Implementation of routine HIV testing policy in medical admissions in the sultanate of Oman: An experience from the Middle East

Abstract

Objectives

To tackle the issue of late HIV diagnosis in the country, the Ministry of Health (MOH) in Oman introduced a national policy of routine opt-out HIV in medical admission units in September 2022. We hereby report the implementation and outcomes of this policy.

Method

All patients aged 16–65 years admitted to a medical ward in secondary and local hospitals were offered an HIV test regardless of their symptoms by medical doctors, with training and support from HIV teams. A retrospective review for the period from September 2022 to September 2023 was conducted to determine the HIV testing rate and outcomes of those testing HIV seropositive.

Result

Over 12 months, there were 23,399 admissions; 6889 had HIV tests. Thirty-two patients (0.46 %) were diagnosed with HIV; all of them were new diagnoses. Two cases were diagnosed during seroconversion. 12 cases had AIDS-defining illnesses. Four contacts were tested HIV positive. Twenty-five out of 28 alive patients are on ART.

Conclusion

This is the first national policy of a routine opt-out HIV in medical admission units in the MENA region. Our experience showed that, even in low HIV prevalence and high HIV stigma settings, this policy is feasible, acceptable, and effective.

Keywords

AIDS < viral disease ART (antiretroviral therapy) < other HIV (human immunodeficiency virus) < viral disease screening < other

Introduction

Early initiation of HIV treatment and strict adherence to treatment can enable people living with HIV to achieve life expectancy comparable to the general population.¹ This is a significant milestone in HIV treatment and highlights the importance of timely diagnosis and consistent treatment. It’s a well-established fact that the treatment of HIV significantly reduces infectivity to the point where transmission becomes negligible, provided there is sustained viral load suppression.²

Despite the remarkable progress of antiretroviral treatment of HIV, HIV and acquired immunodeficiency syndrome (AIDS) remains a global public health threat.³ According to WHO and Joint United Nations Program on HIV/AIDS (UNAIDS), 38.4 million people were living with HIV worldwide in 2021, 650, 000 died as a result of AIDS-related deaths.⁴

Late diagnosis is a major concern due to its negative impact on individuals and communities as it is associated with increased morbidity and mortality rates, as well as a considerable escalation in the cost of treatment.^5,6 Moreover, people who are aware of their HIV status can modify their behavior compared to those who aren’t aware of their HIV status.⁷

In 2006, the Center for Disease Control and Prevention (CDC) updated its recommendation for HIV testing to encourage HIV universal screening for all individuals aged 13–64 in all medical settings annually, irrespective of their risk behavior.⁸ A published study has demonstrated the cost-effectiveness of HIV screening in a population with HIV prevalence of undetected infection of 0.1 or more is equal to screening for hypertension or colon cancer.⁹

WHO recommends that 95% of people living with HIV should know their HIV status by 2030.¹⁰ However, the UNAIDS data showed that 85% of people living with HIV in Oman were aware of their HIV diagnosis in 2022.¹¹ Moreover, recently published study showed that the rate of advanced HIV disease and late diagnosis from 2000 to 2019 was 43% and 71%, respectively.¹² Oman National HIV guidelines recommend HIV testing based on HIV-disease indicators.¹³ However, evidence shows that many cases are still being missed,¹⁴ highlighting the need to reevaluate and improve the current approach.

The country has implemented a variety of measures to combat late diagnosis and undiagnosed HIV, including providing comprehensive training for healthcare workers (HCWs) regarding the importance of early diagnosis and introducing a Primary Healthcare manual to guide best practices in HIV testing. Furthermore, increasing awareness campaigns in the community to improve the knowledge about HIV and its prevention. The objective of this study is to report the implementation and outcomes of a policy of routine opt-out HIV testing in Medical admissions that was introduced by MOH of Oman in September 2022.

Methods

The first case of HIV diagnosed in Oman was in 1985, and 3 years later, the National AIDS Program (NAP) was formed. The UNAIDS data show that Oman has stable HIV incidence (0.07 per 1000 adults) and prevalence (0.2 per 1000 adults) from 2010 to 2019. A total of 4000 were diagnosed with HIV from 1984 to 2023, with 74% being men and 26% women. The country has 14 treatment centers offering HIV care, including viral load, CD4, and genotypic resistance tests. In 2015, Oman adopted a treatment-for-all policy regardless of CD4 account.

