Consistency of state statutes with the Centers for Disease Control and Prevention HIV testing recommendations for health care settings

Principles of Screening for Disease and Health Risk Factors in the Emergency Department

The emergency department serves as a critical access point to the health system for many patients, especially those with limited resources. Screening for disease or risk factors for poor health outcomes can potentially improve both individual and population health. Screening initiatives should focus on evidence-based strategies and take local epidemiology and ED capacity into consideration. Initiatives should strive for community support and transparency with patients. They should also be financially sustainable for those involved. Screening can identify patients who can then be counseled, provided with prophylaxis or treatment, or referred to external resources. Through screening and intervention, the ED can serve as a vital contributor to individual and population health.

HIV Screening Among Gonorrhea-Diagnosed Individuals; Baltimore, Maryland; April 2015 to April 2019

BACKGROUND

Individuals diagnosed with gonorrhea are at elevated risk for HIV. Per US Centers for Disease Control and Prevention guideline, individuals being evaluated for gonorrhea should be screened for HIV concurrently. There is limited information on HIV screening among gonorrhea-diagnosed individuals across different health care settings. Our objective was to identify potential gaps in HIV screening among gonorrhea-diagnosed individuals in Baltimore City, Maryland.

METHODS

We used Sexually Transmitted Disease Surveillance Network project data collected on a random sample of all gonorrhea diagnoses reported to the health department between April 2015 and April 2019. Individuals with known HIV diagnoses were excluded. HIV screening was confirmed through surveys administered to the gonorrhea-diagnosing provider. HIV screening across groups was assessed using Poisson regression models with robust SEs. We examined those with and without recent (≤12 months) sexually transmitted infection (STI) history separately.

RESULTS

Among 2830 gonorrhea-diagnosed individuals with completed Sexually Transmitted Disease Surveillance Network provider surveys, less than half (35.2% with and 44.8% without recent STI history) received concurrent HIV screening. HIV screening was 73% less prevalent among those diagnosed in emergency departments/urgent care centers/hospitals versus sexual health clinics (with and without recent STI history: adjusted prevalence ratio, 0.27 [95% confidence interval, 0.19-0.39]; adjusted prevalence ratio, 0.27 [0.23-0.33]), controlling for diagnosis year, sex, race/ethnicity, age, infection site, and insurance.

CONCLUSIONS

Our findings suggest a considerable gap in HIV screening among individuals at elevated risk for HIV acquisition in Baltimore City, particularly among those diagnosed in emergency departments/urgent care centers/hospital settings. Future work should focus on identifying provider-level barriers to concurrent HIV/STI screening to inform provider education programs.

Effect of CDC 2006 Revised HIV Testing Recommendations for Adults, Adolescents, Pregnant Women, and Newborns on State Laws, 2018

In 2006, the Centers for Disease Control and Prevention updated its recommendations for HIV testing of 4 population groups in health care settings: adults, adolescents, pregnant women, and newborns. Important components of the revised recommendations included opt-out routine HIV screening; eliminating prevention counseling for opt-out routine HIV screening; repeat HIV testing in the third trimester for all women at high risk for acquiring HIV and for women receiving health care in facilities and/or jurisdictions with high HIV burden; testing during labor and delivery for women with undocumented HIV status; and testing the newborn when the mother's HIV status is unknown. To assess the integration of these testing recommendations into state laws and to inform future recommendations, we researched and assessed statutes and regulations that addressed HIV testing in the 4 population groups in all 50 states and the District of Columbia in 2018. We then classified the laws, based on their consistency with the recommendations for each of the 4 population groups. Of 31 states and the District of Columbia that had relevant laws, all addressed at least 1 component of the recommendations. Although no state had laws that incorporated all the recommendations for all the population groups, 5 states (Delaware, Illinois, Louisiana, Maryland, and New Hampshire) had incorporated all the recommendations for adults and adolescents, and 4 states (Connecticut, Nevada, North Carolina, and West Virginia) had incorporated all the recommendations for pregnant women and newborns.

Implementing Updated Recommendations on Hepatitis C Virus Screening: Translating Federal Guidance Into State Practice

CONTEXT

Chronic viral hepatitis is a leading infectious cause of death. The Centers for Disease Control and Prevention (CDC) released updated recommendations for hepatitis C virus testing, including recommending that all individuals born between 1945 and 1965 be tested once. States' consistency with these national testing guidelines is unknown.

OBJECTIVE

To evaluate the extent to which state health departments have current hepatitis C virus testing recommendations listed on their Web sites, consistent with national guidelines.

DESIGN

The CDC guidelines were reviewed to identify the risk groups recommended for or against testing. State health department Web sites (50 US states, the District of Columbia, and Puerto Rico) were then systematically reviewed to classify whether, for each risk group, testing is recommended, not recommended, or with unclear recommendations.

MAIN OUTCOME MEASURE

States' consistency with national recommendations for each risk group mentioned by the CDC.

RESULTS

Among the risk groups that the CDC currently recommends for testing, 50% of states updated their Web sites to include individuals born between 1945 and 1965. All states recommend testing current or former injection drug users, but only 58% recommended testing HIV-positive individuals. Among the risk groups for which the CDC has issued uncertain recommendations, states most frequently recommended testing individuals with tattoos or body piercing done with unsterile materials (46%) or with a history of multiple sex partners (31%).

CONCLUSIONS

There is substantial variation in state Web sites' consistency with the CDC guidelines. The public health importance of risk factors is not associated with their inclusion in Web content. Improving the uptake of these recommendations and the manner in which they are conveyed to the public are critical to implementing the national viral hepatitis action plan, thereby increasing diagnoses and averting new infections.

Spillover effects of HIV testing policies: changes in HIV testing guidelines and HCV testing practices in drug treatment programs in the United States

BACKGROUND

To examine the extent to which state adoption of the Centers for Disease Control and Prevention (CDC) 2006 revisions to adult and adolescent HIV testing guidelines is associated with availability of other important prevention and medical services. We hypothesized that in states where the pretest counseling requirement for HIV testing was dropped from state legislation, substance use disorder treatment programs would have higher availability of HCV testing services than in states that had maintained this requirement.

METHODS

We analyzed a nationally representative sample of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey (NDATSS). Data were collected from program directors and clinical supervisors through telephone surveys. Multivariate logistic regression models were used to measure associations between state adoption of CDC recommended guidelines for HIV pretest counseling and availability of HCV testing services.

RESULTS

The effects of HIV testing legislative changes on HCV testing practices varied by type of opioid treatment program. In states that had removed the requirement for HIV pretest counseling, buprenorphine-only programs were more likely to offer HCV testing to their patients. The positive spillover effect of HIV pretest counseling policies, however, did not extend to methadone programs and did not translate into increased availability of on-site HCV testing in either program type.

