HIV Testing in D.C.: Is the Opt-out Policy Working?

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Approximately 2.7% of people in Washington, D.C. are living with HIV. This is a true epidemic. Primary care physicians (PCPs) play an important role in screening for HIV.  Yet data show that 71.4% of newly diagnosed HIV patients visited a medical provider in the past 12 months but were not tested for HIV.  Fewer than half of PCPs responding to a recent survey reported that they implement routine opt-out testing–a missed opportunity for connecting people to care and treatment in a community with the highest HIV case rates in the country.

Two primary barriers for routine opt-out HIV testing in PCP practices are the demands on physicians’ time and resources and the need for ongoing physician education. Interventions should target these issues to reduce barriers and support physicians routinely testing.

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Percent of Physicians Aware of Opt-Out Screening Recommendations. Source: D.C. Department of Health Offer the Test Pilot Study. 17 Mar. 2011. Raw data. D.C. Department of Health, Washington, D.C.

Interventions are needed to improve the testing process.  Introducing physician training will help practitioners become comfortable with routine testing and counseling. The counseling process could be streamlined by showing videos and having materials available in the waiting room.  Reminders telling the physician to offer HIV testing could be programmed into electronic medical records to standardize the opt-out routine .

Washington D.C. has made significant progress in the fight against HIV/AIDS, but now it is time to overcome the barriers surrounding testing.  The opt-out policy has proven to be cost-effective and to improve health outcomes.  The first step to providing HIV care begins with a diagnosis. The physicians of D.C. need to standardize routine opt-out testing and assure their patients the best preventive care possible.

President Barack Obama getting tested for HIV via oral swab.  Source: http://mpetrelis.blogspot.com/2010/03/nyt-omission-obamas-routine-hiv-test-in.html

President Barack Obama getting tested for HIV via oral swab. Source: http://mpetrelis.blogspot.com/2010/03/nyt-omission-obamas-routine-hiv-test-in.html

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7 Responses to “HIV Testing in D.C.: Is the Opt-out Policy Working?”

  1. aliciamhernandez Says:

    This is a very important issue. I didn’t realize implementation of it was so problematic for physicians. I work in the Johns Hopkins Emergency Department and at least since I first started there in 2008, they have had routine offering of testing by a team of people whose sole function is to go to each patient and offer the test to them. I believe it is volunteer-run. It works very well. In 4 years and hundreds of patients, I’ve seen maybe one or two decline testing. And this relieves the burden of time or even having to remember from the physician. Perhaps something like this could be implemented in primary care settings as well. If it is to be routine and the barriers lie in physician time and resources, why not separate it from them? Testing would still be done in line with the visit so the physician would still be aware of it and results and able to initiate follow-up care and treatment. And more patients would be screened whether or not the physician has the time or inclination to order it.

  2. ldellplain Says:

    Great post!

    @aliciamhernandez, My immediate reaction to the original post as something along the lines of what you said. With the incredibly short amount of time allotted per visit with most PCPs, it is understandable why perhaps the addition of opt-out testing may feel unrealistic given the resource needs. The counseling aspect in particular is a necessarily time consuming process, and I am wary about even a streamlined video replacing a more client-centered, human interaction counseling procedure.

    Task-shifting seems to be an appropriate way to address this issue, perhaps through volunteers (like in the Johns Hopkins Emergency Department) or trained medical assistants who already do the bulk of patient labs. Of course, this may be difficult to streamline across all PCP settings across DC, but it is definitely something important to consider.

  3. stlouisguys2013 Says:

    This is an ongoing problem. I worked in Baltimore in HIV and what I observed is Primary care Physicians do not want to deal with the difficulties that a positive HIV test presents. It is hard to educate Physicians already in practice, but having electronic medical records with HIV antibody as a default order would be easier. I always simply tell patients, HIV testing is part of their routine work up and never had anyone refuse.

  4. oluwanioje Says:

    This is an ongoing problem. I worked in Baltimore in HIV and what I observed is Primary care Physicians do not want to deal with the difficulties that a positive HIV test presents. It is hard to educate Physicians already in practice, but having electronic medical records with HIV antibody as a default order would be easier. I always simply tell patients, HIV testing is part of their routine work up and never had anyone refuse.

  5. marcoslrz Says:

    I agree with the option of training physicians so that they can become more comfortable with the process of screening patients for HIV infection. As shown in the figure, about 30% of physicians are aware but not currently implementing the opt-out screening and this proportion of physicians are the targeted group to focus on by interviewing and asking them the underlying reasons for not getting the HIV screening performed in their practices. I am currently working on a HIV clinic in Mississippi. I have asked the heads of the emergency department at the main hospital in town (500+ beds hospital) to offer the HIV testing as a routine test to complete the work up on the patients visiting the ER. One main problem is that these patients are usually not being followed up as an outpatient basis by the emergency doctors and the ELISA-HIV test has to be confirmed with a western blot test in order to accurately disclose the diagnosis of HIV. Unfortunately, the time to have the western blot test results is about 3 business days. The physicians in the ER are afraid to have legal consequences if the positive ELISA patients are not informed about the western blot results once the patient is at home. “Who is going to follow those results?” they said. Other physicians in their clinics are not doing the HIV test because they think that some patients are at low risk for acquiring HIV. I think that having a reminder about testing for HIV in the electronic medical records may be a good idea. More information and education for physicians and patient is needed. Also, I think there is a new rapid HIV test offered over-the-counter and available to the general public. This may also help in detecting some new cases. Nevertheless, some physicians may be uncomfortable testing their patients for HIV since they may feel unprepared for explaining the need for a test or informing the positive results, etc. Stating that an HIV ELISA test is part of the routine “work up” is a good idea but counseling about a possible positive test and the number of steps to handle such diagnosis (treatment, follow up, etc) are strongly recommended since even doctors tested positive for HIV may become acutely depressed and commit suicide (http://www.nairaland.com/720421/female-doctor-commits-suicide-after). We all hope to have more recommendations for the local governments about testing for HIV since every region in the U.S. may have differences in cultural and social beliefs regarding HIV. For example, HIV/AIDS is a stigma in MS and people don’t want to talk about it.

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