Factors Associated with Refusal of Rapid HIV Testing in an Emergency Department

HIV screening studies in the emergency department (ED) have demonstrated rates of HIV test refusal ranging from 40–67%. This study aimed to determine the factors associated with refusal to undergo routine rapid HIV testing in an academic ED in Boston. HIV counselors offered routine testing to 1,959 patients; almost one-third of patients (29%) refused. Data from a self-administered survey were used to determine independent correlates of HIV testing refusal. In multivariate analysis, women and patients with annual household incomes of $50,000 or more were more likely to refuse testing, as were those who reported not engaging in HIV risk behaviors, those previously HIV tested and those who did not perceive a need for testing. Enrollment during morning hours was also associated with an increased risk of refusal. Increased educational efforts to convey the rationale and benefits of universal screening may improve testing uptake among these groups.     

Low health literacy is associated with HIV test acceptance

BACKGROUND: The Centers for Disease Control and Prevention has proposed increasing the proportion of people who learn their HIV serostatus. The health care setting represents a logical site to accomplish this goal. However, little is known about factors that determine acceptability of HIV testing in health care settings, particularly patients' health literacy. OBJECTIVE: To evaluate the association between patients' health literacy and acceptance of HIV testing among individuals at an urgent care center (UCC). METHODS: As part of a prospective study that sought to increase HIV testing at a UCC located in an inner-city hospital serving an indigent population, we surveyed patients who had been offered an HIV test by their providers and had accepted or refused testing. Pretest counseling was provided using a low-literacy brochure given to patients upon registration into the clinic. We measured health literacy level using the Rapid Estimate of Adult Literacy in Medicine (REALM) scale. RESULTS: Three hundred seventy-two patients were enrolled in the study. In univariate analysis, no statistically significant difference between HIV test acceptors or refusers was found for gender, race/ethnicity, marital status, income, type of health insurance, educational level, or type of test offered. Acceptors were more likely to have a low literacy level (odds ratio [OR], 1.763; 95% confidence interval [CI], 1.084 to 2.866) and be less than 40 years old (OR, 1.639; 95% CI, 1.085 to 2.475). In multivariate analysis, low health literacy was shown to be a predictor of HIV test acceptance controlling for age and education (OR, 2.017; 95% CI, 1.190 to 3.418). CONCLUSIONS: Low health literacy was shown to be a predictor of HIV test acceptance. Patients presenting to a UCC with poorer health literacy appear more willing to comply with health care providers' recommendations to undergo HIV testing than those with adequate health literacy when an "opt-out" strategy combined with a low-literacy brochure is used.     

Individual, household and community factors associated with HIV test refusal in rural Malawi

Objective To investigate individual, household and community factors associated with HIV test refusal in a counselling and testing programme offered at population level in rural Malawi. Methods HIV counselling and testing was offered to individuals aged 18–59 at their homes. Individual variables were collected by interviews and physical examinations. Household variables were determined as part of a previous census. Multivariate models allowing for household and community clustering were used to assess associations between HIV test refusal and explanatory variables. Results Of 2303 eligible adults, 2129 were found and 1443 agreed to HIV testing. Test refusal was less likely by those who were never married [adjusted odds ratio (aOR) 0.50 for men (95% CI 0.32; 0.80) and 0.44 (0.21; 0.91) for women] and by farmers [aOR 0.70 (0.52; 0.96) for men and 0.59 (0.40; 0.87) for women]. A 10% increase in cluster refusal rates increased the odds of refusal by 1.48 (1.32; 1.66) in men and 1.68 (1.32; 2.12) in women. Women counsellors increased the odds of refusal by 1.39 (1.00; 1.92) in men. Predictors of HIV test refusal in women were refusal of the husband as head of household [aOR 15.08 (9.39; 24.21)] and living close to the main road [aOR 6.07 (1.76; 20.98)]. Common reasons for refusal were fear of testing positive, previous HIV test, knowledge of HIV serostatus and the need for more time to think. Conclusion Successful VCT strategies need to encourage couples counselling and should involve participation of men and communities.     

