CA's streamlined HIV testing uncovering hidden infections
Stigma becomes a non-issue
A new study highlighting California's experiences with HIV testing since the state removed legal barriers demonstrates that routine testing in medical settings will prove to be a good testing, prevention, and care strategy for states to adopt.
Investigators found a significantly higher number of new HIV infections once barriers were removed and testing became routine.1
The research helps to make the case that states and AIDS advocates should embrace the trend of removing barriers to HIV testing, including all requirements that make it more difficult to screen for HIV than for other common diseases, an AIDS advocate says.
"AIDS is treated differently than other public health concerns overall," says Michael Weinstein, president of the AIDS Healthcare Foundation of Los Angeles, CA.
"All of the barriers to HIV testing were put in place when AIDS was fatal and when AIDS was much more stigmatized than it is today," Weinstein says. "That's not to say there isn't AIDS discrimination, but the overall attitudes of society have changed."
Whether or not the barriers were a good idea in the beginning of the epidemic, it's clear now that the landscape has changed and the barriers are no longer necessary, he adds.
"We have between 60 and 75 percent of the people with new HIV infections, according to the CDC [Centers for Disease Control and Prevention], who don't even know they're HIV positive," Weinstein says.
With so many untested HIV positive people continuing to transmit the virus, it's imperative that HIV testing be conducted as routinely and made as simple as possible, he adds.
"The main point is we want to eliminate as many barriers as we can to testing in order to find patients who are HIV positive, get them on treatment early, help them live healthy lives, and help prevent transmission to their partners," says Beth Kaplan, MD, a clinical professor of emergency medicine in the department of emergency services at the University of California, San Francisco, CA. Kaplan is a co-author of the study.
The study collected HIV testing data from January 2003 to June 2007 of all adult patients seen at the San Francisco Department of Public Health medical care system. The data compared HIV testing before and after the medical center eliminated required written consent for HIV testing in May, 2006.
Before May 15, 2006, the medical center's clinicians had to complete a separate HIV test laboratory requisition form and have the patient sign an informed consent document in order to order an HIV test. If documentation was incomplete, the laboratory rejected the sample.
Investigators found that by June, 2007, the average monthly rate of HIV tests had increased by 4.38 per 1,000 patient-visits.
There was a 67 percent increase (from 8.9 to 14.9) in the monthly average number of new positive HIV tests.
The increases in HIV testing were seen among all populations, but high risk subgroups had the greatest increases.
Another change has been a switch to the rapid test, which makes it possible for emergency medicine patients to receive their results before they are discharged or transferred, Kaplan notes.
Since HIV testing resources are limited, the hospital has allowed physicians to make a decision about who they should test, based on either diagnostic criteria or risk factor criteria, Kaplan says.
From an emergency medicine doctor's perspective, the HIV testing changes have been very helpful, Kaplan says.
"We can test people in a lot of settings where you couldn't normally test people because we don't have time to do the consent," Kaplan says.
Emergency medicine physicians now can obtain a simple verbal consent from patients.
"I personally feel in my practice at San Francisco General that it's so imperative to let the patient know that I'd like to have them tested and that we'll give them the results during the visit," Kaplan says.
"What we say in the ER is 'We'd like you to get an HIV test with your other tests today,'" Kaplan explains. "'You haven't had a test in a while, or you've never had one, and it's an important part of your health care to know what your status is, and we'll give you the results during your visit; whether the results are positive or negative, we'll have support here, so is that okay?'"
Eight out of 10 times, the patient will agree, she adds.
This streamlined HIV testing has improved clinical care from a diagnostic perspective, as well as helping clinicians identify HIV positive patients earlier in their disease than might have occurred otherwise.
"If they're positive and have a disease that is related to HIV, then it does change significantly our diagnosis and treatment path," Kaplan says. "It allows us to test widely in the emergency department."
For instance, if a patient comes in with chronic diarrhea, the case is very different if the person is found to be HIV positive, she explains.
Although there is no data to confirm it, Kaplan says she is certain the change in policy has reduced HIV stigma, as well.
"We've normalized the test," Kaplan says. "We know that in our practices normalizing the test, talking about it more as part of health care like everything else, including testing for STDs or high cholesterol, helps reduce stigma."
When patients are found to be positive, the health system provides support and services, and it is disclosed in a similar way to the disclosure of other diseases, she adds.
California might lead the way, but other states have been slow to change their HIV testing requirements, despite the CDC's recommendation two years ago for routine HIV testing in medical settings, Weinstein says.
Peeling back the AIDS exceptionalism has been difficult, partly because of lobbying by AIDS organizations that are afraid to eliminate HIV testing barriers, Weinstein says.
"Early detection is the key, and we're not doing a good job of that right now," he says. "For every impediment to finding people who are HIV positive, we have to seriously question whether it's a good idea."
The irony is that AIDS organizations often cite HIV stigma as the reason why they do not support name-based reporting and the removal of consent signatures, and a switch to routine HIV testing in medical settings, he notes.
"I think, inadvertently, all of these provisions are contributing to stigma," Weinstein says. "They are saying that this thing is so big that it requires different practices."
Now that the barriers are removed, the next step is to make HIV testing as routine and universal as can be in the hospital, Kaplan says.
"We have a grant from the CDC to do increased HIV testing," Kaplan says. "So we're going to test every admitted patient in a few months so that no one leaves the hospital through the emergency room admission process without having an HIV test."
Also, anyone who has any diagnosis that might be HIV related will be tested, she says.
The grant is for $240,000 for one year, and it could be renewed, Kaplan says.
Clinicians also will provide HIV testing to patients who have traditional and other risk factors, including homelessness, minority populations, and methamphetamine use, she adds.
"We now do about 100 HIV tests per month, and with the support of this grant, we plan to do 500 to 600 HIV tests per month," Kaplan says. "From the hospital we link 100 percent of patients to care, and no one is falling through the cracks."
So part of the new effort will be to collect CD4 cell counts to see how advanced the newly-diagnosed patients are in their disease process and to link patients to care and get their partners in for HIV testing, as well, Kaplan says.
"As part of the grant we'll test two partners from each positive patient," she adds.
Reference:
- Zetola NM, Grijalva CG, Gertler S, et al. Simplifying consent for HIV testing is associated with an increase in HIV testing and case detection in highest risk groups, San Francisco, January 2003-June 2007. PloS One. 2008:July 2:1-14 [www.plosone.org.]
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