Abstract
Introduction
Routine opt-out screening for the human immunodeficiency virus (HIV) has been recommended for individuals aged 13 to 64 years in all health care settings by the Centers for Disease Control and Prevention (CDC) since 2006. 1 Early diagnosis and initiation of antiretroviral therapy and opportunistic disease prophylaxis allow for HIV to be treated as a chronic medical problem with prospects for a better outcome than in the past. Early diagnosis also impacts secondary prevention, patient counseling, and treatment programs in the community. 2 However, clinicians have been slow to adapt to this recommendation. Only 20% of primary care physicians routinely screen their patients for HIV. 3 In contrast, recommended screening for various cancers and other chronic medical conditions is commonplace. At a 2008 national conference on HIV diagnosis, it was reported that 1 in 5 individuals with HIV in the United States is unaware of the diagnosis. 4 The CDC reported that lifetime testing for HIV remained stable at 40% from 2001-2006 for US adults but rose to 45% in 2009. Additionally, although most patients with HIV today are diagnosed early, nearly a third are still diagnosed late in their infection. 5
We hypothesized that offering HIV testing to all patients who came for an appointment in our primary care center would increase the frequency of HIV testing.
Methods
Our study was conducted at the Good Samaritan Hospital Internal Medicine Center in Dayton, Ohio. The center is a primary care teaching clinic staffed by 24 internal medicine residents from the Boonshoft School of Medicine at Wright State University. The majority of the center’s patients are low income, medically indigent, or uninsured. At the time of the study, the center’s patients were 49% Medicare or Medicaid, 43% self-pay, and 8% classified as other, mainly private insurance. Blood samples were sent to the Samaritan Clinical Laboratory, which uses the enzyme immune assay as the initial test and the Western blot as the confirmatory method for HIV testing. Prior to the initiation of the study, we obtained approval from the Wright State University Institutional Review Board.
Consecutive adult patients younger than 65 years seen at the center between January 30, 2010 and April 30, 2010 were offered screening for HIV at their own expense. Patients with cognitive impairments, acute illness, and those older than 64 years were to be excluded.
In our center, a medical assistant (MA) is the medical professional who first meets with the patient during a health care visit. The MA, previously trained in the HIV request procedure, made the request at the initial phase of the visit—that is, during the MA’s assessment of vital signs and recording of the patient’s reason(s) for today’s visit. After informed consent was obtained, patients completed a brief questionnaire on prior HIV testing.
Patients agreeing to the test were provided fact sheets on HIV disease and testing. Further counseling was performed by the patient’s primary care physician, who also ordered the test during the office visit. Ohio law does not require written consent prior to HIV testing. 6
Results
In total, 272 patients were offered HIV testing. The mean age of the sample was 49.3 years (standard deviation = 10.8 years) with 3 patients not reporting age; 54% were female. Nearly half of the patients (48%) were in the 50- to 64-year age-group.
In all, 111 of 270 (41%) had been tested for HIV in the past. The time since past HIV testing for the 111 patients was evenly distributed over periods (16% within the past 6 months, 17% between 6 and 12 months, 20% between 1 and 2 years, 17% between 2 and 5 years, and 30% more than 5 years ago). Table 1 shows that 46 of 272 (17%) consented to be tested for HIV.
Requests for HIV Testing
Thirty-one patients who agreed to screening had blood drawn at our center, and all were negative for HIV. Fifteen patients opted to be tested at the county public health clinic believing the charge for testing would be less costly. These results were not made available to us.
Discussion
Forty-six patients (17%) offered HIV testing during routine care at our primary care center between January 30, 2010 and April 30, 2010 agreed to be tested for HIV infection at their own expense. The 46 HIV tests during this 3-month period was a notable improvement compared with the 15 HIV tests (0.44%) ordered for 3444 patient visits at the center from January 2009 to October 2009 (see Table 1). The striking increase in the number of patients tested for HIV was likely because of the routine offer of screening by our center’s medical staff.
Our MAs reported that many patients declined testing knowing or speculating that the cost would be borne by them alone. There was a laboratory charge of $115 for the HIV test. Other researchers noted the influence of cost on the decision to agree to screening.7,8 Uninsured patients, who constitute 43% of our practice, are obviously obliged to pay for the full cost of the testing out of pocket. Our 17% rate of request for HIV testing is impressive when compared with most published studies of HIV screening in which testing was free.9,10
We also speculate that if we had used rapid HIV testing, where results are immediately available and also notably cheaper, more patients would have agreed to screening.11-13 Furthermore, consistent with other studies, we believe that the involvement of nonphysicians to initiate HIV screening may yield a higher participation rate than traditional HIV counseling and testing.14,15 Although our study was not designed to explore why patients declined HIV testing, it is possible that stigma, fear, and perceived risk may have influenced patients who decided against screening in addition to cost.
Conclusion
By offering HIV screening to patients presenting at our center, we were able to increase HIV testing for a 3-month period. The CDC’s recommendation for universal HIV screening of individuals aged 13 to 64 years is feasible even in settings where patients have limited resources. To increase HIV screening rates, health care workers should be trained in the best approaches to enhance interest among patients and less costly tests should be used.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.