Short communication routine HIV testing in the emergency department: assessment of patient perceptions

The CDC released revised HIV testing guidelines in 2006 recommending routine, opt-out HIV testing in acute care settings including emergency departments (ED). Patient attitudes have been cited as a barrier to implementation of routine HIV testing in the ED. We assessed patients' perceptions of HIV testing in the ED through a contextual qualitative approach. The study was conducted during a 72-h period. All adults presenting to the ED without life-threatening trauma or psychiatric crisis completed a standardized questionnaire. The questionnaire explored HIV testing history, knowledge of testing resources, and qualitative items addressing participant perceptions about advantages and disadvantages to ED testing. After completion of the interview, participants were offered a free, confidential, rapid HIV test. Among 329 eligible individuals approached, 288 (87.5%) completed the initial interview. Participants overwhelmingly (n=247, 85.8%) reported support for testing and identified increased knowledge (41%), prevention (12.5%), convenience (11.8%), and treatment (4.9%) among the advantages. Fear and denial about one's HIV status, reported by <5% of patients, were identified as the most significant barriers to ED testing. Bivariate analysis determined race and ethnicity differences between individuals completing the interview and those who refused (p<0.05). Among individuals consenting for testing (n=186, 64.6%), no positives were detected. Most patients support HIV testing in the ED, noting knowledge of status, prevention, convenience, and linkage to early treatment as distinct advantages. These data are of particular benefit to decision makers considering the addition of routine HIV testing in EDs.     

Who and Why? HIV-Testing Refusal During Pregnancy: Implication for Pediatric HIV Epidemic Disparity

To identify characteristics of pregnant women who refuse HIV testing and determine predictive factors and the reasons for refusal, we conducted face-to-face interviews of pregnant women at prenatal clinics of public and private hospitals. We found 8% (n=65) of 826 pregnant women interviewed refused HIV testing. In bivariate analysis, foreign-born pregnant women residing in Los Angeles County were twice more likely to refuse HIV testing than U.S.-born pregnant women (odds ratio [OR] = 1.97, 95% confidence interval [CI] 1.11-3.49, p <.05). In a multivariate stepwise logistic regression model analysis, variables that were independent predictors of HIV testing refusal during pregnancy were being foreign-born (OR = 2.11, 95% CI 1.07-4.38), not receiving general information about HIV (OR = 7.48, 95% CI 1.86-30.01), and not receiving specific information about HIV and pregnancy (OR = 3.54, 95% CI 1.91-6.57). The most common reasons for testing refusal were being in a monogamous relationship for foreign-born women (41%) and already being tested for U.S.-born women (65%).     

Offering self-administered oral HIV testing to truck drivers in Kenya to increase testing: a randomized controlled trial

We conducted a randomized controlled trial among 305 truck drivers from two North Star Alliance roadside wellness clinics in Kenya to see if offering HIV testing choices would increase HIV testing uptake. Participants were randomized to be offered (1) a provider-administered rapid blood (finger-prick) HIV test (i.e., standard of care [SOC]) or (2) a Choice between SOC or a self-administered oral rapid HIV test with provider supervision in the clinic. Participants in the Choice arm who refused HIV testing in the clinic were offered a test kit for home use with phone-based posttest counseling. We compared HIV test uptake using the Mantel Haenszel odds ratio (OR) adjusting for clinic.

Those in the Choice arm had higher odds of HIV test uptake than those in the SOC arm (OR?=?1.5), but the difference was not statistically significant (p?=?0.189). When adding the option to take an HIV test kit for home use, the Choice arm had significantly greater odds of testing uptake (OR?=?2.8, p?=?0.002). Of those in the Choice arm who tested, 26.9% selected the SOC test, 64.6% chose supervised self-testing in the clinic, and 8.5% took a test kit for home use.

Participants varied in the HIV test they selected when given choices. Importantly, when participants who refused HIV testing in the clinic were offered a test kit for home use, an additional 8.5% tested. Offering truck drivers a variety of HIV testing choices may increase HIV testing uptake in this key population.     

Sustaining HIV testing in pregnancy- evaluation of routine offer of HIV testing in three London hospitals over 2 years