We reviewed the data of patients admitted to medical wards who were diagnosed with HIV from October Oct 2022 to October 2023. They were all Omani nationals aged 16–65. All government hospitals were informed of the policy through official email, followed by a visit from the HIV central team to the medical doctors and nurses, including the HIV focal points in the regions. Communication tools such as verbal consent to patients and also disclosing the result were the responsibility of medical doctors and HIV focal points.

We analyzed the data retrospectively to identify the number of patients who were admitted since the implementation of the policy including the date of admission, time of testing, CD4, viral load, reason for admission, linkage to care, and contact tracing.

We compiled data related to admissions and testing by gender and age groups based on monthly reports submitted by the institutes that implemented routine opt-out HIV test policy for medical admissions. Routine case-based HIV surveillance by Tarassud electronic notification system was also used for most of the data; any data gaps were filled by the review of medical records.

Statistical analysis

We used MS Office Excel for the entry of monthly reports related data and analyzed variables of interest like age-groups and gender, using chi-square as a test of significance.

The list of diagnosed patients was prepared and the frequency of various variables like demographics, laboratory parameters, health seeking and treatment were analyzed.

Results

Twenty two out of 25 major hospitals have implemented a routine opt-out HIV test policy for medical ward admission, and 30% of admissions (7015 out of 23,076) were tested for HIV in the first year of implementation. 32 HIV cases were diagnosed due to this policy, which equates to 23 cases detected for every 5000 tests performed.

Testing coverage by gender and age groups is depicted in Table 1. The chi-square test for comparison between those tested versus those not tested in different age groups for males and females is significant (Χ² = 13.4236, p = .0012). Testing among males is not significant (Χ² = 5.611, p = .06,047), whereas among females is significant (Χ² = 9.6583, p = .0079), where HIV testing coverage among males (30.37%) and females (30.43%) are very similar.

Table 1.

Testing coverage by gender and age groups (n = 23,076).

Age groups	Male		Female		Total
Age groups	Tested	Not tested	Tested	Not tested	Tested	Not tested
16–24	535	1292	440	1162	975	2454
25–49	2305	5400	1577	3591	3882	8991
50–65	1204	2578	954	2038	2158	4616
TOTAL	4044	9270	2971	6791	7015	16,061
Testing coverage	30.37%		30.43%		30.40%
Chi-square test	X² = 5.611, p = .06047		X² = 9.6583, p = .0079		X² = 13.4236, p = .0012
Chi-square test	Not significant		Significant		Significant

Out of 32 cases, one was previously diagnosed abroad, and the rest 31 were newly diagnosed due to the policy.

Two out of 32 cases, had laboratory evidence of seroconversion, and another 2 cases presented with baseline CD4 counts over 800. These 32 cases are a sizeable 15% of the total 221 cases diagnosed in the year 2023. The median days from the admission of the patient to the medical ward to the HIV testing was 2 days (IQR: 1–5 days).

Characteristics of these 32 HIV cases are summarized in Table 2.

Table 2.

Characteristics of PLHIV diagnosed due to policy of medical admissions (n = 32).

Characteristics	n	%
Gender
Male	24	75.0
Female	8	25.0
Age groups (median-34, average-36)
16–24	4	12.5
25–34	14	43.8
35–44	7	21.9
45–54	5	15.6
55–65	2	6.3
Risk factor
Heterosexual	15	46.9
Homosexual/bi-sexual	9	28.1
Not documented	8	25.0
Reason for admission
Pneumonia	12	37.5
Fever	4	12.5
Weight loss	4	12.5
Diarrhoea	4	12.5
Others	8	25.0
Duration in days between admission and HIV test result
Average in days	3
Median (IQR) in days	2 (1–5)
Baseline CD4 counts (n = 26)
Average	214
Median (IQR)	125 (40–352)
<200	16	61.5
200–349	4	15.4
350–499	3	11.5
500+	3	11.5
Baseline HIV viral load (n = 31)
Average	1,201,824
Median (IQR)	537,000 (197,000–1,180,000)
<100K	3	9.7
100K–1 million	18	58.1
>1 million	10	32.3
Linkage to care
Yes	30	93.8
No	2	6.3
On ART
Yes	25	78.1
No	7	21.9
Status as on the end of 2023
Alive	28	87.5
Dead	4	12.5
Governorate of residence
Muscat	7	21.9
Outside Muscat	25	78.1
Governorate of HIV care (n = 30)
Muscat	13	43.3
Outside Muscat	17	56.7

Discussion

The implementation of routine opt-out HIV testing policies in medical admissions marks a significant step forward in Oman’s efforts to combat HIV/AIDS. This study shows compelling evidence supporting the feasibility, acceptability, and effectiveness of this approach in identifying new HIV cases. By integrating HIV screening into routine medical admissions, Oman’s Ministry of Health (MOH) has demonstrated a proactive stance toward reducing the burden of late HIV diagnosis and associated complications. To our knowledge, Oman is the first country in the Region of Eastern Mediterranean (EMRO) that has implemented this policy.