CONCLUSIONS

Our findings highlight potential positive spillover effects of HIV testing policies on HCV testing practices. They also suggest that maximizing the benefits of HIV policies may require other initiatives, including resources and programmatic efforts that support systematic integration with other services and effective implementation.

HIV testing experience in New York City: offer of and willingness to test in the context of new legal support of routine testing

BACKGROUND

In the United States, routine HIV testing is recommended for persons aged 13-64 years. In 2010, New York State passed a law mandating offer of testing in most health-care settings. We report on the consumer perspective in New York City (NYC) shortly after the law's enactment.

METHODS

We analyzed data from a 2011 telephone survey representative of NYC adults aged 18-64 years (n = 1,846). This analysis focused on respondents' report of HIV test offer at last clinical visit and of willingness to test if recommended by their doctor. Offer and willingness were estimated by age, gender, race/ethnicity, education, income, marital status, sexual identity, partner number, and HIV testing history; associations were examined using multivariable regression.

RESULTS

Among NYC adults, 35.7% reported an HIV test in the past year and 31.8% had never tested. Among 86.7% with a clinical visit in the past year, 31.4% reported being offered a test at last visit. Offer was associated with younger age, race/ethnicity other than white, non-Hispanic, lower income, and previous testing. Only 6.7% of never-testers were offered a test at last clinical visit. Willingness to test if recommended was high overall (90.2%) and across factors examined.

CONCLUSIONS

After a new law was enacted in support of routine HIV testing, approximately 1 in 3 New Yorkers aged 18-64 years were offered a test at last clinical visit; 9 in 10 were willing to test if recommended by their doctor. This suggests that patient attitudes will not be a barrier to complete implementation of the law.

Mandating the offer of HIV testing in New York: simulating the epidemic impact and resource needs

BACKGROUND

A 2010 New York law requires that patients aged 13-64 years be offered HIV testing in routine medical care settings. Past studies report the clinical outcomes, cost-effectiveness, and budget impact of expanded HIV testing nationally and within clinics but have not examined how state policies affect resource needs and epidemic outcomes.

METHODS

A system dynamics model of HIV testing and care was developed, where disease progression and transmission differ by awareness of HIV status, engagement in care, and disease stage. Data sources include HIV surveillance, Medicaid claims, and literature. The model projected how alternate implementation scenarios would change new infections, diagnoses, linkage to care, and living HIV cases over 10 years.

RESULTS

Without the law, the model projects declining new infections, newly diagnosed cases, individuals newly linked to care, and fraction of undiagnosed cases (reductions of 62.8%, 59.7%, 54.1%, and 57.8%) and a slight increase in living diagnosed cases and individuals in care (2.2% and 6.1%). The law will further reduce new infections, diagnosed AIDS cases, and the fraction undiagnosed and initially increase and then decrease newly diagnosed cases. Outcomes were consistent across scenarios with different testing offer frequencies and implementation times but differed according to the level of implementation.

CONCLUSIONS

A mandatory offer of HIV testing may increase diagnoses and avert infections but will not eliminate the epidemic. Despite declines in new infections, previously diagnosed cases will continue to need access to antiretroviral therapy, highlighting the importance of continued funding for HIV care.

HIV testing implementation in two urban cities: practice, policy, and perceived barriers

BACKGROUND

Although funding has supported the scale up of routine, opt-out HIV testing in the US, variance in implementation mechanisms and barriers in high-burden jurisdictions remains unknown.

METHODS

We conducted a survey of health care organizations in Washington, DC and Houston/Harris County to determine number of HIV tests completed in 2011, policy and practices associated with HIV testing, funding mechanisms, and reported barriers to testing in each jurisdiction and to compare results between jurisdictions.

RESULTS

In 2012, 43 Houston and 35 DC HIV-testing organizations participated in the survey. Participants represented 85% of Department of Health-supported testers in DC and 90% of Department of Health-supported testers in Houston. The median number of tests per organization was 568 in DC and 1045 in Houston. Approximately 50% of organizations in both DC and Houston exclusively used opt-in consent and most conducted both pre- and post-test counseling with HIV testing (80% of organizations in DC, 70% in Houston). While the most frequent source of funding in DC was the Department of Health, Houston organizations primarily billed the patient or third-party payers. Barriers to testing most often reported were lack of funding, followed by patient discomfort/refusal with more barriers reported in DC.

CONCLUSIONS

Given unique policies, resources and programmatic contexts, DC and Houston have taken different approaches to support routine testing. Many organizations in both cities reported opt-in consent approaches and pre-test counseling, suggesting 2006 national HIV testing recommendations are not being followed consistently. Addressing the barriers to testing identified in each jurisdiction may improve expansion of testing.

HIV testing among clients in high HIV prevalence venues: disparities between older and younger adults

The Centers for Disease Control and Prevention recommends routine human immunodeficiency virus (HIV) testing of every client presenting for services in venues where HIV prevalence is high. Because older adults (aged ≥50 years) have particularly poor prognosis if they receive their diagnosis late in the course of HIV disease, any screening provided to younger adults in these venues should also be provided to older adults. We examined aging-related disparities in recent (past 12 months) and ever HIV testing in a probability sample of at-risk adults (N = 1238) seeking services in needle exchange sites, sexually transmitted disease clinics, and Latino community clinics that provide HIV testing. Using multiple logistic regression with generalized estimating equations, we estimated associations between age category (<50 years vs. ≥50 years) and each HIV testing outcome. Even after controlling for covariates such as recent injection drug use, older adults had 40% lower odds than younger adults did of having tested in the past 12 months (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.40-0.90) or ever (OR = 0.6; 95% CI = 0.40-0.90). Aging-related disparities in HIV testing exist among clients of these high HIV prevalence venues and may contribute to known aging-related disparities in late diagnosis of HIV infection and poor long-term prognosis.

HIV testing trends: Southeastern Pennsylvania, 2002-2010

There are limited data on HIV testing trends after 2006 when the Centers for Disease Control and Prevention (CDC) introduced opt-out HIV testing with the aims of identifying HIV-infected persons early and linking them to care. We used data from the Southeastern Pennsylvania Household Health Survey between 2002 and 2010 to evaluate HIV testing over time. 50,698 adult (≥18 years) survey respondents were included. HIV testing increased after the CDC recommendations: 42.1% of survey respondents received testing at least once in 2002 versus 51.4% in 2010, p<0.001. Testing trends increased among all demographic groups, but existing differences in testing before 2006 persisted after that year as follows: younger patients, racial/ethnic minorities, patients on Medicaid were all more likely to get tested than their counterparts. Blacks and patients seeking care in community health centers had the fastest rise in HIV testing. The probability of HIV testing in Blacks was 0.56 (95% CI 0.54-0.60) in 2002 and increased to 0.73 (0.70-0.76) by 2010. Patients seeking care in community health centers had a probability of HIV testing of 0.57 (0.47-0.66) in 2002, which increased to 0.69 (0.60-0.77) by 2010. In comparison, patients in private clinics had an HIV testing probability of 0.40 (0.36-0.43) in 2002 compared to 0.47 (0.40-0.54) in 2010. HIV testing is increasing, particularly among ethnic minorities and in community health centers. However, testing remains to be improved in that setting and across all clinic types.