This study sets out to examine how routine offers of HIV testing for pregnant women in ante-natal (prenatal) clinics are managed over time. Data was collected over two time periods (2002, 2004) from all women booking clinics at three London hospitals. Data from 3,560 women, comprising 2,710 in 2002 (time 1) and 850 in 2004 (time 2) were gathered. Uptake of HIV testing, demographic variables, HIV-associated risks, pregnancy variables and uptake of other ante-natal tests were monitored. In the later study, details of partner testing and time spent discussing HIV was monitored. HIV test uptake with routine offer (RCT) was high. There was a significant increase in HIV testing over time from 85 to 91% (p<0.0001). In 2004, significantly more women had been previously tested for HIV (25 versus 41%, p<0.0001), more women refused all other ante-natal tests (rubella [0 versus 4% p<0.0001], syphilis [1 versus 5%, p<0.0001], Haemoglobin [1 versus 3%, p<0.0001], Down's syndrome [0 versus 13%, p<0.0001] and hepatitis B [1 versus 5%, p<0.0001]). Significantly less women refused HIV test (15 versus 9%, p<0.0001). Initially, HIV was the most frequently refused test (15%), whereas at time 2 Down's syndrome tests were most frequently declined. At time 1, 2% declined any test. By time 2, 14% of the sample declined any test (p<0.0001). Three percent of women had an established HIV risk at time 1 and 6% at time 2. Women with risk factors were significantly less likely to accept testing at time 2, but not at time 1 or not overall. Multivariable analysis was carried out to look at predictors of opting in and opting out of testing. At time 2 HIV test uptake was more likely if less than 3 min was spent discussing it (chi2=9.3, p=0.002). This information was not available at time 1. HIV testing in ante-natal care can be sustained over time. Challenges for the future relate to complex cases, test declining, ensuring that women with risk factors do not systematically decline and providing skills for midwives or referral pathways to deal with more demanding cases. It has been possible to normalise HIV testing. Women have responded with high HIV test uptake, but are also questioning other tests which were previously routinely offered.     

Correlates of HIV Testing Refusal Among Emergency Department Patients in the Opt-Out Testing Era

Opt-out HIV screening is recommended by the CDC for patients in all healthcare settings. We examined correlates of HIV testing refusal among urban emergency department (ED) patients. Confidential free HIV screening was offered to 32,633 ED patients in an urban tertiary care facility in Washington, DC, during May 2007–December 2011. Demographic differences in testing refusals were examined using χ² tests and generalized linear models. HIV testing refusal rates were 47.7 % 95 % CI (46.7–48.7), 11.7 % (11.0–12.4), 10.7 % (10.0–11.4), 16.9 % (15.9–17.9) and 26.9 % (25.6–28.2) in 2007, 2008, 2009, 2010 and 2011 respectively. Persons 33–54 years of age [adjusted prevalence ratio (APR) 1.42, (1.36–1.48)] and those ≥55 years [APR 1.39 (1.31–1.47)], versus 33–54 years; and females versus males [APR 1.07 (1.02–1.11)] were more likely to refuse testing. Opt-out HIV testing is feasible and sustainable in urban ED settings. Efforts are needed to encourage testing among older patients and women.     

Evaluation of opt-out inpatient HIV screening at an urban teaching hospital

This study evaluated opt-out inpatient HIV screening delivered by admitting physicians, and compared number of HIV tests and diagnoses to signs and symptoms-directed HIV testing (based on physician orders) in the emergency department (ED). The opt-out inpatient HIV screening program was conducted over a one year period in patients who were admitted to the 386-bed University of California San Diego (UCSD) teaching hospital. Numbers of HIV tests and diagnoses were compared to those observed among ED patients who underwent physician-directed HIV testing during the same time period. Survey data were collected from a convenience sample of patients and providers regarding the opt-out testing program. Among 8488 eligible inpatients, opt-out HIV testing was offered to 3017 (36%) patients, and rapid antibody testing was performed in 1389 (16.4%) inpatients, resulting in 6 (0.4% of all tests) newly identified HIV infections (5/6 were admitted through the ED). Among 27,893 ED patients, rapid antibody testing was performed in 88 (0.3%), with 7 (8.0% of all tests) new HIV infections identified. HIV diagnoses in the ED were more likely to be men who have sex with men (MSM) (p?=?0.029) and tended to have AIDS-related opportunistic infections (p?=?0.103) when compared to HIV diagnoses among inpatients. While 85% of the 150 physicians who completed the survey were aware of the HIV opt-out screening program, 44% of physicians felt that they did not have adequate time to consent patients for the program, and only 30% agreed that a physician is best-suited to consent patients.

In conclusion, the yield of opt-out HIV rapid antibody screening in inpatients was comparable to the national HIV prevalence average. However, uptake of screening was markedly limited in this setting where opt-out screening was delivered by physicians during routine care, with limited time resources being the major barrier.     

Which patients attending genitourinary medicine clinics have HIV tests?

