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Abstract

Objectives:

Many US HIV-positive patients are unaware of their infection. Although there are multiple studies assessing the acceptance of testing, there are none that assess the patient’s expectations of routine HIV testing.

Methods:

Through a prospective, cross-sectional, unfunded, convenience sample survey, we assessed the patient’s expectation of testing at a regional medical center serving an indigent population. Also, we compared the providers’ predictions of the proportion of patients expecting a test.

Results:

Of the 69 patients, 23% expected a test. The only factor that correlated with this was their desire to be tested (P = .004). Providers’ (N = 59) mean prediction was that 21% of the patients expected a test (range: 0%-100%). The proportion of emergency department (ED) patients wanting a test was 52% (of 30) and internal medicine inpatients were 44% (of 39).

Conclusions:

Nearly a quarter of patients expected routine HIV testing. This finding should encourage a review of policies promoting HIV testing, especially within the ED.

Keywords

HIV test HIV transmission HIV prevention Emergency Department

Introduction

HIV has caused an estimated 617 025 deaths in the United States, as of 2008.¹ Of the estimated 1.2 million people living with HIV, approximately one-fifth are unaware of their infection.^2,3 The majority of new infections are transmitted by those unaware of their infection, and once aware of the infection most employ prevention strategies.⁴ Persons unaware will not take opportunistic infection prophylactic therapy, will not take advantage of highly active antiretroviral therapy (that will provide healthier, prolonged lives and prevent transmission), and will not know to protect their sex or drug partners from becoming infected.^5–7 Sadly, many persons unaware of their positive status often link to care late and already meet the criteria for AIDS by the time they have a positive test result.⁸ In one study, persons who had a delay in diagnosis and were found to be in late stages of the disease were more likely to have been exposed through heterosexual contact and be African American or Hispanic.² Many of these patients lacked the traditional risk factors such as high-risk heterosexual contact, occurrence of a sexually transmitted disease (STD), men having sex with men, and intravenous drug use.

Moreover, the vast majority of those who received their first positive test result in the same study presented to an acute care or referral medical center when already seriously ill from HIV rather than much earlier, when asymptomatic, at a primary care office or HIV testing center for screening.² Periodic, routine, and universal testing is essential to control the HIV pandemic by identifying transmitters and providing prevention messages.

In another study, patients and providers felt that HIV should be equated with other chronic diseases, for which the testing is routine, and favored by including HIV testing along with other routine blood work typically included in the primary care visits. The most salient reason in favor of routine HIV testing expressed by both patients and providers was the value of knowing one's HIV status and then acting upon it.⁹

In the past decade, recommendations for HIV screening have evolved from limited to broader strategies, having patients sign a written consent when the physician thought of a possible HIV diagnosis, to opt in strategies for testing of high-risk populations, and lately to routine opt out screening and counseling of all patients aged 13 to 64 years in all the settings. The US Centers for Disease Control and Prevention (CDC) issued the latter strategy guidelines in 2006, replacing those from 1993 with the expansion of HIV screening to both inpatient and outpatient settings and suggesting that testing become a routine part of prenatal care.¹⁰ Also, testing should be initiated using the opt out approach in which the patients are informed that the test will be performed, without requiring a specific consent form or requiring prevention counseling prior to testing.² Now, years later, screening is still not routine in practice other than in prenatal care. Recently, the US Preventive Services Task Force reiterated the latest CDC guideline.¹¹

The setting may influence the expectation and acceptance of routine HIV testing. In the obstetric setting, pregnant women are inclined to be tested if they think it can benefit their newborns; this practice has rapid uptake and acceptance when testing is routinely discussed, offered, and well integrated into prenatal care.¹² Pregnant women now experience HIV testing as routine, much like STD testing. Routinizing HIV testing can be done.

Emergency departments are the most frequent source of medical services for indigent and low-income populations, and these populations are disproportionately at greater risk of HIV infection.^13,14 One study implemented routine HIV screening in a Washington DC ED using the new CDC guidelines and showed that in an area with one of the highest AIDS prevalence rates in the United States, almost 60% of the patients who were eligible for screening agreed to be tested for HIV, although it was unplanned on their part.¹⁵ Most hospitalized patients respond positively when asked how they would feel about an unsolicited HIV test.¹⁶ The EDs and inpatient floors are acceptable places to perform routine HIV tests.