What Makes Me Screen for HIV? Perceived Barriers and Facilitators to Conducting Recommended Routine HIV Testing among Primary Care Physicians in the Southeastern United States

The Centers for Disease Control and Prevention have recommended routinely testing patients (aged 13-64) for HIV since 2006. However, many physicians do not routinely test. From January 2011 to March 2012, we conducted 18 in-depth individual interviews and explored primary care physicians' perceptions of barriers and facilitators to implementing routine HIV testing in North Carolina. Physicians' comments were categorized thematically and fell into 5 groups: policy, community, practice, physician, and patient. Lack of universal reimbursement was identified as the major policy barrier. Participants believed endorsement from the United States Preventive Services Tasks Force would facilitate adoption of routine HIV testing policies. Physicians reported HIV/AIDS stigma, socially conservative communities, lack of confidentiality, and rural geography as community barriers. Physicians believed public HIV testing campaigns would legitimize testing and decrease stigma in communities. Physicians cited time constraints and competing clinical priorities as physician barriers that could be overcome by delegating testing to nursing staff. HIV test refusal, low HIV risk perception, and stigma emerged as patient barriers. Physicians recommended adoption of routine HIV testing for all patients to facilitate and destigmatize testing. Physicians continue to experience a variety of barriers when implementing routine HIV testing in primary care settings. Our findings support multilevel approaches to enhance physician routine HIV testing in primary care settings.

Increases in HIV screening in primary care clinics through an electronic reminder: an interrupted time series

OBJECTIVE AIM

Identify and eliminate barriers to HIV testing in primary care and to decrease the rates of patients never being tested, and limit unnecessary repeat testing.

SETTING

Primary care clinics within an urban publicly funded safety net hospital and community health system in Cleveland, Ohio. Reported HIV prevalence among male Cleveland residents is 1193.5/100 000.

DESIGN

A time series analysis using statistical process control was used.

METHODS

Primary care encounters of patients aged 13-64 years from selected sites were reviewed throughout the initiative for HIV testing prior to the visit and associated with the visit.

RESULTS

Run charts of the proportion of men and women never tested for HIV demonstrated marked improvement and special cause variation with six sequential quarters falling outside of the trend lines. Evaluation of encounters associated with a first HIV test confirmed testing occurring within primary care rather than elsewhere in the health system.

CONCLUSIONS

Implementing an electronic medical record-based reminder effectively increased HIV testing among primary care patients not previously tested, while education and practice feedback alone did not.

Point-of-Care HIV Testing and Linkage in an Urban Cohort in the Southern US

The Southern states experience the highest rates of HIV and AIDS in the US, and point-of-care (POC) testing outside of primary care may contribute to status awareness in medically underserved populations in this region. To evaluate POC screening and linkage to care at an urban south site, analyses were performed on a dataset of 3,651 individuals from an integrated rapid-result HIV testing and linkage program to describe this test-seeking cohort and determine trends associated with screening, results, and linkage to care. Four percent of the population had positive results. We observed significant differences by test result for age, race and gender, reported risk behaviors, test location, and motivation for screening. The overall linkage rate was 86%, and we found significant differences for clients who were linked to HIV care versus persons whose linkage could not be confirmed with respect to race and gender, location, and motivation. The linkage rate for POC testing that included a comprehensive intake visit and colocated primary care services for in-state residents was 97%. Additional research on integrated POC screening and linkage methodologies that provide intake services at time of testing is essential for increasing status awareness and improving linkage to HIV care in the US.

HIV testing in the nation's opioid treatment programs, 2005-2011: the role of state regulations

OBJECTIVE

To identify the extent to which clients in a national sample of opioid treatment programs (OTPs) received HIV testing in 2005 and 2011; to examine relationships between state laws for informed consent and pretest counseling and rates of HIV testing among OTP clients.

DATA SOURCE

Data were collected from a nationally representative sample of OTPs in 2005 (n = 171) and 2011 (n = 200).

STUDY DESIGN

Random-effects logit and interval regression analyses were used to examine changes in HIV testing rates and the relationship of state laws to HIV testing among OTPs.

DATA COLLECTION

Data on OTP provision of HIV testing were collected in phone surveys from OTP managers; data also were collected on state laws for HIV testing.

PRINCIPAL FINDINGS

The percentage of OTPs offering HIV testing decreased significantly from 93 percent in 2005 to 64 percent in 2011. Similarly, the percentage of clients tested decreased from an average of 41 percent in 2005 to 17 percent in 2011. OTPs located in states whose laws do not require pretest counseling and that use opt-out consent were more likely to provide HIV testing and to test higher percentages of clients.

CONCLUSIONS

The results show the need to increase HIV testing among OTP clients; the results also underscore the beneficial possibilities of dropping pretest counseling as a requirement for HIV testing and of using the opt-out approach to informed consent for testing.

Human immunodeficiency virus testing behaviors among US adults: the roles of individual factors, legislative status, and public health resources

BACKGROUND

The Centers for Disease Control and Prevention recommended an "opt-out" human immunodeficiency virus (HIV) testing strategy in 2006 for all persons aged 13 to 64 years at healthcare settings. We conducted this study to identify individual, health, and policy factors that may be associated with HIV testing in US adults.

METHODS

The 2008 Behavioral Risk Factors Surveillance System data were utilized. Individuals' residency states were classified into 4 categories based on the legislation status to HIV testing laws in 2007 and HIV/acquired immune deficiency syndrome morbidity. A multivariate logistic regression adjusting for survey designs was performed to examine factors associated with HIV testing.

RESULTS

A total of 281,826 adults aged 18 to 64 years answered HIV testing questions in 2008. The proportions of US adults who had ever been tested for HIV increased from 35.9% in 2006 to 39.9% in 2008. HIV testing varied across the individual's characteristics including sociodemographics, access to regular health care, and risk for HIV infection. Compared with residents of "high morbidity-opt out" states, those living in "high morbidity-opt in" states with legislative restrictions for HIV testing had a slightly lower odds of being tested for HIV (adjusted odds ratio = 0.96; 95% confidence interval = 0.92, 1.01). Adults living in "low morbidity" states were significantly less likely to be tested for HIV, regardless of legislative status.

