The Role of Public Health in HIV Opt-out Testing: An Expert Interview With Dr. Wayne A. Duffus

August 27, 2008

Editor’s Note:
In a recent interview with Peggy Keen, PhD, FNP, Editorial Director of Medscape Public Health and Prevention, Wayne A. Duffus, MD, PhD, Assistant Clinical Professor of Infectious Diseases, University of South Carolina School of Medicine, Columbia, South Carolina; Medical Director, STD/HIV Division, South Carolina Department of Health and Environmental Control, discussed some of the common issues related to opt-out HIV testing, focusing particularly on the role of public health.

Medscape: What do you see as the role of public health in implementing opt-out HIV testing?

Dr. Duffus: Ironically, many citizens, including healthcare workers, are aware of the national HIV epidemic but are uninformed of the extent of the HIV epidemic in their local community. Also, the dramatic improvement in antiretroviral therapy may have led to the false perception among uninfected individuals that HIV disease is no longer a serious health problem. Consequently, public health has the dual role of educating both the local community and healthcare workers on the epidemiologic profile of HIV disease in the surrounding jurisdictions.

With increased knowledge, individuals may be more likely to accept HIV testing when it is routinely offered and providers may be more comfortable with performing testing if it conducted as part of general medical care. Local health departments should utilize the AIDS Education Training Centers (AETC) to assess the capacity of local healthcare facilities to conduct routine, opt-out HIV testing. By forming partnerships with local community groups, churches, schools, and participating in health fairs and similar activities, public health can help to improve the social desirability of HIV testing.

Medscape: What have turned out to be the greatest barriers to implementation of opt-out testing?

Dr. Duffus: A frequently asked question regarding the implementation of routine opt-out HIV testing is, “Who will pay for the testing and how many per year will be needed?” For opt-out testing to be fully implemented and sustainable, third-party payers will need to buy into the proven concept that routine HIV testing is cost-effective.

Several states have had laws requiring signed informed consent for HIV testing, as well as pretest counseling. These laws would need to be changed in order to fully implement opt-out testing. Twenty-three states have had these testing and counseling laws and many are in the process of reversing these rulings. Continued lobbying efforts by concerned organizations will be needed to change these laws.

In addition, because of the disparate state laws, many local healthcare facilities are surprisingly unaware of the laws that govern their jurisdictions and are fearful that HIV testing an individual without specific written consent has severe medico-legal implications. Time will be needed to convince administrators to seek legal counsel and to incorporate HIV testing as part of the general consent for care.

Theoretically, routinely offering HIV testing to all individuals, regardless of risk, should lessen the stigma associated with testing. Improvements in therapy have reduced the morbidity associated with a positive test result. However, it is unclear what impact a positive test results will have in certain situations, such as health insurance cost and domestic violence. Also, in small rural communities, where the perceived fear of test results becoming public is high, new ideas will need to be developed to promote the confidentiality of testing and reduce stigma.

Medscape: What advice/tips for surmounting obstacles would you offer to various levels/settings in public health?

Dr. Duffus: Health department partnerships with individuals and institutions to promote opt-out HIV testing will help surmount many of the barriers. For example, many hospitals have healthcare lobbyists who can be utilized to convince legislatures that laws favorable to the recent Centers for Disease Control and Prevention (CDC) testing recommendations are needed and that such testing is cost effective. When individuals are tested early and have access to medications, they remain healthy and employed, and thus contribute to the local tax base.

In resource-poor settings, the AETC can be very helpful in accomplishing many of the tasks associated with increasing uptake of opt-out testing by institutions and healthcare providers. For instance, they can provide training on rapid testing, cultural competence, and basic HIV epidemiology in settings where HIV testing was not previously performed.

Health departments should become knowledgeable of the coverage policies of their state Medicaid office regarding HIV-related disbursements. Identifying a specific individual/committee in the Medicaid office responsible for HIV disbursements and educating them on the local epidemiologic data will help sway towards payment for routine HIV testing. It is hoped that commercial insurance will then follow suit.