The testing coverage achieved, with 30% of medical admissions undergoing HIV testing, reflects a substantial uptake of testing among the target population. Importantly, the testing coverage among males and females was similar, indicating the lack of targeting patients based on their gender. However, significant differences in testing coverage were observed across age groups, with younger individuals (16–24 years) exhibiting lower testing rates compared to older age groups. This highlights the need for targeted interventions to promote HIV testing among younger populations, who may be at high risk of HIV acquisition.

The implementation of routine opt-out HIV testing in medical admissions has yielded notable results in Oman, as evidenced by the diagnosis of 32 new HIV cases within the first year of implementation. These findings underscore the effectiveness of the policy in identifying previously undetected HIV infections and facilitating early access to care and treatment for affected individuals.

The high rates of linkage to care and viral suppression among newly diagnosed patients reflect the effectiveness of HIV treatment programs in Oman. Furthermore, the relatively short median time from admission to confirmation of HIV diagnosis underscores the efficiency of the testing process and the importance of rapid turnaround times for test results.

Notably, the implementation of routine opt-out testing identified a substantial proportion (15%) of the total HIV cases diagnosed in 2023. This highlights the significance of medical admissions as an appropriate setting for HIV screening, especially considering that a proportion of these cases may have remained undiagnosed without the policy in place. The timely detection of HIV cases, as evidenced by the short median time from admission to HIV testing, allowed for prompt initiation of ART, improved clinical outcomes, and reduced transmission risk. Furthermore, the prevalence of advanced HIV disease among the diagnosed cases, as indicated by low baseline CD4 counts and high viral loads, underscores the urgency of early detection and linkage to care.

The policy’s cost-effectiveness was demonstrated in two cases of seroconversion and another two cases were screened with high CD4 counts. These cases may be missed diagnoses that result in late diagnosis leading to increased treatment cost.

The results of this study align with previous research demonstrating the effectiveness of routine opt-out HIV testing strategies in increasing HIV case detection rates and facilitating early linkage to care. Studies conducted in other settings have reported similar outcomes. For example, a study conducted in a general hospital in the UK reported that over 21 months, there were 12 682 admissions; 4122 (32.5%) had HIV tests. 20 patients (0.48%) were diagnosed with HIV; 17 (85%) of them were new diagnoses.¹⁵

Despite the success of the testing policy, some challenges were identified. Notably, data on the offer rate was not available and hence it was difficult to ascertain the rate of acceptability of the HIV testing offer. We were also unable to identify patients who would have been diagnosed with HIV in the absence of the policy. In addition, the testing coverage of 30% was still low and yielded HIV cases at a late stage of the disease; factors contributing to this low HIV testing coverage might include logistical challenges, lack of awareness, potential operational issues within the medical admission units and stigmatization of HIV. Furthermore, while the testing policy resulted in the diagnosis of a significant proportion of the total HIV cases in 2023, additional efforts may be needed to further scale up testing and reach underserved populations. Strategies to enhance testing uptake among key populations, including targeted outreach and education campaigns, may be warranted to ensure comprehensive coverage and equitable access to HIV testing services. Moreover, while the findings of this study demonstrate the feasibility and effectiveness of routine opt-out HIV testing in Oman, caution should be exercised when generalizing these results to other contexts.

This study has some limitations, and the results should be viewed in this context. First limitation is the inherent drawback of retrospective studies of missing data, particularly data concerning HIV positive cases. Another limitation is that the results are not generalizable and may only be applicable to Oman or countries with similar HIV epidemics and resources. Finally, it was difficult to assess patients’ acceptance to HIV testing in the absence of data on HIV testing offer rates.

In conclusion, the implementation of routine opt-out HIV testing in medical admissions represents a pivotal step towards achieving early diagnosis and treatment of HIV cases in Oman. Our study provides robust evidence supporting the feasibility, acceptability, and effectiveness of this approach in identifying previously undiagnosed HIV infections. Moving forward, continued investment in HIV testing strategies, healthcare provider training, and linkage to care initiatives are crucial for further reducing the burden of HIV/AIDS and improving health outcomes in Oman.

Footnotes

Acknowledgements

To all participating hospitals, the Directorate, and HCWs.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical statement

ORCID iDs

Zeyana Al-Habsi

Ali Elgalib

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