CONCLUSIONS

To implement routine HIV testing in the general population, the role of public health resources should be emphasized and legislative barriers should be further reduced. Strategies need to be developed to reach people who do not have regular access to health care.

HIV testing practices among black primary care physicians in the United States

BACKGROUND

The Centers for Disease Control and Prevention recommends routine HIV testing in all healthcare settings, but it is unclear how consistently physicians adopt the recommendation. Making the most of each interaction between black physicians and their patients is extremely important to address the HIV health disparities that disproportionately afflict the black community. The goal of this survey-based study was to evaluate the perceptions and practices of black, primary care physicians regarding HIV testing.

METHODS

A physician survey was administered at the 2010 National Medical Association Annual Convention, via online physician panels, and by email. Physician eligibility criteria: black race; practicing at least 1 year in the US; practice comprised of at least 60% adults and 20% black patients. Contingency tables and ordinary least squares regression were used for comparisons and statistical analyses. A Chi-square test compared percentages of physicians who gave a particular response and a t-test compared the means of values provided by physicians.

RESULTS

Physicians over-estimated HIV prevalence and believed that HIV is a crisis in the black community, yet reported that only 34% of patients were HIV tested in the past year. Physicians reported that 67% of those patients tested did so due to a physician recommendation. Physicians who were younger, female, obstetricians/gynecologists, and had a higher proportion of black, low-socioeconomic status, and Medicaid patients reported higher testing rates. Most testing was risk-based rather than routine, and three of the five most commonly reported barriers to testing were related to disease stigma and perceived value judgments. Physicians reported that in-office patient informational materials, increased media attention, additional education and training on HIV testing, government mandates requiring routine testing, and accurate pre-packed tests would most help them test more frequently for HIV.

CONCLUSIONS

In this sample of black, primary care physicians, HIV testing practices differed according to physician characteristics and practice demographics, and overall reported testing rates were low. More physician education and training around testing guidelines is needed to enable more routine testing, treatment, and long-term management of patients with HIV.

HIV diagnosis and testing: what every healthcare professional can do (and why they should)

Over the last thirty years, the human immunodeficiency virus (HIV) epidemic has matured. In the United States, HIV has changed from an explosive outbreak to an endemic disease; currently, an estimated 1.1 million people are infected with HIV, including a substantial number who are unaware of their status. With recent findings demonstrating the high transmissibility of HIV early in infection, and the potential benefit of early initiation of treatment, it is essential to identify as many infected individuals as possible. The Centers for Disease Control and Prevention (CDC) has expanded HIV testing to include any healthcare setting, including dental offices. Testing advances, including oral testing, have reduced the window period of HIV infection. Dental care represents a key, reliable, independent, and confidential link between the healthcare system and the general population that has been under-utilized in the effort to control the HIV epidemic. HIV testing is straightforward, and knowledge of the types of testing will afford dentists an important opportunity to help advance and preserve the health of their patients and to promote the public health of their community. Here, we review the basics of HIV testing and discuss new changes in the approach to HIV diagnostics.

HIV antibody testing and its correlates among heterosexual attendees of sexually transmitted disease clinics in China

Background

This study was conducted to determine the prevalence of HIV antibody testing and associated factors among heterosexual sexually transmitted disease (STD) clinic attendees in China.

Methods

A self-administered questionnaire was administered among 823 attendees of 4 STD clinics of Zhejiang Province, China in October to December 2007. Psychosocial and behavioural factors associated with HIV antibody testing were identified in both genders using univariate and multivariate analyses.

Results

Of all 823 STD clinic attendees, 9.3% of male and 18.0% of female attendees underwent HIV antibody testing in the most recent 6 months, and 60% of the participants had gotten no educational/behavioral intervention related to HIV prevention. The correlates for HIV antibody testing in the most recent 6 months as identified by multivariate analysis were ever condom use [odds ratio (OR), 10.37; 95% confidence interval (CI), 1.32–81.22]; ever anal/oral sex (OR, 3.13; 95% CI, 1.03–9.50) during their lifetime; having ever received three to seven types of behavioural interventions in the most recent 6 months (OR, 3.70; 95% CI, 1.32–10.36) among male subjects; and ever condom use (OR, 12.50; 95% CI, 2.20–71.01), STD history (OR, 3.86; 95% CI, 1.26–11.86) over their lifetime, or having ever received three to seven types of behavioural interventions in the most recent 6 months (OR, 8.68; 95% CI, 2.39–31.46) in female subjects. A lifetime experience of casual/commercial sex partners was strongly negatively associated with HIV testing in female subjects (OR, 0.08; 95% CI, 0.01–0.83).

Conclusion

The low prevalence of HIV antibody testing and behavioural intervention among STD clinic attendees indicates a need for more targeted, intensive behavioural interventions to promote HIV antibody testing in this population.

Routine HIV testing among providers of HIV care in the United States, 2009

In 2006, CDC recommended HIV screening as part of routine medical care for all persons aged 13-64 years. We examined adherence to the recommendations among a sample of HIV care providers in the US to determine if known providers of HIV care are offering routine HIV testing in outpatient settings. Data were from the CDC's Medical Monitoring Project Provider Survey, administered to physicians, nurse practitioners and physician assistants from June-September 2009. We assessed bivariate associations between testing behaviors and provider and practice characteristics and used multivariate regression to determine factors associated with offering HIV screening to all patients aged 13-64 years. Sixty percent of providers reported offering HIV screening to all patients 13 to 64 years of age. Being a nurse practitioner (aOR = 5.6, 95% CI = 2.6-11.9) compared to physician, age<39 (aOR = 1.9, 95% CI = 1.0-3.5) or 39-49 (aOR = 2.1, 95% CI = 1.4-3.3) compared with ≥50 years, and black race (aOR = 2.6, 95% CI = 1.2-6.0) compared with white race was associated with offering testing to all patients. Providers with low (aOR = 0.2, 95% CI = 0.1-0.3) or medium (aOR = 0.4, 95% CI = 0.2-0.6) HIV-infected patient loads were less likely to offer HIV testing to all patients compared with providers with high patient loads. Many providers of HIV care are still conducting risk-based rather than routine testing. We found that provider profession, age, race, and HIV-infected patient load were associated with offering HIV testing. Health care providers should use patient encounters as an opportunity to offer routine HIV testing to patients as outlined in CDC's revised recommendations for HIV testing in health care settings.

