HIV testing in ED nets hidden infections
Simplifying consent removes stigma
With the commemoration June 27 of National HIV Testing Day came the disturbing news that some 250,000 people in the United States are completely unaware they are carrying the AIDS virus in their bloodstreams.
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. One solution may be to test people in hospital emergency departments. A recent study shows it works, and part of the reason may be that there is less stigma associated with HIV infection than in the days when positive results spelled a death sentence.
"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 and a co-author of the study.1
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 2006.1
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.1
Investigators found that by June 2007, the average monthly rate of HIV tests had increased by 4.38 per 1,000 patient visits.1
There was a 67% increase (from 8.9 to 14.9) in the monthly average number of new positive HIV tests.1
The increases in HIV testing were seen among all populations, but high-risk subgroups had the greatest increases.1
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,'" she 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 OK?'"
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 are 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.
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.
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. Accessed at www.plosone.org.
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