HIV Screening in the Health Care Setting: Status, Barriers, and Potential Solutions

Thirty years into the human immunodeficiency virus (HIV) epidemic in the United States, an estimated 50,000 persons become infected each year: highest rates are in black and Hispanic populations and in men who have sex with men. Testing for HIV has become more widespread over time, with the highest rates of HIV testing in populations most affected by HIV. However, approximately 55% of adults in the United States have never received an HIV test. Because of the individual and community benefits of treatment for HIV, in 2006 the Centers for Disease Control and Prevention recommended routine screening for HIV infection in clinical settings. The adoption of this recommendation has been gradual owing to a variety of issues: lack of awareness and misconceptions related to HIV screening by physicians and patients, barriers at the facility and legislative levels, costs associated with testing, and conflicting recommendations concerning the value of routine screening. Reducing or eliminating these barriers is needed to increase the implementation of routine screening in clinical settings so that more people with unrecognized infection can be identified, linked to care, and provided treatment to improve their health and prevent new cases of HIV infection in the United States.     

HIV testing in emergency departments: a recommendation with missed opportunities.

The purpose of this study was to determine the effective use of the 2001 Centers for Disease Control and Prevention (CDC) HIV testing recommendations in emergency department settings. A postal questionnaire was distributed to health care providers in emergency departments across the United States to evaluate the rate HIV tests are routinely offered to individuals presenting to emergency departments for care. A total of 223 emergency department providers responded. Results indicated that health care providers generally were not aware that their institutions were located in areas with high HIV seroprevalence rates. Only 3% of the health care providers surveyed claimed they routinely offered an HIV test to everyone who sought care in their emergency department regardless of patients' presentation to care. The conclusion was that, in 2004, testing for HIV in emergency departments was not a priority for those providing care. In general, despite the fact that the CDC 2001 HIV testing guidelines were less universal than the 2006 recommendations, many had not implemented routine HIV testing programs in their emergency departments. The number of patients who use emergency departments for routine care is on the rise, and missed opportunities for offering HIV tests have detrimental effects for the individual as well as for the public health.     

Design and Implementation of a Controlled Clinical Trial to Evaluate the Effectiveness and Efficiency of Routine Opt-out Rapid Human Immunodeficiency Virus Screening in the Emergency Department

In 2006, the Centers for Disease Control and Prevention (CDC) released revised recommendations for performing human immunodeficiency virus (HIV) testing in health care settings, including implementing routine rapid HIV screening, the use of an integrated opt-out consent, and limited prevention counseling. Emergency departments (EDs) have been a primary focus of these efforts. These revised CDC recommendations were primarily based on feasibility studies and have not been evaluated through the application of rigorous research methods. This article describes the design and implementation of a large prospective controlled clinical trial to evaluate the CDC's recommendations in an ED setting. From April 15, 2007, through April 15, 2009, a prospective quasi-experimental equivalent time-samples clinical trial was performed to compare the clinical effectiveness and efficiency of routine (nontargeted) opt-out rapid HIV screening (intervention) to physician-directed diagnostic rapid HIV testing (control) in a high-volume urban ED. In addition, three nested observational studies were performed to evaluate the cost-effectiveness and patient and staff acceptance of the two rapid HIV testing methods. This article describes the rationale, methodologies, and study design features of this program evaluation clinical trial. It also provides details regarding the integration of the principal clinical trial and its nested observational studies. Such ED-based trials are rare, but serve to provide valid comparisons between testing approaches. Investigators should consider similar methodology when performing future ED-based health services research.     

Beyond the end of exceptionalism: integrating HIV testing into routine medical care and HIV prevention

In September 2006, the US CDC issued new guidelines for HIV testing. These guidelines were designed not only to simplify and expand HIV testing but also to integrate testing into routine medical care in the USA. The nationwide implementation of these guidelines is currently facing several political and legal barriers. In this article, we examine the origins of current patient-driven and risk-based HIV testing in the USA and highlight shortcomings of this strategy. We then demonstrate how the changing HIV epidemic in the USA requires routine HIV screening at all points of contact in the medical system in order to control the HIV epidemic and how novel testing strategies could increase the yield of testing in these settings.     

Beyond the end of exceptionalism: integrating HIV testing into routine medical care and HIV prevention

In September 2006, the US CDC issued new guidelines for HIV testing. These guidelines were designed not only to simplify and expand HIV testing but also to integrate testing into routine medical care in the USA. The nationwide implementation of these guidelines is currently facing several political and legal barriers. In this article, we examine the origins of current patient-driven and risk-based HIV testing in the USA and highlight shortcomings of this strategy. We then demonstrate how the changing HIV epidemic in the USA requires routine HIV screening at all points of contact in the medical system in order to control the HIV epidemic and how novel testing strategies could increase the yield of testing in these settings.     