HIV screening practices in U.S. hospitals, 2009-2010

OBJECTIVE

A 2004 national survey of hospitals showed that 23.4% of hospitals screened for HIV in at least one department, most frequently in labor and delivery departments. However, less than 2% of these hospitals screened patients in inpatient units, urgent care clinics, or emergency departments. In 2006, the Centers for Disease Control and Prevention (CDC) recommended HIV screening for all individuals 13-64 years of age in health-care settings. We determined the frequency of hospital adoption of these CDC recommendations.

METHODS

We surveyed hospital infection-control personnel at a randomly selected sample of U.S. general medical and surgical hospitals in 2009-2010.

RESULTS

Of the 1,476 hospitals selected for the survey, 754 (51.1%) responded to the survey; of those responding, 703 (93.2%) offered HIV tests for patients at the hospital and 206 (27.3%) screened for HIV in at least one department. Screening was most common in larger hospitals (45.7%), hospitals in large metropolitan areas (50.5%), and teaching hospitals (44.4%); it was least common in public hospitals (19.1%). By department, screening was most common in labor and delivery departments (34.6%) and substance abuse clinics (20.7%); it was least common in emergency departments (11.9%), inpatient units (9.6%), and psychiatry/mental health departments (9.4%). More than half of hospitals were not considering implementing CDC's recommendations within the next 12 months.

CONCLUSIONS

Since 2004, HIV screening in hospitals increased overall and by department. However, the majority of U.S. hospitals have not adopted the CDC recommendations.

A framework for elimination of perinatal transmission of HIV in the United States

The availability of effective interventions to prevent mother-to-child HIV transmission and the significant reduction in the number of HIV-infected infants in the United States have led to the concept that elimination of mother-to-child HIV transmission (EMCT) is possible. Goals for elimination are presented. We also present a framework by which elimination efforts can be coordinated, beginning with comprehensive reproductive health care (including HIV testing) and real-time case-finding of pregnancies in HIV-infected women, and conducted through the following: facilitation of comprehensive clinical care and social services for women and infants; case review and community action; allowing continuous quality research in prevention and long-term follow-up of HIV-exposed infants; and thorough data reporting for HIV surveillance and EMCT evaluation. It is emphasized that EMCT will not be a one-time accomplishment but, rather, will require sustained effort as long as there are new HIV infections in women of childbearing age.

Patient and provider acceptance of oral HIV screening in a dental school setting

In 2006, the Centers for Disease Control and Prevention (CDC) recommended routine HIV screening in health care settings regardless of the patient's level of risk. This pilot study was developed in response to the suggestion by some health care professionals that dental settings would be appropriate for expansion of HIV testing. This project consisted of two parts: oral fluid HIV testing of patients in the clinic of a dental school and a survey of the clinical dental faculty members' attitudes about acceptability of routine HIV testing in the dental clinic. When patients' agreement to participate in oral fluid HIV testing was examined, 8.2 percent of the patients contacted by the clinic administration staff completed testing. When approached by a faculty member or student during the dental visit admission and tested during the dental visit, however, 88.2 percent completed testing. Of the faculty members who took the survey, 27.4 percent were neutral, 26.4 percent were somewhat in agreement, and 32.1 percent were willing to incorporate HIV testing into routine dental care. In this pilot study, HIV testing of dental patients was most successful when a dental care provider approached patients about testing. If consent was given, the testing was performed during the visit. For the faculty members, the major barrier to testing was a lack of protocol familiarity.

Decreasing Missed Opportunities for HIV Testing in Primary Care through Enhanced Utilization of the Electronic Medical Record

OBJECTIVES

We sought to decrease "missed opportunities" for HIV testing by implementing an electronic medical record based intervention designed to increase HIV testing among previously untested men and women ages 18-64 seeking primary medical care in an urban publicly-funded health care system.

METHODS

In July 2010, we implemented an electronic medical record based reminder to alert providers to the absence of an HIV test among all patients' ages 13-64 years old. We compared the rate of missed opportunities for HIV testing among primary care patients seen during the two and a half years before the intervention with that of patients seen during the two years after the intervention was begun. A "missed opportunity" was defined as the failure of a previously untested patient to obtain HIV testing despite having made one or more primary care office visits during a specified time period.

RESULTS

After the implementation of HIV testing reminders, first-time HIV testing increased significantly for both men and women 18-64 years old, resulting in a significant reduction in "missed opportunities." The intervention was equally effective across different racial and ethnic groups. An increase in new HIV diagnoses after the intervention was observed, consistent with an increase in the number of individuals in the population who received testing.

CONCLUSIONS

An electronic medical record-based reminder can significantly increase HIV testing among men and women ages 18-64 who are seeking primary care services.

Characteristics of U.S. emergency departments that offer routine human immunodeficiency virus screening

OBJECTIVES

The association between emergency department (ED) characteristics, ED director's perceptions of preventive services, and the availability of human immunodeficiency virus (HIV) screening are unknown. The authors hypothesized that, after adjusting for ED operational and demographic characteristics, teaching hospital status would be associated with increased availability, and ED crowding and ED director agreement with barriers to screening would be associated with decreased availability.

METHODS

This was a secondary, cross-sectional analysis on previously collected data from 2008 to 2009 regarding availability of ED preventive services. Data were obtained from a random sample of 277 EDs in which ED directors provided information on ED characteristics and availability of HIV screening and rated five barriers to providing preventive services. The association between the availability of HIV screening and teaching hospital and crowding status, ED volume, urban-rural location, ownership, geographic region, patient demographics, state HIV testing consent laws, and ED director opinions on barriers to providing preventive services were determined in univariate analyses and a multivariate logistic regression model.

RESULTS

Nineteen percent of the sampled EDs offer HIV screening. Teaching hospitals offer HIV screening more frequently than nonteaching hospitals (38% vs. 18%; p = 0.03), but after adjusting for other characteristics in a multivariate model, this association was not significant (relative risk ratio [RR] = 2.07, 95% confidence interval [CI] = 0.91 to 3.59). ED crowding also was not significantly associated with screening availability (RR = 0.66, 95% CI = 0.34 to 1.21). However, public ownership (RR = 2.13, 95% CI = 1.28 to 3.14), 24-hour social work (RR = 1.87, 95% CI = 1.02 to 2.99), uninsured population ≥35% (RR = 2.48, 95% CI = 1.39 to 3.69), increased local nonwhite minority population percentage (RR = 1.14 per 10%, 95% CI = 1.02 to 1.26), and state laws allowing opt-out consent for testing (RR = 1.76, 95% CI = 1.01 to 2.74) were associated with increased availability of screening in multivariable analysis. EDs whose directors were concerned about added costs were associated with decreased availability of screening (RR = 0.45, 95% CI = 0.23 to 0.85).