Healthcare settings are important venues for opt-out HIV screening. An approach that works well in one jurisdiction may not be suitable for another locale because of issues, such as staffing shortages, hours of operation, administrative support, etc. This suggests that healthcare facilities should be both patient and flexible during implementation, and consult with colleagues about their experience. A good resource is the National Alliance of State and Territorial AIDS Directors’ HIV Testing in Emergency Departments: A Primer and Strategies for Health Departments, available at:

Medscape: How do you measure the extent of success of opt-out testing recommendations?

Dr. Duffus: The revised HIV testing recommendations were initially published in September 2006;[1] thus, many institutions are still in the implementation stage. Consequently, it is still too early to measure success of the recommendations in the public health arena.

At a later date, a measure of success should be the increased numbers of people who report ever being tested for HIV infection — positive and negative test results. Local epidemiologic profiles of HIV-infected individuals should also reflect, over time, higher median CD4+ T-cell counts at diagnosis and fewer individuals with an AIDS diagnosis within 1 year of their first positive HIV test result. Higher rates of linkage to HIV medical care and access to highly active antiretroviral therapy for eligible individuals are also important measures of success.

Medscape: What are important issues regarding linkage to appropriate care and management that have come from increased HIV testing/recognition of HIV-positive individuals?

Dr. Duffus: A major consideration of increased HIV testing should be promoting early entry into HIV medical care. It is estimated that approximately 50% of HIV-infected individuals are not in routine HIV care, and therefore do not benefit from the advances in therapy or from counseling to reduce transmission.[2] The use of rapid HIV tests will be a major contribution to prevention if those identified as HIV-infected can be quickly linked to a care provider.

The availability of funding to allow implementation of the findings of the Antiretroviral Treatment Access Study (ARTAS) will serve to improve rates of linkage to care. Using the ARTAS model, 78% of the recently diagnosed HIV-infected individuals who received brief case management were linked to care within 6 months compared to 60% of patients who received standard of care referral.[3]

Although most practitioners would agree that providing accessible testing benefits patients, the capacity of already-overburdened treatment and preventive services will need to be increased if opt-out testing is to translate into earlier treatment. Funding for HIV prevention and treatment services will need to be adjusted quickly in order to reflect changing epidemiologic trends.

An increased number of diagnoses also will increase demands for public health services, especially partner notification. Providers will need to become familiar with the health department partner counseling and referral services (PCRS) staff and how to access other prevention services.

Medscape: Are there certain settings that are most logical/pressing/important for implementation of opt-out testing?

Dr. Duffus: South Carolina (SC) Department of Health and Environmental Control reviewed medical encounters that occurred before the date of the first positive HIV test for 3021 HIV-positive individuals newly diagnosed between 2001 and 2005.[4] Analysis revealed that before the date of the first positive HIV test, 79.3% of healthcare visits were to emergency departments in the state. Total visits ranged from 1 to 133 per patient, and the median number of visits was 4 per individual.

It is well known that individuals without health insurance, especially those at risk for HIV-infection, utilize the emergency department as the source of their primary care. The SC findings suggest that jurisdictions with similar populations should target emergency departments as a venue for implementation of opt-out testing.

The CDC recommendations call for routine prenatal screening, with a second test in the third trimester of pregnancy, for all high-risk patients. With the advent of rapid HIV test technology and the efficacy of highly active antiretroviral therapy, a second HIV test during pregnancy will help to eliminate a child being born HIV-infected.

It will also remain necessary to maintain nontraditional sites for HIV testing, such as community-based organizations, because many individuals will choose not to test in hospital or other healthcare settings because of stigma. Similarly, testing in correctional settings will provide difficult-to-reach populations the benefit of early HIV testing.

Medscape: To what extent, and in what settings, has opt-out HIV testing been adopted in the public health arena? Have the results to date been what leaders in the field expected/hoped for?