To identify factors associated with uptake of HIV testing a questionnaire was given to patients attending a GUM clinic over a three-week period. One hundred and twenty (69.4%) of 189 patients accepted and 53 (30.6%) refused testing. Variables associated with having a HIV test were: being tested previously (P=0.045), given a leaflet about testing (P=0.001), told about the window period (P=0.006), told about availability of counselling (P=0.030), given insurance advice (P=0.014), and a past history of sexually transmitted infections (P=0.044). Most patients perceived a low risk of being HIV positive (n=143, 75.7%) with no difference between those accepting or declining testing. The principal reason for testing was a check-up, and for refusal was a lack of perceived risk. Patients who are well informed about HIV testing are more likely to accept a test.     

Acceptability of HIV/AIDS counseling and testing among premarital couples in China.

Premarital counseling is required for couples wishing to be married in China. The counseling primarily provides information about contraception. We evaluated adding premarital HIV/AIDS counseling and voluntary HIV testing to the standard counseling. The test was offered free to one group and at the standard cost to the other. The proportion of those accepting HIV testing among all participants receiving premarital counseling was used as a measure of acceptability. Sixteen percent of participants not charged chose to accept testing versus 1.4% of those charged ( p < .001). Lack of HIV/AIDS knowledge and charging for the test were correlated with refusal. Over 5% of participants admitted to premarital sex, most with their fianceé, and a significantly higher portion was female. Only 22% used condoms. Study participants were randomized for 1-year follow-up. Only four participants reported extramarital sexual activity during that year. Acceptance of HIV testing was disappointingly low. Implementing strategies to reduce stigmatization and increase knowledge of HIV/AIDS, in addition to not charging for testing, may increase the acceptance of HIV testing.     

Acceptance of rapid HIV testing among medical inpatients in New York City

Early diagnosis of HIV infection is important for both individual and public health. This study examined patient acceptability of routine, voluntary HIV testing in a New York City hospital serving East Harlem, a diverse community with an HIV seroprevalence of 2.6%. Consecutive admissions to the general medicine service were screened for enrollment between October 27 and November 22, 2005, and March 13 and May 9, 2006. Participants completed a self-administered printed survey and underwent rapid HIV testing. Of the 420 patients approached, 100 patients participated. The most common reason for declining participation was, "I feel too sick to participate." Participants were more likely to be men (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.05, 2.77) and to be in a younger age group (20-49 years; OR 2.70, 95% CI 1.64, 4.45). Participants who reported one or more HIV risk factors were not more likely to answer "Yes" when responding to the statement, "I have risk factors for HIV" compared to patients who did not report any specific clinical or behavioral HIV risk factors (OR = 1.16, 95% CI 0.38,3.53). In addition, patients who reported one or more specific clinical and/or behavioral HIV risk factors were not more likely to have received prior HIV testing (OR = 1.58, 95% CI 0.58, 4.32). Three individuals were newly diagnosed with HIV/AIDS. Risk-based testing may be inadequate, as patients do not accurately assess risk and do not seek or accept testing based on risk. Routine, voluntary HIV testing is able to identify patients missed in the risk-based model of HIV testing, expanding the opportunities for timely diagnosis and intervention. In order to fully implement the new Centers for Disease Control and Prevention (CDC) recommendations for routine, voluntary testing, the optimal timing to offer HIV testing to acutely ill inpatients warrants further investigation.     

HIV/AIDS Stigma and Refusal of HIV Testing Among Pregnant Women in Rural Kenya: Results from the MAMAS Study

HIV/AIDS stigma is a common thread in the narratives of pregnant women affected by HIV/AIDS globally and may be associated with refusal of HIV testing. We conducted a cross-sectional study of women attending antenatal clinics in Kenya (N = 1525). Women completed an interview with measures of HIV/AIDS stigma and subsequently information on their acceptance of HIV testing was obtained from medical records. Associations of stigma measures with HIV testing refusal were examined using multivariate logistic regression. Rates of anticipated HIV/AIDS stigma were high—32% anticipated break-up of their relationship, and 45% anticipated losing their friends. Women who anticipated male partner stigma were more than twice as likely to refuse HIV testing, after adjusting for other individual-level predictors (OR = 2.10, 95% CI: 1.15–3.85). This study demonstrated quantitatively that anticipations of HIV/AIDS stigma can be barriers to acceptance of HIV testing by pregnant women and highlights the need to develop interventions that address pregnant women’s fears of HIV/AIDS stigma and violence from male partners.     