Many studies of acceptance of opt in versus opt out testing, separately or together, of rapid HIV testing in EDs, address the question, “Do you want to be tested for HIV if offered?”¹⁷ ^- ¹⁹ Our main study question is different, “Do you expect to be tested for HIV in this setting?” thereby determining their opinion of whether HIV testing should be part of routine care.

Methods and Aims

The primary aim of this study was to determine what proportion of patients expected a routine HIV test in the ED or after admission to the internal medicine (IM) department floors, through a prospective, cross-sectional survey. We looked for correlations between this end point and demographic variables, HIV risk behaviors, and whether they wanted a test. We also measured how well providers could predict the proportion of patients who expected a routine HIV test.

Study Setting and Population

In the latter half of 2010, we recruited patients at the Arrowhead Regional Medical Center (ARMC), a county-funded hospital serving mainly the indigent, located in an economically depressed area of Southern California.

We included patients of any gender, 18 to 64 years of age, English or Spanish speaking who seemed competent to complete the written informed consent procedure and survey. We excluded obstetric patients, those who seemed unable to understand or cooperate or too busy with care at the time, those who spontaneously mentioned a previous HIV diagnosis, or those in isolation. We did not review medical records. Patients and providers were approached when the researchers were available; and there was no randomization. The Western University of Health Sciences (WU) institutional review board (IRB) was more comfortable with 18 being the lower age limit for this study due to concerns about children being a vulnerable group, whereas the CDC recommends routine testing of those 13 to 64 years old.

The providers included resident and attending physicians from family and emergency and internal medicine, general, and neurosurgery.

Study Design/Protocol

After ARMC and WU IRB approvals and after completion of the written informed consent procedure, the patients, in private, underwent a verbal survey by the researcher in their clinical setting (ED or IM). The researcher clarified any items, if needed, and the patient placed the survey documents in a sealed envelope to ensure confidentiality. The envelope was then coded with setting and patient number. Large print, Spanish or English surveys were used as needed. If the patients desired HIV testing, they were given a list of local testing centers or directed to ask their setting medical provider.

Providers were encountered as individuals or groups, given a verbal study description, and then given a confidential, written survey. Opportunities for answering the questions were provided.

Key Outcome Measures

The verbal patient survey included whether they expected or wanted an HIV test in their clinical setting, age, race, level of education, and income level. The risk factor survey in written form for even greater privacy, included sexual orientation, having unprotected sex with multiple partners, having unprotected sex with an HIV-positive person or an injection drug user, having an STD history (common STDs were listed), having been treated for tuberculosis, having a transfusion outside the United States, having used injection drugs, having a previous HIV test, and having had a positive HIV test in the past.

In the provider survey, demographic and HIV testing history details were asked along with their prediction of what percentage of patients would expect to have an HIV test in the clinical settings.

Data Analysis

The deidentified data from the surveys were transcribed to Microsoft Excel and then exported to SPSS (version 12.01 Apache Software Foundation, Forest Hill, MD, USA) for analysis. Logistic regression was used to determine the variables that correlated with the patient’s expectation and look for correlations of accurate and inaccurate provider predictions with their characteristics as well. The Pearson chi-square test was used to test the difference between percentage of patients who expected to be tested and providers’ predictions. A P < .05 was considered to be statistically significant.

If the patient listed more than 1 racial descent, we coded only the first.

Results

Patients

Table 1 describes the population of patients and their survey responses. Of the patients surveyed, 23% expected to be tested for HIV in each of the 2 settings. There was a highly statistically significant correlation between expecting a test and wanting it. There were no other significant correlations for expecting a test. More than 40% of patients wanted an HIV test. The ED had the highest proportion at 52%. Another interesting finding was that many patients said they had no history of unprotected sex, yet their mean age was about 45.

Table 1.