Dr. Duffus: The National Alliance of State and Territorial AIDS Directors “Report on Findings from an Assessment of Health Departments Efforts to Implement HIV Screening in Health Care Settings,” published in June 2007 indicated that 64% of health departments were implementing HIV screening in healthcare settings.[5] The report concluded that “most health departments have been successful in conducting screening in ‘traditional’ public health venues, such as STD and family planning clinics.”

Several specific early examples of implementation included efforts by the San Francisco Department of Public Health Medical Care System and the New York State (NYS) Department of Health. In May 2006, the San Francisco System stopped requiring a separate signed informed consent, and HIV testing was added to the regular lab requisition. The monthly rate of HIV testing increased from 13.5 tests per 1000 patient-visits (June 2006) to 17.9 tests per 1000 patient visits by the end of the year (December 2006). Before the change in policy, the mean number of positive tests per month was 20.6; this increased to 30.6 after the change in policy.[6] Several other unmentioned jurisdictions continue to have success with their own implementation process.

Medicaid is the largest payer of HIV testing and healthcare in New York State (NYS). Effective November 2006, the NYS Department of Health began receiving Medicaid reimbursement for pretest counseling without testing; for HIV testing in inpatient, outpatient, and emergency departments (which must perform rapid testing); and for counseling of infected individuals.[7]

Subsequently, in 2007, the CDC awarded 23 cooperative agreements to eligible jurisdictions for expanding and integrating HIV testing for populations disproportionately affected by HIV, primarily African-Americans. These states and directly funded cities and counties included in this award accounted for 95% of the AIDS cases among blacks in 2005.[8]

The goals for this program are to test 1.5 million persons for HIV and to identify 20,000 infected persons who were previously unaware of their HIV status. The funds allow for screening and related activities, including linkage to care and PCRS and the purchase of HIV rapid test kits. The award is for a 3-year pilot project, with subsequent funding after the initial year, based on the appropriation of funds. The first grantee meeting, held in Atlanta, Georgia, January 31-February 1, 2008, had funded participants from facilities likely to achieve the HIV testing goals: hospital inpatient and emergency departments; correctional facilities; community-based organizations; and clinics that serve primary care patients and individuals with tuberculosis, sexually transmitted diseases, or substance abuse problems.

In addition to the CDC-funded activity focused on populations disproportionately affected by HIV, other more recent efforts to implement opt-out HIV testing have taken place. For example, Illinois Senate Bill 929 will go into effect June 1, 2008. This law will make prenatal HIV testing a routine part of medical care statewide.[9] Instead of a written consent, after securing a verbal informed consent providers can proceed to HIV testing. The new law allows for provision of pretest information in verbal or written form or by video, electronic, or other means.

The New York City Health and Hospitals Corporation (HCC) also recently expanded HIV testing within their multisite healthcare system. Although NYS does not yet have opt-out testing, HHC increased the number of individuals tested for HIV by implementing NYS’s streamlined consent process and developing a successful rapid HIV testing program. The goals of increasing the number of individuals who received an HIV test, decreasing concurrent diagnosis of AIDS, and linking and retaining patients in care was accomplished through a leadership commitment, clinical staff buy-in, defining agency capacity (funding to purchase kits, staffing requirements) and operational considerations (physical space and associated costs and linkage to care). The New York City Council awarded $3 million to HHC towards the expansion plan.[7]

Medscape: If you had the chance, would you change the CDC recommendations in any way?

Dr. Duffus: Perhaps one way in which the CDC recommendations could be amended is to extend the upper age limit for routine HIV testing from age 64 to age 80. As citizens of the US continue to live longer and remain healthy, we would expect them to continue many of the behaviors that put them at risk for HIV acquisition and transmission. The higher HIV-associated mortality and morbidity of those diagnosed when they are older than age 50, and the ready availability of erectile dysfunction medications, should make this expanded age group a priority for testing also.

This activity is supported by an independent educational grant from Gilead.



Reviewed by Ramaz Mitaishvili, MD


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