HIV counseling, testing, and referral

Over the past decade, the annual number of new cases of human immunodeficiency virus (HIV) infection has been relatively stable but remains unacceptably high (an estimated 40,000 new cases per year). Furthermore, the demographics for HIV infection are changing. Rates of new infections are declining in newborns, older men who have sex with men, and whites. However, rates of new infections are rising in young persons, women, Hispanics, and blacks. In 2001, the Centers for Disease Control and Prevention issued revised guidelines for HIV counseling, testing, and referral. The guidelines focus on the reduction of barriers to testing, voluntary routine testing of high-risk populations and persons with risk factors, case management and partner tracing for infected persons, and universal testing of pregnant women. Effective strategies for reducing HIV infection include behavioral interventions, comprehensive school-based HIV and sex education, access to sterile drug equipment, screening of the blood supply, and postexposure prophylaxis for health care workers.     

Availability of Rapid Human Immunodeficiency Virus Testing in Academic Emergency Departments

Objectives:  The Centers for Disease Control and Prevention (CDC) recommends routine human immunodeficiency virus (HIV) screening of emergency department (ED) patients aged 13 to 64 years. The study objectives were to determine the accessibility of rapid HIV testing in academic EDs, to identify factors that influence an ED's adoption of testing, and to describe current HIV testing practices.
Methods:  Online surveys were sent to EDs affiliated with emergency medicine (EM) residency programs ( n  = 128), excluding federal hospitals and facilities in U.S. territories. Eighty percent ( n  = 102) responded. Most e-mail recipients ( n  = 121) were Emergency Medicine Network (EMNet) investigators; remaining contacts were obtained from residency-related Web sites.
Results:  Most academic EDs ( n  = 58; 57%; 95% confidence interval (CI) = 47% to 66%) offer rapid HIV testing. Among this group, 26 (45%) allow providers to order tests without restrictions. Of the other 32 EDs, 100% have policies allowing for rapid HIV testing following occupational exposures, but less than 10% have guidelines for testing in other clinical situations. Forty-seven percent expect to routinely offer HIV testing in the next 2 to 3 years. Only 59% of the EDs that offered rapid tests in any situation could link an HIV-positive patient to subspecialty care. The facility characteristic most important to availability of rapid HIV testing was the presence of on-site HIV counselors.
Conclusions:  Most academic EDs now offer rapid HIV testing (57%), but few use it in situations other than occupational exposure. Less than half of academic EDs expect to implement CDC guidelines regarding routine screening within the next few years. The authors identified facility characteristics (e.g., counseling, ability to refer) that may influence adoption of rapid HIV testing.     

HIV testing policies for pregnant women: A roundtable discussion

The Institute of Medicine's (IOM) Committee on Perinatal Transmission of HIV released its report in October 1998. Universal and routine HIV testing with the right of refusal for all pregnant women in the United States was recommended. This recommendation differed from the CDC guidelines in 1995 that recommended universal counseling but only voluntary testing for all pregnant women. Dr. Nancy Kass from the IOM committee and Dr. Howard Minkoff of the Maimonides Medical Center discuss the policy and its implications with Dr. Deborah Cotton, editor of AIDS Clinical Care and IOM committee member. Medical and social advantages of the policy are described, and steps are detailed for implementing IOM's recommendations.     

HIV and sexually transmitted diseases. Latest views on synergy, treatment, and screening

While STDs have an important impact on HIV transmission, experimental intervention studies demonstrating that STD control reduces HIV incidence have had mixed results. STDs can impact the clinical management of patients infected with HIV by increasing both viral load and HIV infectiousness. The clinical management of STDs is a dynamic field that has seen the advent of new diagnostic assays as well as changes in susceptibility to and availability of antimicrobial agents. As a result, excellence in HIV medical care requires physicians to be current in STD medicine. Physicians who care for patients with HIV infection should be familiar with recent guidelines recommending routine risk assessment and STD screening in these patients.     