Features of the Patient Populations and Their Survey Responses.^a

	Int Med Admission	ED Visit	Correlation With Expectation
Number of patients	39	30	NA
Expected HIV/AIDS test	23%	23%	1 end point
Mean age	46	45	NS
Descent			NS
European	36%	33%
Hispanic	55%	40%
African American	3%	20%
Other	3%	3%
Asian	3%	3%
Strictly heterosexual	97%	96%	NS
Family income, US$/year			NS
0-20 000	57%	71%
21 000-40 000	22%	11%
41 000-60 000	16%	7%
61 000-85 000	3%	7%
86 000 and above	3%	4%
Highest education			NS
Middle school	24%	10%
High school	47%	57%
Some college	16%	30%
Associate's degree	5%	0%
Bachelor's degree/higher	8%	3%
Wanted HIV/AIDS test	43.5%	52%	P = .004
Previous HIV/AIDS testing	40.5%	40%	NS
Any unprotected sex	18%	53%	NS
Sex with HIV/AIDS-positive person	2.7%	7%	NS
Sexually transmitted disease	5%	13%	NS
Hepatitis treatment	10.5%	3%	NS
TB treatment	5%	13%	NS
Transfusion before 1985	10.5%	10%	NS
Non-US transfusion	10%	0%	NS
Injected illegal drugs/steroids	5%	13%	NS
Sex with illegal drug/steroid user	3%	17%	NS
Past positive HIV test	8%	7%	NS

Abbreviations: Int Med, internal medicine inpatient; ED, emergency department patient; NA, not applicable; NS, not statistically significant; TB, tuberculosis.

^a Logistic regression.

Some patients did not answer all the questions, so denominators for some questions are fewer than the total number of patients.

Providers

Table 2 describes the provider’s characteristics and the mean prediction. Figure 1 presents the frequency graph of the provider’s predictions (note the nonlinear x axis). The mean of providers’ prediction is quite close to the percentage of patients expecting to be tested, but the spread of prediction data points is quite wide and the graph is unlike a bell curve.

Figure 1.

General providers’ predictions of percentage of patients expecting an HIV test.

Table 2.

Providers’ Features.^a

	Providers
Number	59
Mean prediction	21%
Mean age	34
Female	37%
Married	56%
HIV tested	64%
Mean number of tests	1.9
Years since tested for HIV, mean	3

^a None correlate with prediction accuracy.

We attempted to find correlations between the accuracy of provider’s predictions and the other provider variables by categorizing the predictions into wide and narrow ranges and then performing multinomial logistic regression. None of the variables listed in Table 2 were correlated with an accurate prediction. Most of the providers had the HIV test previously as a requirement for employment.

Discussion

We found that nearly a quarter of patients expected to be tested for HIV routinely in the ED or IM setting and that individual providers were poor at predicting what percentage of patients is expected to be tested, although their mean prediction was very close.

Patients

We have frequently heard this phrase spoken by discharged patients, “They tested me for everything!” Many patients, who expect to be HIV tested but are not counseled about the result (whether the test was performed or not) upon conclusion of the visit, may assume they are negative and continue risky behavior. The positive ones may not alter their activities and transmit HIV before becoming so ill that they are finally tested. The CDC estimates that 33% of the newly diagnosed HIV cases in 2008 were diagnosed with an AIDS-defining condition within a year of being tested, and they estimate that these cases were probably undiagnosed for 10 years.²⁰

Contrary to our anticipation that the ED patient’s expectations would be lower than those admitted to the IM (since IM patients are in the hospital longer, have more blood tests, and are more ill), we found that the proportion of patients expecting the test were equal in these 2 settings. The vast majority of the ARMC admissions are first seen in the ED, and roughly 85% of ED patients are not admitted. Therefore, in our setting the ED is an attractive place to routinize HIV testing.

Surprising findings among the patients in the IM and ED encourage us to test patients according to the guidelines; the percentage of patients who wanted to be tested for HIV and the percentage of those who had been tested before were similar in the 2 settings, but being tested before was not correlated with expecting a test on the current visit. This might indicate that even though tested before, a good number of them did not think it was routine—to be expected. Some of those previously tested may have wanted to be tested again to show they had not contracted HIV since the last test. About 60% of the patients had not been tested before—an opportunity not to be missed. In any case, communicating HIV test results are great opportunities for reinforcing prevention messages.

