We read with interest the study by Hernández-Febles et al.,1 in which they describe the experience in a Canary Islands hospital where the request for HIV serology was made standard for 16 months, with 6407 tests and the diagnosis of 18 new cases (0.3%). Late diagnosis and occult infection are two problems that are still prevalent here in Spain, and so we believe it is of great importance to have strategies such as those shared in this article.
Since 2021, the Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) [Spanish Society of Emergency Medicine] has been implementing the “Deja tu huella” (DTH) [Leave your mark] programme in hospital Accident and Emergency (A&E) departments, in which it recommends requesting an HIV serology in six specific circumstances: sexually transmitted infections; community-acquired pneumonia; herpes zoster; chemsex; mononucleosis syndrome; and post-exposure prophylaxis.2 The project seeks to minimise missed diagnostic opportunities, which remains a problem in our healthcare setting.3 From January 2021 to June 2024, 170,256 serologies were performed, and 1997 new cases of HIV infection were diagnosed (positive rate of 1.17%). Currently, 161 hospitals are participating in the programme throughout Spain.
In the Autonomous Region of the Canary Islands, eight of the nine public hospitals now participate in this initiative, after gradually joining over the past few years. Table 1 shows the results obtained, with 13,168 serologies and 124 new infections, which represents 28.7% of the new diagnoses made in the Canary Islands.4 The weight of A&E diagnoses compared to the overall number of diagnoses underscores the importance that A&E departments can have in the fight against HIV. From 2022 to 2023, the number of serologies performed tripled, despite the fact that only one new centre was incorporated into the project. The reason is the implementation of automated alerts in the electronic medical records of the A&E, to prevent a patient who meets the requirements from going unnoticed in a busy department such as A&E, and avoid lost opportunities.
Results of the “Deja tu huella" [Leave your mark] programme in the Canary Islands.
| Year | Participating hospitals | Serologies performed | New diagnoses | Positivity rate % | New diagnoses made in the Canary Islands | Rate of new diagnoses in the A&E compared to the overall rate % |
|---|---|---|---|---|---|---|
| 2022 | 5 | 3699 | 50 | 1.35 | 193 | 25.9 |
| 2023 | 6 | 9469 | 74 | 0.78 | 238 | 31.1 |
| Total | 6 | 13,168 | 124 | 0.94 | 431 | 28.7 |
DTH: "Deja tu huella" [Leave your mark]; A&E: Accident and Emergency department.
We also want to point out that the DTH project has been evaluated in recent years through various scientific studies, which have led to the recent publication of new recommendations.5 First, although the DTH programme has achieved good results, there is still room for improvement in adherence to the established recommendations,6 which has led to the incorporation of information on how to establish or make pre-configured computer alerts, such as those implemented in the Canary Islands. Second, we have found that half of the serologies and new diagnoses are in centres not included in the DTH, due to a cultural change in A&E physicians, which makes them more sensitive to thinking about HIV. The reasons for requesting and its level of efficiency were analysed7 and, based on the results, three new situations were included: thrombocytopenia; fever without known aetiology after assessment in A&E; and migrants. The third recommendation comes from the fact that nursing participation has increased serology requests by 20%,8 so it is recommended to include this group directly in the programme, both in each hospital and in the coordination of the programme. Fourth, the DTH programme is being carried out with an opt-in strategy, but the document discusses the legal viability and strategic advantages that an opt-out strategy may have to increase the number of new diagnoses, an issue widely debated in the literature.9 Fifth and last, in different studies carried out in A&E departments on HCV screening, the conclusion was that active infection is higher among the population treated in A&E than in the general population. Consequently, following the guidelines of a consensus document recently published by SEMES,10 it has been decided to include the request for HCV when requesting HIV.
In conclusion, any strategy aimed at diagnosing the hidden fraction of HIV and early diagnosis is positive for the general population, by interrupting the chains of transmission, and for the patients themselves, as it improves their prognosis by giving them the chance of starting antiretroviral treatment as soon as possible.
FundingNone.