2009 - 2010年山西省大同市艾滋病自愿咨询检测结果分析

目的 通过了解大同市疾病预防控制中心(CDC)艾滋病自愿咨询检测(VCT)服务人群现状,为大同市艾滋病防治措施的制定提供依据。 方法 对2009 - 2010年在大同市CDC接受艾滋病VCT服务的人员的人口学状况、求询原因、危险行为等进行统计学分析。 结果 2326名求询者99.91%接受了HIV抗体检测,检出阳性1例,HIV感染检出率为0.04%;求询者男女性别比为1.5 ∶ 1;年龄主要集中在21~49岁,占总体的93.94%;初中学历占全部求询者学历的41.49%;高危性行为占各种求询原因的19.87%。求询的问题主要涉及HIV检测相关问题,艾滋病症状、传播途径及感染概率等。 结论 青壮年性接触是大同市艾滋病传播的危险人群及方式;目前亟须对进城务工人员和男同性恋人群提供艾滋病知识宣传和VCT服务;提高求询者安全套使用率和转介率应是今后VCT工作努力的重点。     

Emergency Provider Attitudes and Barriers to Universal HIV Testing in the Emergency Department

Background: The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED). Study Objective: The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines. Methods: Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions. Results: There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]). Conclusions: After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.     

Disease severity and symptoms of depression in Black Americans infected with HIV.

The purpose of this study was to examine depressive symptomatology in a sample of human immunodeficiency virus (HIV) infected Black Americans and to determine the extent to which measures of HIV disease severity were associated with depressive symptoms. Seventy-nine HIV-infected Black men and women (ages 25 to 68 years) participated. Measures included the Center for Epidemiologic Studies Depression Scale (CES-D) and multiple HIV disease severity variables including CD4+ lymphocyte count, CDC HIV stage, and HIV RNA viral load. Levels of self-reported depressive symptoms were high, with 58% (n = 48/79) of study participants exhibiting elevated depressive symptoms (CES-D score of > or =16). No relationship was found between CD4+ count, CDC HIV stage, sociodemographic variables, and depressive symptoms. Viral load, however, was positively correlated with elevated depressive symptoms. Although the level of depressive symptomatology was high, only two participants were receiving antidepressant medication. This study suggests that there is a significant unmet need for identification and treatment of depressive symptoms among Blacks receiving routine care for HIV disease.     

Addressing HIV infection in office practice. Assessing risk, counseling, and testing.

HIV risk assessment, counseling, and testing performed by primary care physicians can be valuable in the early identification of persons infected with HIV, can contribute to their appropriate medical treatment, and may help to prevent the further spread of the disease. HIV risk assessment comprises a detailed sexual and drug use history, awareness of the mechanisms of HIV transmission, and knowledge of which patients should be encouraged to undergo counseling and testing. During pretest counseling, the physician asks for informed consent for the HIV test, explains the meaning of positive and negative test results, reviews risk behaviors, and offers an appropriate prevention message. During posttest counseling, the physician informs the patient of the results, reviews the meaning of the test results, and reinforces the appropriate prevention messages. Follow-up care for seropositive patients should be arranged, including appropriate medical care, referral to social and support services, and, if indicated, mental health care.     

Acceptance of Rapid HIV Screening in a Southeastern Emergency Department

Objectives:  The objective was to assess the acceptance of an emergency department (ED) human immunodeficiency virus (HIV) screening program based on the Centers for Disease Control and Prevention (CDC) recommendations for routine HIV screening in health care settings.
Methods:  Rapid HIV screening was offered on an opt-out basis to patients aged 13 to 64 years presenting to the ED by trained HIV counselors. Patients were excluded if they had a history of HIV, were physically or mentally incapacitated, did not understand their right to opt-out, or did not speak English or Spanish. Statistical analyses, including logistic regression, were performed to assess the associations between the demographics of patients offered testing and their test acceptance or refusal.
Results:  From March 2008 to January 2009, a total of 5,080 (91%) of the 5,585 patients offered the HIV test accepted, and 506 (9%) refused. White and married patients were less likely to accept testing than those who were African American and unmarried (p < 0.001). Adult patients were almost twice as likely to accept testing as pediatric patients (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.50 to 2.53). As age increased among pediatric patients, testing refusal decreased (OR = 0.71; 95% CI = 0.59 to 0.85), and as age increased among adult patients, testing refusal increased (OR = 1.17; 95% CI = 1.12 to 1.22). Two percent of persons accepting the test were considered high risk. Males were more likely to report high-risk behavior than females (OR = 1.83; 95% CI = 1.23 to 2.72).
Conclusions:  The opt-out approach results in high acceptance of routine HIV screening. Widespread adoption of the CDC's recommendations, although feasible, will require significant increases in resources.     