HIV testing in the setting of inpatient acute substance abuse treatment

We examined patients' attitudes toward HIV testing in the setting of acute substance abuse treatment and determined the prevalence of offering routine on-site testing for human immunodeficiency virus (HIV) in inpatient state-funded detoxification centers in New England. Voluntary questionnaires were administered to patients (N = 66 respondents) at the only two state-funded inpatient drug detoxification treatment centers in Rhode Island, and a telephone survey of all state-funded inpatient detoxification facilities across the New England area was conducted. In New England, 17/38 (44.7%) of all state-funded inpatient detoxification facilities didnot routinely offer on-site HIV testing to clients. Of participants, 97% responded positively to the question, "Do you think HIV testing should be available to patients in drug detoxification facilities such as this one?" There were 89% who reported that they would cope "about the same" or "better" with receiving a positive HIV test result while in detoxification treatment versus elsewhere. The greatest number of participants ranked the Orasure HIV test, an assay for HIV-1 transmucosal antibody, as the test they would most prefer while in drug treatment. However, 59% of patients responded that the type of test offered would not make a difference in whether they chose testing. Most patients indicated that they would want to see a physician within a few days of a positive diagnosis of HIV infection. Despite the controversy surrounding the provision of HIV testing to patients in inpatient acute substance abuse treatment, HIV testing is desired among these patients provided that HIV clinical care is readily available.     

Concerns of pregnant women about bing tested for HIV: a study in a predominately Mexican-American population

More than 90% of pediatric acquired immune deficiency syndrome (AIDS) cases are due to mother-to-child (vertical) transmission. Medical intervention can reduce the risk of vertical transmission human immunodeficiency virus (HIV) from 25% to less than 8%. However, studies have suggested that approximately one-fourth of women may refuse HIV testing as part of routine prenatal care. The purpose of this study was to identify concerns that pregnant women might have that would impact their decision to undergo HIV testing in pregnancy. The study is a cross-sectional survey of 413 pregnant women in south Texas. A survey questionnaire was used to assess reasons why subjects might avoid HIV testing and to assess their risks for HIV infection. The reasons for not wanting HIV testing grouped around four themes: (1) fear of being stigmatized as sexually promiscuous or as an injecting drug user; (2) denial about the possibility of being infected; (3) fatalism; and (4) of rejection leading to loss of emotional and financial support. Overall, 15% of subjects who had not been previously tested (5% of all subjects) indicated that they would refuse HIV testing, a rate which is below rates of 20%-24% in previous studies. The lower rate of refusal for HIV testing in our study may reflect a downward trend nationally in the rate of refusal for prenatal testing. Many women have concerns about HIV testing, although these concerns may not necessarily prevent them from undergoing testing. Physicians and policy makers need to be aware of women's concerns and fears when implementing HIV testing policies.     

Opportunistic testing for chlamydial infection in people attending a sexual medicine clinic for HIV tests

Patients presenting for an HIV test alone represent an opportunity for screening for Chlamydia trachomatis. This audit was designed to assess the uptake of chlamydial screening by urinary ligase chain reaction (LCR) in adults attending a genitourinary clinic. All patients requesting an HIV test were offered full genital screening in the first audit period, if they declined they were offered chlamydial LCR. During the second period patients who refused full screening were asked to provide a urine sample for LCR testing unless they declined. Nine hundred and forty-two patients presented for HIV tests alone during the first audit period. Two hundred (22%) agreed to provide a urine sample for LCR testing, 7 (3.5%) were positive for chlamydia. During the second audit period 794 patients presented for HIV tests alone, 426 (55.1%) provided urine for LCR testing, 15 (3.4%) were positive. The uptake of urinary LCR, a non-invasive test for a potentially serious infection remained disappointingly low despite changes to the audit protocol. Reasons for this are discussed.     

Acceptance of HIV antibody testing among inpatients and outpatients at a public health hospital: a study of rapid versus standard testing

