Case Scenario

A 41-year-old healthy male patient often presents at my office requesting human immunodeficiency virus (HIV) testing, but always refuses to give me a reason for his requests. He came in again today, after a previous visit for the same reason two or three months ago. In fact, this is his fourth request in the past 18 to 24 months. I explained that routine HIV testing is not recommended. I asked him if he had any known exposure, and he replied, “That’s none of your business.” I reviewed HIV-prevention precautions with him and informed him that following these precautions was sufficient protection from infection. His response was: “I know all that, but I still want the test.” I told him I did not think that it is appropriate to bill his insurance for his repeat testing. If he wanted the testing, he should pay out of pocket. Was I out of line in telling him this? What are my obligations in this setting to my patient and to the insurance company? To what extent can I require a patient to give me a risk history, when I feel such a risk history helps optimize the care I can provide?

Commentary

Two valuable questions are raised by this clinical dilemma in primary care. The first is whether it is appropriate to perform tests at a patient’s request without clear indications. The second is whether billing the insurance carrier for these tests is proper. These questions are just as relevant for relatively inexpensive hematology and chemistry tests as they are for extremely expensive tests such as magnetic resonance imaging (MRI) to evaluate a variety of musculoskeletal complaints or the often requested “heart scans” and “total body” MRIs. There are no all-inclusive formulas for deciding when to perform and bill for these tests, so as primary care physicians we individualize each case, all under a degree of pressure to try to satisfy the legitimate needs of our patients as well as those of insurance carriers. The process is indeed imperfect and can be trying.

The difference in this case is that the patient is requesting an HIV test. Why is this different from other similar requests? The compelling reason for performing HIV testing for this patient is because this is an all-important primary care prevention opportunity even in the absence of admitted risk factors. An estimated 25 percent of the approximate 850,000 to 950,000 HIV-positive persons in the United States remain unaware of their infection.¹ Many are not diagnosed until they have advanced disease and therefore do not receive the benefit of earlier diagnosis and treatment. They may fuel the epidemic by unknowingly transmitting HIV to others. Transmissions from these undiagnosed persons account for as many as two thirds of the country’s estimated 40,000 new HIV infections each year. It has been shown that many infected persons decrease behaviors that transmit infection to their needle-sharing or sex partners once they are aware that they have HIV.² Thus, early knowledge of infection is now recognized as a critical component in controlling the spread of the disease. The recent Advancing HIV Prevention initiative¹ has emphasized the importance of wider testing in primary care. The push toward broader testing as a powerful prevention tool is not only understandable but also compelling. According to the Centers for Disease Control and Prevention’s (CDC’s) HIV Counseling and Testing Guidelines,² voluntary HIV testing and prevention counseling ideally should be offered routinely to all patients. Why do so many HIV-infected persons remain undiagnosed? Factors include fear of losing confidentiality, fear of finding out the diagnosis, failure to recognize or denial of) risk factors for infection, fear of discrimination, concern that the test can be falsely positive, and even fear that the test can lead to HIV/AIDS. For some, especially minority and poor patients, there can be concerns about the interaction with the health care system, including lack of confidence that confidentiality will be honored, fear of HIV status being reported to agencies that oversee child and family care issues, financial considerations, concerns about decreased access to care, and fear of jeopardizing their existing health care.

Some patients, such as the one in this scenario, likely will never admit risk factors, even to their physicians. This patient’s persistence in asking for the test might indicate unprofessed risk factors, an obsessive concern, or other personal factors. Recognizing this all-too-common phenomenon, the federal guidelines² specifically address patients such as this one. Such patients “should receive additional HIV prevention counseling and follow-up testing when requested. Efforts should be made to understand why these clients repeatedly seek follow-up testing. These clients should be considered for in-depth prevention counseling and referral to support services, where appropriate.”²

Any physician might feel stymied by this patient’s “none of your business” response to a request for a risk history. The two main possibilities for this patient’s attitude seem to be that the patient has an obsessive trait but no real risk factors, or he has risk factors but will not disclose them. If the physician suspects the latter, there may be some ways to facilitate discussion and allow some productive counseling to begin. Although it seems difficult in this case, here are a few thoughts: (1) give the patient positive reinforcement for his concern about his HIV risk and his repeated testing; (2) acknowledge that it can be embarrassing to discuss specific HIV risk behaviors; (3) be explicit about patient confidentiality issues; and (4) be respectful and nonjudgmental. The physician might want to break the ice by discussing the approximate risk of various sexual behaviors (Table) or by using a written risk-screening questionnaire.² When the test results are available, the physician should again review, in person, the essentials of HIV prevention precautions with his patient. If the physician does not feel comfortable discussing specific risk behaviors nonjudgmentally, then he or she should refer the patient to local or regional counseling resources.

The physician should not deny the patient an HIV test because of concern about billing the insurance company. Most insurance companies pay the modest costs of this important screening test. The price of an HIV screening test varies widely. We checked prices at two sites. A private-pay patient obtaining an enzyme-linked immunosorbent assay (ELISA) at one San Francisco hospital would be billed $150. A repeat ELISA, if indicated by an initial positive result, would cost another $150. If the repeat test is also positive, the confirmatory Western blot technique would cost $35. The bill for an insured patient depends on the contract between the carrier and the hospital. In contrast, a nearby county clinic sends its HIV antibody tests to a public health laboratory and is charged $31 for each ELISA and $67 for the confirmatory indirect immunofluorescent antibody assay (IFA) if indicated. The Clinical Laboratory Improvement Amendments (CLIA)-waived Oraquick rapid HIV antibody test kit, which can test a fingerstick specimen, costs less than $20 and is coming into wider use. The sensitivity and specificity of this test are comparable to the ELISA screening test. The more important concern regarding billing is the potential loss of confidentiality through disclosure of HIV risk to insurance carriers. For this and other reasons, some patients will choose to have the test done outside the context of covered care, often at anonymous testing sites. This option can be offered to patients who seem reluctant to be tested or who have privacy concerns.

The physician’s obligation to the patient and to the community at large is clear. Physicians should provide the requested testing, perform counseling about risk reduction, refer the patient for further counseling if needed, and bill appropriately for this important preventive measure.