Needle stick injuries: nurses at risk

According to the Centers for Disease Control and Prevention (CDC), American health care workers suffer between 600,000 and 1 million needle sticks and other sharps injuries every year. Needle stick injuries are considered to be widely underreported. Eighty percent of blood contacts occur through needle sticks, making this the most common cause of health care work-related exposure to bloodborne pathogens. More than 20 pathogens can be transmitted through small amounts of blood. These include HIV, hepatitis B and C, other forms of hepatitis, syphilis, Rocky Mountain spotted fever, varicellazoster, and malaria. Hepatitis B is the most common infectious disease transmitted through work-related exposure to blood. The CDC reports that 5,100 health care workers become infected with hepatitis B each year through job-related blood contact. There have been 54 documented cases of HIV seroconversions among U.S. health care workers resulting from occupational exposures. Needle stick injuries caused by hollow-bore needles accounted for 86 percent of all reported occupational HIV exposures. Nurses make up 24 percent of the cases of HIV infection among health care workers known or thought to have been infected on the job. Research shows that 83 percent of these injuries can be prevented--most through the use of needles with safety features or needleless systems. According to the American Hospital Association, one case of serious infection by bloodborne pathogen can result in expenditures of $1 million or more for testing, follow-up, time lost from work, and disability payments. The cost of follow-up for a high-risk exposure is almost $3,000 per needle stick injury, even when no infection occurs. Safe needle devices cost about 28 cents more than standard devices.     

Promoting healthy behaviors in HIV primary care

Recent treatment advances have prolonged the life expectancy of persons with human immunodeficiency virus (HIV). HIV care providers must now promote healthy behaviors, such as smoking cessation, exercise, and screening for general medical problems, such as diabetes and hyperlipidemia. This report describes recently published evidence and recommendations for providing HIV primary care.     

Acute seroconversion of HIV infection in the ambulatory care setting

Patients frequently visit ambulatory care settings with acute human immunodeficiency virus (HIV) seroconversion illness, but the illness is often misdiagnosed. This acute viral syndrome, or seroconversion illness, occurs after initial exposure to the HIV virus; it is often resolved before the development of HIV-specific antibodies. Primary HIV infection refers to the 12 months following infection; it includes an acute time period after exposure when routine HIV antibody testing is negative. Primary HIV infection is recognized with the help of a detailed screening history. Diagnosis is confirmed through laboratory tests that detect virus presence. The accurate diagnosis of primary HIV infection can have a beneficial effect on the patient's clinical course and also on public health prevention efforts.     

Universal HIV Screening in Ambulatory Care Settings

Statistics reveal that clinicians are not offering or recommending routine HIV screening in almost all health care settings, despite strongly recommended clinical guidelines published in 2006 and 2013. The Centers for Disease Control and Prevention estimates that less than half of the US population aged 18–64 years has ever been tested for HIV.^1,2 To increase HIV screening rates, it is crucial to provide education on the guidelines and a mechanism for readily available testing to increase HIV screening rates. Employing evidence-based universal screening will potentially identify new HIV diagnoses earlier. Timely identification decreases the spread of HIV, reduces the complications from living with HIV, and provides significant cost savings. Undiagnosed persons living with HIV pose a substantial epidemiologic risk. Without increased HIV screening and linkage to care, ending the HIV epidemic within the United States will be unattainable.     

Blood screening by nucleic acid amplification technology: current issues, future challenges.

BACKGROUND: Nucleic acid amplification technology (NAT) is presently being evaluated in US clinical trials to determine the safety and efficacy of mini-pool testing for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) RNA in the blood-donor population. Although the risk for transfusion-transmitted HIV and HCV infection is extremely low, there is still a small chance that blood donated by infected individuals before seroconversion can escape detection by current antibody-based assays. METHODS: This report describes the amplification technologies being used and reviews several issues surrounding NAT-based blood screening. The performance features of NAT and current enzyme immunoassay technologies are compared, and the benefits of NAT in reducing transfusion-transmitted infections are discussed. CONCLUSIONS: The current US clinical trials of mini-pool NAT testing for HIV and HCV RNA have successfully identified preseroconversion infectious blood units. Although the current NAT-based screening systems are semiautomated, mini-pool testing represents an unprecedented innovation among government and nongovernment agencies in the highly regulated blood transfusion industry. Despite cost-effectiveness issues, based on the public perception of infectious diseases acquired through blood transfusion, NAT-based screening of the blood supply is expected to become a standard in transfusion medicine.     

Sexual prevention of HIV: a model for Latinos.

Despite reductions in AIDS deaths in the general population, Latino AIDS deaths in the United States have been increasing. The underlying cause of the rising HIV infection rates in the U.S. Latino population is not fully understood. Focus groups among Mexicans in North Carolina revealed methods of prevention that were different from those recommended by the Centers for Disease Control and Prevention (CDC). A research-based Mexican model of HIV prevention is proposed and contrasted with a model deducted from CDC prevention strategies. Recently immigrated Mexicans may be unlikely to adopt the CDC model of HIV prevention due to their culturally specific views of prevention.