Why did 77% of the patients not expect an HIV test in ED or IM settings? They may not consider themselves at risk even though we assume they have had unprotected sex. The medical culture and culture in general have not promoted this possible risk and testing as routine. Stigma is a factor with HIV, but we encountered little patient hesitancy during the adoption of screening with mammograms or prostate-specific antigen (PSA) years ago. HIV is many times thought to be due to “bad behavior by bad people,” and cancer is caused due to “bad luck.” Another factor responsible for lack of expectation may be the lack of robust industrial financing promoting HIV testing as occurred previously with mammograms and PSA.^21,22 There may be poor health literacy in our patients due to the following barriers: low incomes, low education, and being mainly Hispanic (possible cultural and language barriers). We must make concrete plans to dispel the stigma, overcome the barriers, and make testing routine in the minds of all patient populations.

Only a few HIV-positive patients participated, because the study did not spontaneously mention this exclusion fact during the survey session. Perhaps they were concerned about confidentiality; some of our current HIV clinic patients chose not to mention their positive status to other providers if they think it might be irrelevant or it might cause discrimination in care. Others may not have admitted their positive status.

The majority of the ED and IM patients belonged to lower income and non-Anglo target groups who typically access testing less and late.² We must reach out to these groups, and good proportions expect and want a test.

Providers

The wide data spread of predictions in the providers underscores the need for this study; many providers were unaware of the proportion of patients in these settings who expected or wanted to be tested.

Study Limitations

The study did not have robust enrollment. This was an unfunded student project with limited vacation time windows available; so, the patients and providers were selected by convenience rather than randomly, and we excluded inconvenient patients. Also, our patient population may not be representative of other populations, but lately it had an ethnic mix that adequately included the ethnicities and income ranges of many of those testing disproportionately positive in the United States.²³

The survey has not been validated. If the patient listed more than 1 racial descent, we included only the one listed first. We did not include the full age range recommended by the CDC. Not all patients answered every question.

Even with our extra effort at confidentiality, there were few risks admitted to. Perhaps there may have been denial or embarrassment to admit risk factors, for example, unprotected sex or a lack of understanding of the risk terms. Perhaps this survey section should have been worded and explained better. On the other hand, we should expect fewer risks in the general population we recruited.

Conclusion

The appreciable proportion of patients who expected or wanted HIV testing should fuel a clinical and ethical response to include routine, universal testing, especially in the ED as the CDC guidelines suggest. Some ED clinicians are disregarding an opportunity to offer testing, that is, a gateway to treatment for HIV-positive patients who may never get HIV testing in another setting until very late in their disease or just prior to death.² Financial arguments against testing are not meritorious; when looking at the population studies, rapid HIV testing is probably cost effective compared to the overall cost of AIDS treatment and hospitalization for avoidable complications.^24,25 As demonstrated with pregnant patients, the strategy of routinization is acceptable to patients and fosters an environment that lessens the associated stigma.

Over 43% of the patients wanted an HIV test, and 23% expected it. The desire exceeded the expectation; we should capitalize on the desire and make the test expected. The patient expectation and the mean providers’ prediction of it are close to each other. Each of the 3 end points discussed previously was far less than the universal testing goal of the guidelines; again this may be a reflection of the current, inadequate state of our policies and procedures. What is preventing us from creating policies and procedures to increase the desire and expectation? We must move past the barriers of inadequate time, inadequate resources, concerns regarding provision of follow-up care, and waning enthusiasm listed as barriers to ordering HIV testing routinely.²⁶

Each time an HIV test result is discussed, it is a brief, but important, opportunity to educate and increase awareness of HIV transmission risk, that is, prevent it in that individual and their contacts. Also, we must make a stronger effort to identify and link the estimated 230 000 HIV-positive people in the United States, who are unaware of their status to HIV specialty care, which will also save resources and prevent suffering.²⁴

Footnotes

Acknowledgments

The authors appreciate the patients and providers who participated in this study. Helpful comments on study and survey design from the Western University Graduate Nursing statistics class were valuable.

Authors’ Note

This study received support from the volunteer labor of authors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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A Survey of a Small Sample of Emergency Department and Admitted Patients Asking Whether They Expect to Be Tested for HIV Routinely

Abstract

Objectives:

Methods:

Results:

Conclusions:

Keywords

Introduction

Methods and Aims

Study Setting and Population

Study Design/Protocol

Key Outcome Measures

Data Analysis

Results

Patients

Providers

Discussion

Patients

Providers

Study Limitations

Conclusion

Footnotes

Acknowledgments

Authors’ Note

Declaration of Conflicting Interests

Funding

References