Am Fam Physician. 2009;80(12):1441-1444
Author disclosure: Nothing to disclose.
An estimated one fourth of persons with human immunodeficiency virus (HIV) are not aware they are infected. Early diagnosis of HIV has the potential to ensure optimal outcomes for infected persons and to limit the spread of the virus. Important barriers to testing among physicians include insufficient time, reimbursement issues, and lack of patient acceptance. Current HIV testing guidelines address many of these barriers by making the testing process more streamlined and less stigmatizing. The opt-out consent process has been shown to improve test acceptance. Formal pretest counseling and written consent are no longer recommended by the Centers for Disease Control and Prevention. Nevertheless, pretest discussions provide an opportunity to give information about HIV, address fears of discrimination, and identify ongoing high-risk activities. With increased HIV screening in the primary care setting, more persons with HIV could be identified earlier, receive timely and appropriate care, and get treatment to prevent clinical progression and transmission.
Nearly 1 million persons in the United States are living with human immunodeficiency virus (HIV), of which an estimated 25 percent are not aware they are infected.1 Adults who are unaware of their infection account for 54 percent of new sexual transmissions of HIV each year.2 A meta-analysis of persons newly diagnosed with HIV found that men and women reduce the frequency of unprotected vaginal or anal intercourse by 64 percent after being notified of their HIV status.3 To identify more persons who are unaware of their infection, the Centers for Disease Control and Prevention (CDC) now recommends routine HIV testing in all persons 13 to 64 years of age, regardless of risk.4 Position statements of the American College of Obstetricians and Gynecologists (ACOG)5 and the American College of Physicians6 are consistent with the CDC's HIV testing guidelines. The need for increased HIV testing is also emphasized by the American Academy of Family Physicians (AAFP) and the U.S. Preventive Services Task Force (USPSTF); however, these groups do not recommend routine HIV testing in low-risk populations.7,8
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Screening for HIV should be done using either a routine approach for all persons 13 to 64 years of age or a risk-based approach, depending on the practice setting. | C | 4, 6–8 |
| All pregnant women should be tested for HIV in the first trimester. | A | 4–8 |
| A second HIV test should be considered in the third trimester for pregnant women with risk factors or for those in high-prevalence areas. | C | 4, 5 |
| If allowed by state law, an opt-out consent process should be used when testing for HIV. | C | 4, 19, 20 |
| HIV pretest counseling should be tailored to individual patients' needs. | C | 4, 7 |
The trend toward increased testing is in part a response to the fact that a substantial number of persons with HIV are diagnosed late in their illness. Of the 34 states reporting to the CDC in 2005, 36.4 percent of persons newly diagnosed with HIV developed AIDS within the following year.9 Early diagnosis of HIV has a role not only in preventing new transmissions, but also in identifying persons in need of treatment.4 Early initiation of antiretroviral treatment has been shown to prevent progression to AIDS and death.10,11
Despite the absence of large-scale trials documenting that early diagnosis leads to early treatment initiation, facilitating access to HIV care for those who are newly diagnosed should be a priority. Approximately 50 percent of persons with HIV have limited access to HIV care; many of these are in the larger population of socioeconomically disadvantaged persons with poor access to health care in general.12,13 To facilitate HIV care, clinical and social services are available through the federal Ryan White HIV/AIDS program and through Medicaid and Medicare programs. Medication costs can be covered by the AIDS Drug Assistance Program.
Primary care physicians have been identified as a group that has the potential to perform broader testing with the goal of decreasing new transmissions and facilitating early linkage to care.4 National data indicate that more than one half of HIV tests and 38 percent of positive tests are conducted in primary care settings.13 Primary care physicians, however, have been found to experience several real and perceived barriers to HIV testing. These include insufficient time, competing priorities, lack of knowledge and training, perceived burden of consent and counseling requirements, lack of patient acceptance, and inadequate reimbursement.14 Current HIV testing guidelines attempt to address these barriers by making the process more streamlined and less stigmatizing, factors that should increase routine HIV testing and make it a time-efficient component of primary care that is well-accepted by the patient.
Patient Selection
Screening for HIV should be done using either a routine approach for all persons 13 to 64 years of age4,6 or a risk-based approach, depending on the practice setting.7,8 Traditionally, HIV tests have been offered only to those persons with high-risk sexual activity or injection drug use. Risk-based screening, however, can lead to missed opportunities for diagnosis, because some patients are reluctant to disclose risks and others might not realize they are at risk because of their partners' risks.15 The CDC's HIV testing guidelines recommend offering routine HIV testing to all persons 13 to 64 years of age at least once, regardless of risk, with repeat testing at least annually for persons with risk factors.4 Persons likely to be at high risk include injection drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected or high-risk persons, and men who have sex with men. The AAFP, which bases its recommendations on those of the USPSTF, recommends routine voluntary testing in high-risk settings, such as emergency departments or outpatient clinics in high-prevalence areas. In all other practice settings, the AAFP recommends testing on the basis of individual risk.7,16–18 Whichever approach is used, more widespread HIV testing is the goal.
