods Injury patients presenting to the Kenyatta National Hospital Accident and Emergency Department were enrolled from March to May 2021. Likert item data on HIVST assessing domains of general acceptability, personal acceptability, and acceptability to distribute to social and/or sexual networks were collected. Ordinal regression was performed yielding adjusted odds ratios (aOR) to identify characteristics associated with high HIVST acceptability across domains. Results Of 600 participants, 88.7% were male, and the median age was 29. Half reported having primary care providers (PCPs) and 86.2% reported prior HIV testing. For each Likert item, an average of 63.5% of the participants reported they ‘Agree Completely’ with positive statements about ED-HIVST in general, for themselves, and for others. In adjusted analysis for general acceptability, those <25 (aOR = 1.67, 95%CI:1.36–2.08) and with prior HIV testing (aOR = 1.68, 95%CI:1.27–2.21) had greater odds of agreeing completely. For personal acceptability, those with a PCP (aOR = 3.31, 95%CI:2.72–4.03) and prior HIV testing (aOR = 1.83, 95%CI:1.41–2.38) had greater odds of agreeing completely. For distribution acceptability, participants with a PCP (aOR = 2.42, 95%CI:2.01–2.92) and prior HIV testing (aOR = 1.79, 95%CI: 1.38–2.33) had greater odds of agreeing completely. Conclusions ED-HIVST is perceived as highly acceptable, and young people with prior testing and PCPs had significantly greater favourability. These data provide a foundation for ED-HIVST programme development in Kenya