CONCLUSIONS

After adjusting for other ED operational and demographic characteristics, ED crowding and teaching hospital affiliation were not independently associated with the availability of HIV screening. EDs whose directors were concerned about the cost of preventive services were less likely to provide routine HIV screening. Addressing ED director's concerns about the added costs of ED preventive services, increasing social work availability, and implementing testing laws consistent with Centers for Disease Control and Prevention (CDC) recommendations may facilitate increased adoption of ED HIV screening.

Factors affecting clinician educator encouragement of routine HIV testing among trainees

BACKGROUND

Adoption of CDC recommendations for routine, voluntary HIV screening of all Americans age 13–64 years has been slow. One method to increase adherence to clinical practice guidelines is through medical school and residency training.

OBJECTIVE

To explore the attitudes, barriers, and behaviors of clinician educators (CEs) regarding advocating routine HIV testing to their trainees.

DESIGN/PARTICIPANTS

We analyzed CE responses to a 2009 survey of Society of General Internal Medicine members from community, VA, and university-affiliated clinics regarding HIV testing practices.

MAIN MEASURES

Clinician educators were asked about their outpatient practices, knowledge and attitudes regarding the revised CDC recommendations and whether they encouraged trainees to perform routine HIV testing. Associations between HIV testing knowledge and attitudes and encouraging trainees to perform routine HIV testing were estimated using bivariate and multivariable logistic regression.

RESULTS

Of 515 respondents, 367 (71.3%) indicated they supervised trainees in an outpatient general internal medicine clinic. These CEs demonstrated suboptimal knowledge of CDC guidelines and over a third reported continued risk-based testing. Among CEs, 196 (53.4%) reported that they encourage trainees to perform routine HIV testing. Higher knowledge scores (aOR 5.10 (2.16, 12.0)) and more positive attitudes toward testing (aOR 8.83 (4.21, 18.5)) were independently associated with encouraging trainees to screen for HIV. Reasons for not encouraging trainees to screen included perceived low local prevalence (37.2%), competing teaching priorities (34.6%), and a busy clinic environment (34.0%).

CONCLUSIONS

Clinician educators have a special role in the dissemination of the CDC recommendations as they impact the knowledge and attitudes of newly practicing physicians. Despite awareness of CDC recommendations, many CEs do not recommend universal HIV testing to trainees. Interventions that improve faculty knowledge of HIV testing recommendations and address barriers in resident clinics may enhance adoption of routine HIV testing.

Short communication routine HIV testing in the emergency department: assessment of patient perceptions

The CDC released revised HIV testing guidelines in 2006 recommending routine, opt-out HIV testing in acute care settings including emergency departments (ED). Patient attitudes have been cited as a barrier to implementation of routine HIV testing in the ED. We assessed patients' perceptions of HIV testing in the ED through a contextual qualitative approach. The study was conducted during a 72-h period. All adults presenting to the ED without life-threatening trauma or psychiatric crisis completed a standardized questionnaire. The questionnaire explored HIV testing history, knowledge of testing resources, and qualitative items addressing participant perceptions about advantages and disadvantages to ED testing. After completion of the interview, participants were offered a free, confidential, rapid HIV test. Among 329 eligible individuals approached, 288 (87.5%) completed the initial interview. Participants overwhelmingly (n=247, 85.8%) reported support for testing and identified increased knowledge (41%), prevention (12.5%), convenience (11.8%), and treatment (4.9%) among the advantages. Fear and denial about one's HIV status, reported by <5% of patients, were identified as the most significant barriers to ED testing. Bivariate analysis determined race and ethnicity differences between individuals completing the interview and those who refused (p<0.05). Among individuals consenting for testing (n=186, 64.6%), no positives were detected. Most patients support HIV testing in the ED, noting knowledge of status, prevention, convenience, and linkage to early treatment as distinct advantages. These data are of particular benefit to decision makers considering the addition of routine HIV testing in EDs.

Racial/ethnic and gender differences among older adults in nonmonogamous partnerships, time spent single, and human immunodeficiency virus testing

BACKGROUND

A higher frequency of nonmonogamy, due in part to lower marriage prevalence, may contribute to elevated human immunodeficiency virus (HIV)/sexually transmitted disease rates among older blacks.

METHODS

To examine race and gender differences in nonmonogamy, time spent single (i.e., not married or cohabiting), and HIV testing in older adults, we analyzed US population-based data from the 2005-2006 National Social Life, Health, and Aging Project for 2825 heterosexual participants ages 57 to 85 years.

RESULTS

Blacks spent greater portions of their adult lives single than did Hispanics or whites and were far more likely to report recent nonmonogamous partnerships (23.4% vs. 10.0% and 8.2%). Among individuals reporting sex in the prior 5 years, nonmonogamous partnerships were strongly associated with time spent single during the period. Control for time spent single and other covariates reduced the association of black race with nonmonogamous partnerships for men, but increased it for women. Less than 20% reported ever testing for HIV; less than 6% had been recommended testing by a provider. Testing rates, highest in black men and white women, differed little by history of nonmonogamous partnerships within gender strata.

CONCLUSIONS

Singlehood helps to explain higher nonmonogamous partnership rates in older black men but not in older black women. Older adults rarely receive or are recommended HIV testing, a key strategy for reducing heterosexual HIV transmission.

Barriers to routine HIV testing among Massachusetts community health center personnel

OBJECTIVES

We assessed the extent to which Centers for Disease Control and Prevention (CDC) recommendations have influenced routine HIV testing among Massachusetts community health center (CHC) personnel, and identified specific barriers and facilitators to routine testing.

METHODS

Thirty-one CHCs were enrolled in the study. We compared those that did and did not receive funding support from the federal Ryan White HIV/AIDS Program. An anonymous survey was administered to a maximum five personnel from each CHC, including a senior administrator, the medical director, and three medical providers. Overall, 137 participants completed the survey.

RESULTS

Among all CHCs, 53% of administrators reported having implemented routine HIV testing at their CHCs; however, only 33% of medical directors/providers reported having implemented routine HIV testing in their practices (p<0.05). Among administrators, 60% of those from Ryan White-supported CHCs indicated that both they and their CHCs were aware of CDC's recommendations, compared with 27% of administrators from non-Ryan White-supported CHCs. The five most frequently reported barriers to the implementation of routine HIV testing were (1) constraints on providers' time (68%), (2) time required to administer counseling (65%), (3) time required to administer informed consent (52%), (4) lack of funding (35%), and (5) need for additional training (34%). In a multivariable logistic regression model, the provision of on-site HIV testing by nonmedical staff resulted in increased odds of conducting routine HIV testing (odds ratio [OR] = 9.84, 95% confidence interval [CI] 1.77, 54.70). However, the amount of time needed to administer informed consent was associated with decreased odds of providing routine testing (OR=0.21, 95% CI 0.05, 0.92).

