Facilitating HIV Testing: Exploring Provider and Patient-Centered Barriers

Abstract

HIV testing can no longer be plausibly thought of as relegated to sexually transmitted disease (STD) clinics. Recent Centers for Disease Control and Prevention (CDC) guidelines recommend that patients between 13 and 64 be tested at least once per lifetime; 1 implementing this recommendation would impact healthcare settings in that frontline staff would need to be equipped to perform HIV testing for a variety of patients. 2,3 Compliance with this protocol means that providers need to be profi cient in offering such tests. Of the over 1.3 million people in the United States infected with HIV, it is estimated that approximately 25% do not know their status. 4 CDC data suggest that those unaware of their HIV positive status are 3.5 times more likely to infect others than those who are aware. Additionally, upon diagnosis, half of those who are positive present with a CD4 + cell count of less than 200 per cubic millimeter, suggesting that the individual was infected approximately 8‐10 years before. 5 Delays in detection mean delays in treatment, leading to further degradation of the immune system, and a potentially less favorable outlook. Considering the lengthy asymptomatic nature of HIV, it may not occur to patients, who look and feel fi ne, to request an HIV test, thereby shifting the weight of proposing diagnostics to providers. Provider Barriers Broadly speaking, few providers would argue against testing, which facilitates earlier detection, affording the opportunity to address health issues in their early stage(s), when they are most amenable to treatment, but when it comes to testing for HIV, there are some real-world factors that can stand in the way. Providers in a variety of treatment settings (e.g., prenatal, emergency, primary care) indicate that the time involved in appropriate HIV pretest counseling, balanced against other competing health concerns, served to lower the priority of HIV testing. This combined with lack of training negatively impacted providers’ willingness to offer HIV testing on a regular basis. 6 To address this problem, in 2006 the CDC revised their guidelines regarding HIV counseling and testing. New recommendations suggest routinely offering HIV testing to everyone between the ages of 13 and 64, regardless of risk, and that prevention counseling need not be required with HIV diagnostic testing or as part of HIV screening programs in healthcare settings. 1 Effective post-test counseling is also an essential step in the pathway toward reducing risky behavior and facilitating prompt entry into treatment. A study involving newly diagnosed HIV positive patients revealed that those who received comprehensive post-test counseling consisting of referrals for medical services, prevention services, and psychological support services, sought medical care immediately, compared to a median delay of 7 months among those who did not receive such counseling ( p = 0.009). Additionally, patients who received their post-test counseling from a qualifi ed counselor or social worker fared better than those who received post-test counseling from physicians or nurses; such patients were 11.6 times more likely to follow-up with medical care ( p = 0.029) and 8.7 times more likely to take antiretroviral therapy ( p = 0.004). 7 Such proactive behavior among patients can serve to decrease morbidity and mortality rates 8 and also serve as effective prevention strategies. 9 Embarking on HIV testing may necessitate breaking bad diagnostic news to some patients, which can cause serious discomfort to some healthcare professionals. 10 This anxiety may contribute to detouring some providers when it comes to more regularly offering HIV tests. Part of the challenge is that there is no single predictable patient reaction when it comes to bad news, hence providers must be prepared to cope with a spectrum of emotions. 8 As such, providers may benefi t from stress management skills 11 along with increased peer support and professional guidelines detailing skills for delivering positive HIV test results, 12,13 which typically involve becoming familiar with some selected phrases, preparing to disclose the news, disclosing the news, and responding to the patient’s reaction. 14