Patients of unknown HIV status who were admitted to the inpatient unit or who were undergoing evaluation in the outpatient clinic of a public health hospital were randomized to receive either the standard HIV test or a rapid HIV test. Patients ranged from 21-71 years of age, and 71% were male. Eleven percent were Hispanic, 36% black, and 48% Caucasian. 35% were injection drug users (IVDU) and 3% men who have sex with men (MSM). The waiting period for the standard test was 2 weeks, and that for rapid testing was approximately 20 minutes. Patients were provided with a telephone number and told to call and schedule a follow-up appointment to receive their standard test results. We found no statistical difference in the acceptance rates of either testing modality overall or with respect to age or gender. We did find a significantly greater percentage of Hispanic patients accepting rapid testing over standard testing (p = 0.04). The overall acceptance rates of rapid and standard testing were 60% and 41%, respectively. This was far lower than expected, and was due in part to the 40% of patients who refused testing because of their having a previous HIV test. All patients who had received previous testing had tested HIV negative, and we did not discover any new cases of HIV in the 103 patients tested during the study. Of those we tested, 95% of those receiving the rapid test and 43% of those receiving the standard test were informed of their status (p < 0.001). Failure of patients to return for follow-up visits accounts for the low percentage of individuals successfully informed of their standard test results. The study suggests that rapid HIV testing is at least as palatable as standard testing in our population. In addition, a far greater percentage of patients are informed of their status using the rapid HIV test. HIV testing programs at our hospital may not be cost effective as our population appears to have been heavily tested previously. Prior to initiating an HIV testing program within a hospital setting, it is imperative to determine the percentage of patients previously tested for HIV.     

Would offering rapid point-of-care testing or non-invasive methods improve uptake of HIV testing among high-risk genitourinary medicine clinic attendees? A patient perspective

While most genitourinary (GU) medicine clinics achieve a high uptake for testing HIV in new patients, they may still miss testing those at highest risk. Point-of-care testing (POCT) and salivary samples are acceptable and feasible but have not yet been shown to increase uptake among high-risk patients (HRP). This study aimed to describe reasons why HRP decline HIV testing and whether offering POCT along with standard testing would increase the uptake of testing HIV in two London GU medicine clinics. Anonymous self-administered questionnaires were offered to all new and rebooked patients. Eight hundred and ninety-nine questionnaires were analysed of which 598 were HRP. Uptake of HIV testing was 77.1% among HRP and 65.8% among the rest. A total of 51.1% of HRP who declined HIV testing said they would be more likely to accept a POCT and 32.8% a salivary test. Introduction of rapid POCT for HIV would increase patient's choice and may increase the likelihood of HRP accepting an HIV test.     

Beneficial Effects of Offering Prenatal HIV Counselling and Testing on Developing a HIV Preventive Attitude among Couples. Abidjan, 2002–2005

Prenatal HIV counselling and testing is mainly an entry-point to the prevention of mother-to-child transmission of HIV, but it may also play an important role in triggering the development of spousal communication about HIV and sexual risks and thus the adoption of a preventive attitude. In Abidjan, Côte d’Ivoire, we investigated couple communication on STIs and HIV, male partner HIV-testing and condom use at sex resumption after delivery among three groups of pregnant women who were offered prenatal counselling and HIV testing: HIV-infected women, uninfected women, and women who refused HIV-testing. The proportion of women who discussed STIs with their regular partner greatly increased after prenatal HIV counselling and testing in all three groups, irrespective of the women’s serostatus and even in the case of test refusal. Spousal communication was related to more frequent male partner HIV-testing and condom use. Prenatal HIV counselling and testing proposal appears to be an efficient tool to sensitize women and their partner to safer sexual practices.     

Identifying undiagnosed human immunodeficiency virus: the yield of routine, voluntary inpatient testing

BACKGROUND: Despite current recommendations for human immunodeficiency virus (HIV) counseling and testing among patients admitted to hospitals with at least a 1% prevalence of HIV infection, an estimated 300 000 people in the United States remain unaware of their HIV infection. METHODS: We implemented the Think HIV program, which offered voluntary HIV counseling and testing to patients admitted to the medical service of a Boston, Mass, teaching hospital. We compared the results of this effort with testing results from a 15-month historical control period. RESULTS: Patients admitted during the program period were 3.4 times more likely to undergo testing for HIV than those admitted during the control period (95% confidence interval [CI], 2.8-4.1). The testing program detected approximately 2 new diagnoses of HIV infection per month, compared with 1 per month during the control period. Patients who underwent testing during the program, and who likely would not have done so without this initiative, had an estimated prevalence of HIV infection of 3.8% (95% CI, 1.8%-5.8%). CONCLUSIONS: Testing efforts for HIV targeted to only symptomatic patients are inadequate to identify the one third of HIV-seropositive people in the United States who are unaware of their infection. We have shown that in a single urban hospital, offering voluntary, routine inpatient HIV counseling and testing can be successful as a screening program by identifying a substantial number of patients with undiagnosed HIV. These patients then can be informed, counseled, and linked to care and treatment. Seventy-two hospitals nationwide have demographics similar to those of the study hospital, suggesting that these results are generalizable to many urban hospitals.