CONCLUSIONS

Routine HIV testing is not currently being implemented uniformly among Massachusetts CHCs. Future efforts to increase implementation should address personnel concerns regarding time and staff availability.

Barriers and facilitators to routine HIV testing: perceptions from Massachusetts Community Health Center personnel

Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended routine, voluntary HIV testing for persons aged 13-64 in all health care settings, including the elimination of separate informed consent, which remains in effect in five states including Massachusetts. Community health centers (CHCs) represent an important HIV testing site for at-risk populations. From April to December 2008 a qualitative interview was administered to one senior personnel from each of 30 CHCs in Massachusetts, to identify barriers and facilitators to implementing CDC recommendations and to elucidate strategies to improve routine HIV testing. The following themes emerged as routine HIV testing barriers: (1) provider time constraints, including time to administer counseling and separate informed consent; (2) lack of funding, staff, and space; (3) provider, patient, and community discomfort; (4) inconsistent levels of awareness regarding CDC recommendations; and (5) perceived incompatibility with Massachusetts HIV testing policy. Facilitators included designation of personnel to serve as organizational "champions" for routine testing and use of clinical reminders within electronic medical records to prompt HIV testing. Strategies identified to improve routine HIV testing rates among Massachusetts CHCs included more explicit state-level guidelines; organizational buy-in; collaborative analysis to integrate testing within existing activities; and provider, patient and community education.

Provider and practice characteristics associated with use of rapid HIV Testing by general internists

BACKGROUND

Rapid HIV testing could increase routine HIV testing. Most previous studies of rapid testing were conducted in acute care settings, and few described the primary care providers' perspective.

OBJECTIVE

To identify characteristics of general internal medicine physicians with access to rapid HIV testing, and to determine whether such access is associated with differences in HIV-testing practices or perceived HIV-testing barriers.

DESIGN

Web-based cross-sectional survey conducted in 2009.

PARTICIPANTS

A total of 406 physician members of the Society of General Internal Medicine who supervise residents or provide care in outpatient settings.

MAIN MEASURES

Surveys assessed provider and practice characteristics, HIV-testing types, HIV-testing behavior, and potential barriers to HIV testing.

RESULTS

Among respondents, 15% had access to rapid HIV testing. In multivariable analysis, physicians were more likely to report access to rapid testing if they were non-white (OR 0.45, 95% CI 0.22, 0.91), had more years since completing training (OR 1.06, 95% CI 1.02, 1.10), practiced in the northeastern US (OR 2.35; 95% CI 1.28, 4.32), or their practice included a higher percentage of uninsured patients (OR 1.03; 95% CI 1.01, 1.04). Internists with access to rapid testing reported fewer barriers to HIV testing. More respondents with rapid than standard testing reported at least 25% of their patients received HIV testing (51% versus 35%, p = 0.02). However, access to rapid HIV testing was not significantly associated with the estimated proportion of patients receiving HIV testing within the previous 30 days (7.24% vs. 4.58%, p = 0.06).

CONCLUSION

Relatively few internists have access to rapid HIV testing in outpatient settings, with greater availability of rapid testing in community-based clinics and in the northeastern US. Future research may determine whether access to rapid testing in primary care settings will impact routinizing HIV testing.

Can computer-based feedback improve emergency department patient uptake of rapid HIV screening?

OBJECTIVE

We determine whether (1) an audiocomputer-delivered tailored feedback intervention increases emergency department (ED) patient uptake of opt-in, nontargeted rapid HIV screening; and (2) uptake is greater among patients who report more HIV risk and among those whose self-perceived HIV risk increases from baseline after completion of an HIV risk assessment.

METHODS

ED patients aged 18 to 64 years were randomly assigned to receive either an assessment about reported and self-perceived HIV risk or an identical assessment plus feedback about their risk for having or acquiring an HIV infection, tailored according to their reported risk. All participants were offered a fingerstick rapid HIV test. Two-sample tests of binomial proportions were used to compare screening uptake by study arm. Multivariable logistic regression was used to assess the relationship of reported HIV risk and an increase in self-perceived HIV risk with uptake of HIV screening.

RESULTS

Of the 566 participants, the median age was 29 years, 62.2% were women, and 66.9% previously had been tested for HIV. Uptake of HIV screening was similar in the intervention and no intervention arms (54.1% versus 55.5% [Δ=-0.01%; 95% confidence interval {CI} -0.09% to 0.07%]). An increase in self-perceived HIV risk predicted greater uptake of HIV screening for women (odds ratio 2.15; 95% CI 1.08 to 4.28) but not men (odds ratio 1.61; 95% CI 0.60 to 4.30). Uptake of HIV screening was not related to reported HIV risk.

CONCLUSION

Uptake of rapid HIV screening in the ED was not improved by this feedback intervention. Other methods need to be investigated to improve uptake of HIV screening by ED patients.

General internists' beliefs, behaviors, and perceived barriers to routine HIV screening in primary care

The Centers for Disease Control and Prevention (CDC) recommends routine HIV screening in primary care but little is known about general internists' views of this practice. We conducted a national, cross-sectional, Internet-based survey of 446 general internists in 2009 regarding their HIV screening behaviors, beliefs, and perceived barriers to routine HIV screening in outpatient internal medicine practices. Internists' awareness of revised CDC guidelines was high (88%), but only 52% had increased HIV testing, 61% offered HIV screening regardless of risk, and a median 2% (range 0-67%) of their patients were tested in the past month. Internists practicing in perceived higher risk communities reported greater HIV screening. Consent requirements were a barrier to screening, particularly for VA providers and those practicing in states with HIV consent statutes inconsistent with CDC guidelines. Interventions that promote HIV screening regardless of risk and streamlined consent requirements will likely increase adoption of routine HIV screening in general medicine practices.

Projected survival gains from revising state laws requiring written opt-in consent for HIV testing

BACKGROUND

Although the Centers for Disease Control and Prevention recommends HIV testing in all settings unless patients refuse (opt-out consent), many state laws require written opt-in consent.

OBJECTIVE

To quantify potential survival gains from passing state laws streamlining HIV testing consent.

DESIGN

We retrieved surveillance data to estimate the current annual HIV diagnosis rate in states with laws requiring written opt-in consent (19.3%). Published data informed the effect of removing that requirement on diagnosis rate (48.5% increase). These parameters then served as input for a model-driven projection of survival based on consent method. Other inputs included undiagnosed HIV prevalence (0.101%); and annual HIV incidence (0.023%).

PATIENTS

Hypothetical cohort of adults (>13 years) living in written opt-in states.

MEASUREMENTS

Life years gained (LYG).

