Rao, Aditi

School of Public Health


South Africa

South Africa - Implementing and evaluating emergency department based HIV testing strategies in South Africa

Emergency Departments (EDs) are episodic care centers that provide care to large volumes of patients (in SA 150-700 patients per day) for short periods of time. ED populations are typically younger, and have a higher prevalence of substance abuse and mental health disorders (1 in 8 ED visits) . In addition vulnerable patients (i.e., persons with substance abuse, homelessness, mental health problems and victims of violent crime) are 1.4-2 times more likely to seek care in the ED compared to primary care settings. The ED is a high-yield HIV testing venue, however in South Africa ED-based testing is really implmented.

The larger project seeks to explore the current HIV testing paradigm within an emergency department setting in South Africa and then develop and implement a locally informed ED-based HIV testing strategy that bridges the HIV care continum (i.e., optimizes testing, initiation of treatment and enagagement in care).

This research proposal was developed in collaboration with the International HIV/STD section at NIAID (NIH), the SAMRC, the faculty of Health Sciences at Walter Sisulu University (WSU) and the Albertina Sisulu Center for Global Health Research at WSU

Global Health PI/Mentor: Bhakti Hansoti

For my practicum I traveled to South Africa to work on implementing and evaluating HIV testing strategies in Emergency Departments. The study was based in Mthatha – capital of the Eastern Cape Province - from June to September 2017. Living and working in Mthatha was a challenging, yet hugely rewarding experience. Going in, my aim was to explore a new country and culture, establish a successful study site, build valuable relationships, and expand on my own competencies and limitations.


I began working on the project in April at Hopkins, when we began putting together the IRB submission, study protocol, data collection tools, training material etc. On the team were, Dr. Bhakti Hansoti (the PI) from the Hopkins Department of Emergency Medicine, Victoria Chen, an undergraduate student and Katie Clark, a first year med student from Hopkins, and myself. Having spent many hours putting everything in place and talking through all sorts of possible challenges, I believe we were well prepared for our trip to South Africa.


Once we got there, it was ofcourse nothing like we expected it to be. Despite having grown up in a developing country, I was taken aback by the uniqueness of Mthatha. It lies amidst mountains in an expansive valley, there’s not a lot of buildings visible at first, but instead concrete houses arranged haphazardly in colourful clusters. A highway cut through the town and served as the main thoroughfare to get to almost any point in Mthatha. In complete contrast to the general landscape was the hospital complex we worked in. It was an immense campus, which housed two hospitals – Nelson Mandela Academic Hospital (NMAH) and Mthatha Regional Hospital (MRH). What surprised me the most however was a huge mall located downtown with brands from around the world, it was so incongruous. Interestingly though, I found quite a few similarities between Mthatha and my home New Delhi in their cultural practices, foods, historical influences, and importantly the similar lack of resources in hospitals. While, the differences with Baltimore were quite stark.


Previously, I had spent time working in the Hopkins Emergency Department conducting HIV counselling and testing, and was expecting a similar environment in the two hospitals in Mthatha. While that was true to a large extent, it was a lot more chaotic than I could have imagined. The EDs were mostly one big room, with beds lined up closely against the wall. Sometimes there were monitors hooked up, sometimes there weren’t. There was little organization or privacy, and all gaps between beds were occupied by more patients or family members. The proportion of trauma cases that came in was quite overwhelming, especially on weekends and pay days. But we soon realised the pertinent issues facing the region, such as the high prevalence of violence and traumatic injuries, alcohol abuse, lack of access to primary care, and the frequent loss of water supply, network, and electricity.


My time in Mthatha constantly kept me on my toes, as we faced new problems everyday and learned to problem solve with few resources and little guidance. I believe I came away with an enriched mind, unique skills, some great friends, and immense admiration for everyone in Mthatha, who work in challenging settings to provide care to a vulnerable population. We also got to travel some outside of Mthatha, to Cape Town, East London, Port St. Johns, and Durban, which were all incredible experiences. Since returning from Mthatha, I have continued working with the team at Hopkins and in South Africa to use the results of this study to bring about effective change. Next summer, I hope to return to South Africa to repeat this study in Port Elizabeth.


Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program

Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

October 2018



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