Special Considerations During Pregnancy
Opt-Out and Opt-In Consent Processes
The CDC's HIV testing guidelines recommend an opt-out consent process in which the patient is informed that the HIV test will be performed as part of routine screening, unless it is specifically declined. In contrast, with opt-in testing, the patient is offered the test and can elect to have it performed. Opt-out testing can help normalize and destigmatize the testing process and has demonstrated greater test acceptance than opt-in testing.2,19,20 Laws regarding consent processes vary from state to state and can be found in the Compendium of State HIV Testing Laws at http://www.nccc.ucsf.edu/StateLaws/Index.html.21 If allowed by state law, an opt-out consent process should be used when testing for HIV.4,19,20
Pretest Counseling in Primary Care
A common barrier to HIV testing has been the time required for traditional pretest counseling.14 The CDC no longer recommends formal pretest counseling or separate written consent; however, patients should always be informed when an HIV test will be performed and should be allowed an opportunity for discussion, because the results can have an enormous impact on patients and their families.22 Physicians might want to include a brief description of the HIV testing process and the meaning of positive or negative test results.22 HIV pretest counseling should be tailored to individual patients' needs.4,7 Some patients with concerns about the test might need more extensive discussion of HIV risks, and those with ongoing risk factors might benefit from risk-reduction counseling. Discussing the potential personal impact of a positive test can be helpful. Physicians should be aware of their state's laws regarding partner notification.21,23
If a patient declines to be tested, physicians can explore the reasons for refusal, because many patients who decline the test know they are at risk and might be afraid of the results.23 Confidentiality concerns are also an important barrier for many patients. Significant stigma persists with HIV, and many patients fear disclosure of sexual orientation or drug use, rejection by loved ones, and violence.22,24 An HIV diagnosis can lead to discrimination that can affect access to health insurance, employment, and psychological well-being, which can result in persons entering care late in their illness.25 Physicians can help reduce the stigma associated with the test by offering it as a routine part of preventive care, instead of targeting persons based on risk assessment alone. Addressing misinformation about HIV and fear of discrimination could reduce these important barriers to patient acceptance of testing. A sample pretest counseling script is presented in Table 1, and a list of helpful resources for HIV testing and counseling can be found in Table 2.
| “I recommend an HIV test for all my patients, whether or not they think they are at risk.” | |
| “HIV is treatable, and early diagnosis can help keep you healthy.” | |
| “If you do not want the test, you may decline.” | |
| If a rapid HIV test is being used: | |
| “Further testing is always required to confirm a preliminary positive rapid test result.” | |
| If patient declines testing, further discussion might be warranted, beginning with: | |
| “What are your concerns about the test?” | |
| Organization | Resources |
|---|---|
| AIDS Education and Training Centers | An example from the San Francisco center offering routine HIV testing curriculum, guides, and resources: http://www.sfaetc.ucsf.edu/resources/PDF/TESTINGBINDERMarch09.pdf |
| General resources: http://www.aidsetc.org/aidsetc?page=etres-display&resource=etres-426 | |
| American Academy of Family Physicians | Policy statement: https://www.aafp.org/patient-care/clinical-recommendations/all/hiv.html Patient information materials: https://familydoctor.org |
| American Academy of HIV Medicine | Tools include a brochure on current procedure terminology codes for HIV testing: http://www.aahivm.org |
| American College of Obstetricians and Gynecologists | Resources for HIV screening in women, including prenatal HIV testing resources (membership required for access to many materials): http://www.acog.org |
| Centers for Disease Control and Prevention | Guidelines, fact sheets, slide sets, and journal articles: http://www.cdc.gov/hiv/topics/testing/healthcare/index.htm |
| Health Research and Educational Trust | A practical guide for HIV testing in the emergency department: http://www.edhivtestguide.org |
| HIV Medicine Association | Practical tools for HIV testing and clinical care: http://www.hivma.org/Content.aspx?id=1942 |
| National HIV/AIDS Clinicians' Consultation Center | Expert telephone consultation for physicians regarding HIV testing and treatment: Warmline (Telephone: 800–933–3413) |
| Compendium of State HIV Testing Laws: http://www.nccc.ucsf.edu/StateLaws/Index.html | |
| State and local health departments and state offices of AIDS | An example from New York City, with office flowchart, chart stickers, patient resources, and physician script: http://www.nyc.gov/html/doh/html/csi/csi-hivtestkit.shtml |
Reimbursement
Lack of reimbursement by some public and private insurers is another substantial barrier to routine HIV testing.26 Currently, some insurance companies and an increasing number of state Medicare and Medicaid programs pay for routine HIV tests. More third-party carriers are expected to provide this coverage as recommendations for routine testing gain acceptance. Some states have enacted, or are in the process of enacting, laws that require insurance companies to cover the cost of routine HIV testing. In addition, federal legislation mandating insurance coverage for routine HIV testing has been proposed.