RESULTS

In the base-case, of the 53,036,383 adult persons living in written opt-in states, 0.66% (350,040) will be infected with HIV. Due to earlier diagnosis, revised consent laws yield 1.5 LYG per HIV-infected person, corresponding to 537,399 LYG among this population. Sensitivity analyses demonstrate that diagnosis rate increases of 24.8-72.3% result in 304,765-724,195 LYG. Net survival gains vanish if the proportion of HIV-infected persons refusing all testing in response to revised laws exceeds 18.2%.

CONCLUSIONS

The potential survival gains of increased testing are substantial, suggesting that state laws requiring opt-in HIV testing should be revised.

Factors associated with declining a rapid human immunodeficiency virus test in labor and delivery

The Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists recommend routine rapid HIV testing in labor and delivery (L&D) for women with undocumented HIV status using an opt-out approach. Identifying factors associated with declining a rapid HIV test in L&D will be helpful in developing strategies to improve rapid HIV testing uptake. Data from the Mother-Infant Rapid Intervention at Delivery study were analyzed. Women ≥24 weeks gestation, in labor, with undocumented HIV status were offered rapid HIV testing using informed consent. Women who declined rapid HIV testing (decliners) but agreed to be interviewed were compared to women who accepted testing (acceptors). 102 decliners and 478 acceptors met inclusion criteria for analysis. Decliners of rapid HIV testing were more likely to have had prenatal care (PNC), after adjusting for age, Hispanic ethnicity, high-school education and city of enrollment (adjusted OR 2.4, 95% CI 1.06-5.58). Having had PNC was collinear with prior HIV education and previous offer of an HIV test during the current pregnancy, so these factors were not part of the model. During PNC, standard informed consent may involve discussions that negatively affect later uptake of testing in L&D. Therefore an opt-out approach to testing may improve testing rates. Furthermore, decliners may have felt that testing in L&D was redundant because of previous testing during PNC; however, if previous testing occurred, this was undocumented at L&D. Documentation and timely communication of HIV status is critical to provide appropriate HIV prophylaxis.

Diagnosis of HIV: challenges and strategies for HIV prevention and detection among pregnant women and their infants

Diagnosis and management of perinatally acquired human immunodeficiency virus infection poses many challenges in the areas of diagnosis, clinical and psychosocial intervention, and public health policy. Diagnostic tests have evolved over the years and many are currently used in the perinatal setting. Considerable progress has been realized in each of these areas through cooperative efforts of laboratory scientists, clinical teams, and stakeholders. However, there remain multiple challenges to address in the future.

Expanded HIV screening in the United States: what will it cost government discretionary and entitlement programs? A budget impact analysis

OBJECTIVE

The US Centers for Disease Control and Prevention (CDC) recently revised their HIV screening guidelines to promote testing and earlier entry to care. Prior analyses have examined the policy's cost-effectiveness but have not evaluated its impact on government budgets.

METHODS

We used a simulation model of HIV screening, disease, and treatment to determine the budget impact of expanded HIV screening to US government discretionary, entitlement, and testing programs. We estimated total and incremental testing and treatment costs over a 5-year time horizon under current and expanded screening scenarios. We used CDC estimates of HIV prevalence and annual incidence, and considered variations in screening frequency, test return rates, linkage to care, test characteristics, and eligibility for government screening and treatment programs.

RESULTS

Under current practice, 177,000 new HIV cases will be identified over 5 years. Expanded screening will identify an additional 46,000 cases at an incremental 5-year cost of $2.7 billion. The financial burden of expanded HIV screening will fall disproportionately on discretionary programs that fund care for newly identified patients and will not be offset by entitlement program savings. Testing will represent a small proportion (18%) of the total budget increase. Costs are sensitive to the frequency of screening and the proportion linked to care.

CONCLUSIONS

The expanded HIV screening program will have a large downstream impact on government programs that fund HIV care. Expanded HIV screening will not meet early treatment goals unless government programs have sufficient budgets to expand testing and provide care for newly identified cases.

Patients' attitudes toward and factors predictive of human immunodeficiency virus testing of academic medical clinics

INTRODUCTION

More than 1,000,000 persons in the United States are living with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome, with 24% unaware of their HIV status. In this study, the authors explored patients' attitudes toward HIV testing in academic medical clinics and investigated the possible impact of the 2006 Centers for Disease Control and Prevention (CDC) HIV screening guidelines.

METHOD

Cross-sectional survey study of adult patients in 9 academic internal medicine clinics (response rate 73%). The survey consisted of 76 questions, which assessed demographics, HIV risk factors, knowledge, beliefs, attitudes and characteristics of patient-physician interactions. Patient self-reported HIV testing was the main outcome. Bivariate analyses were performed, and variables with a P-value of <0.1 were included in a logistic regression model to determine characteristics most associated with HIV testing.

RESULTS

Four hundred forty-three patients completed the survey (response rate 73%) and 61% reported being screened for HIV. Physician recommendation (P < 0.0001), patient's own request (P < 0.0001), African American race (P < 0.0001) better knowledge about HIV (P = 0.0002), agreement with CDC recommendations (P < 0.0001), being comfortable with their doctor (P < 0.0001) and using street drugs (P < 0.0001) were all strongly associated with testing. In logistic regression, the only factors that remained statistically significant predictors of patients self-reported HIV testing were a patient's request for testing (OR: 103.3) and patient's knowledge about HIV (OR: 1.3).

CONCLUSION

In this study, patient request was the strongest predictor for HIV screening and majority of patients accepted the idea of HIV testing in congruence with the CDC recommendations. Therefore, simple waiting room prompts and public education campaigns may represent the most efficient interventions to increase HIV testing rate.

Assessing targeted screening and low rates of HIV testing

OBJECTIVES

We assessed rates of HIV testing based on targeting patients with identified risk factors at the Veterans Affairs Medical Center in Washington, DC (VAMC-DC), where written informed consent along with pretest and posttest counseling had, until recently, been required by federal law.

METHODS

A cumulative retrospective review of the period 2000 through 2007 was conducted to assess the number of patients who were provided medical care at VAMC-DC, tested for HIV, and underwent confirmatory testing. Data on demographic characteristics and risks for HIV acquisition were also collected.

RESULTS

At VAMC-DC, 3.8% to 4.9% (mean=4.25%) of patients in care without known HIV infection underwent HIV screening annually. On average, HIV was confirmed at a yearly rate of 3.4% among those tested. During the study period, HIV prevalence ranged from 2.1% to 2.5%. Among patients receiving HIV care, 41.5% disclosed no risk factors for HIV acquisition.

CONCLUSIONS

Given that the HIV prevalence observed in this study was above 2% and that 41.5% of patients in care did not disclose any acquisition risks, targeted HIV screening has not been sufficient. HIV testing must be broadened and offered as part of routine medical care.